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- 1) Initial patient contact with health providers (triage) occurred at an INAMPS or other public (state or municipal) facility, where walk-in patients would be examined by a physicianauditor (employed by INAMPS). The physician-auditor either treated the patient or referred him./her for hIigher level set vices as needed. Walk-in patients were not authorized to go directly to private facilities.

- 2) The INAMPS physician-auditor assigned the patient to a service group, and case-based reimbursement rates were tied to assignment, regardless of the treatment setting (e.g., public clinic, private hospital, etc.). Facilities and providers are reimbursed a fixed amount per case, and only for the procedures specified by the physician-auditor. If a hospital treated a patient at less cost than the reimbursement amount, it profited. If treatment costs exceeded the case payment rate, the hospita oore the financial loss.

These features, which were implemented more broadly throughout INAMPS in 1983 as part of the Hosp;.al Certification System (AIH), were aimed at many of the problems inherent under the GIH system. Prior *o implementation of the Curitiba Plan, nmany walk-in patients were treated by private hospitals as emergency cases, whick received substantially higher fee-for-service reimbursements from INAMPS. The public triage requirement created a structured referral system to address this. In addition, by separating the decision on the course of treatment from the facility which would actually provide (and be reimbursed for) the care, the financial incentive to overprescribe and overuse complementary examinations and services in private facilities was diminished.' Under the initial Ctiritiba project, hospitalizations were reduced to _5_ percent of initial consultations, compared to a Brazilian average of 6.5 percent. By mid-1982 (the Curitiba pilot began in 1981), INAMPS declared that the plan had reduced hospital admissions by 30 percent (McGreevey, 1988). Unfortunately, however, we are not aware of any subsequent follow-up studies that would demonstrate ti- long term effects of these changes.

INAMPS reforms altered some, but not all, of the key characteristics of the health insurance system. The reimbursement system remained retrospective, but on a case basis rather than fee-forservice. There were still no cost-sharing provisions for INAMPS beneficiaries. By requiring entrance to services via public primary care providers (i.e., its own employees), the role of INAMPS in enforcing cost discipline on private providers became more active.<sup>2</sup> Under the AIH system, the financing and administration of curative and preventive care remained separate, but in 1987 the Unified and Decentralized Health System (SUDS) was announced with the aim of correcting this situation. The objective of SUDS was to unify the functions and resources of INAMPS and the MOH I This would be true to the extent that the INAMPS physician-auditor did not also work in pnvate practice or for a private hospital, or was immune to influence from private providers. One problem of the system prior to 1983 noted by McGreevcy (1988) was a conflict of interest arising because most physicians who were employed in public clinics were also holding positions with at least one private health care provider. Indeed, a 1981 survey of physicians in Greater Sao Ptulo found that they average 3.5 jobs each. This conflict of interest continues to be an issue fc. he post-1983 INAMPS physician-auditors, as the reformed system places tremendous resource allocatior. -owers in **t..** hands of these public employees. Private contractors clearly ha-e much to gain by trying to influence the I hysician-auditors' decisions.

**2** Other activities undertaken by INAMPS reflective of its more active role vis-a-vis the private provider network included implementation of more systematic and thorough audits of private contractors, establishment of public reference centers for high-technology services, and modification of procedures by which high-cost items were procured by private contractors (Briscoe, 1990).