Evaluando la situación financiera de los hospitales públicos a partir de los costos actualizados de sus prestaciones / Evaluation of financial status of public hospitals considering the updated costs of their services

In 2011 the Chilean National Health Fund (FONASA) commissioned a study to assess the costs of the 120 most relevant hospital care services with an established fee, in a large sample of public hospitals. We herein report the cost evaluation results of such study, considering the financial condition of those hospitals in the year of the study. Based on the premise that the expenses derived from the provision of institutional and appraised hospital services should be identical to the billing of hospitals to FONASA, the prices are undervalued, since they cover only 56% of billing, generating a gap between expenses and invoicing. This gap shows an important limitation of tariffs, since their prices do not cover the real costs. However not all hospitals behave in the same way. While the provision of services of some hospitals is even higher than their billing, most hospitals do not completely justify their invoicing. These assumptions would imply that, generally speaking, hospital debts are justified by the costs incurred. However, hospitals have heterogeneous financial situations that need to be analyzed carefully. In particular, nothing can be said about their relative efficiency if cost estimations are not adjusted by the complexity of patients attended and comparison groups are not defined.

La persistencia del gasto de bolsillo de los hogares en salud: 1997-2007 / The persistence of out of pocket expenditure in health of the households: 1997-2007

El gasto de bolsillo en salud de los hogares del Gran Santiago medido por el INE el año 1997 y el año 2007 ha aumentado en un 8 por ciento. A su vez, ha diminuido la brecha de la proporción de gasto en salud de los quintiles 4-5 respecto a 1-2-3 a causa de la disminución de dicha proporción en el estrato más acomodado, con estancamiento en los más pobres. Entre estos últimos no se observa una reducción del gasto de bolsillo en salud como proporción del gasto total del hogar. De acuerdo estos datos las políticas de control, de esta forma regresiva de financiamiento de la salud, no han logrado tener un impacto significativo.

The out of pocket expenditures in health of the households of the Great Santiago measured by the INE the year 1997 and the year 2007 has increased in 8 percent. In turn, there is diminish the gap of the proportion of expenditure in health of the quintiles 4-5 with regard to 1-2-3 because of the decrease of the above mentioned proportion in the most well-off stratum, with stagnation in the poorest. Between the above mentioned is not observed a reduction of the out of pocket expenditure in health as proportion of the total expense of the households. In agreement this information the policies of control, of this regressive form of financing of the health, they have not managed to have a significant impact.

Una metodología para evaluación de servicios de salud con deudausando ajuste de riesgos con morbilidad / A methodology to evaluate indebted health authorities using diagnosis-based risk adjustment

En este trabajo se desarrolla una metodología de evaluación de Servicios de Salud en búsqueda de explicaciones a la deuda. Pretende abrir ámbitos de explicación, a través del estudio de perfiles de riesgos de personas atendidas a nivel hospitalario en cada Servicio de Salud y la construcción de índices de eficiencia relativa. El trabajo tiene un carácter ilustrativo y pretende resaltar la metodología. De los ocho Servicios de Salud con deuda considerados, cinco presentan gastos esperados de sus pacientes superiores al promedio y son los únicos cinco, del grupo de 17 Servicios de Salud considerados, en esta situación. Esto implica que, en general, los Servicios de salud con deuda muestran gastos esperados superiores que los Servicios de Salud sin deuda. A su vez, 5 Servicios de Salud con deuda justifican sus gastos observados y se desempeñan de manera relativamente eficiente. Sin embargo, tres de ellos arrojan como resultados un indicador que muestra ineficiencia relativa. La metodología se muestra robusta a la hora de comparar Servicios de Salud, dado que permite homogeneizar su producción, al ajustar por riesgos de la población atendida a nivel hospitalario. No obstante, para ser más precisos ella puede ser mejorada en varios aspectos que se señalan.

The present study aims at developing a methodology to explain deficits in different Chilean Health Authorities in Chile. It intends to make comparable the Health Authorities by studying the diverse risk and hence casemix of the different Health Authorities, this resulting in different degrees of efficiency. The present study case is used illustratively being the centre of the research the proposed methodology. The results show that al least 5 of the more indebted HA are those with highest observed expenditures and functioning with relatively good degrees of efficiency in comparison to the rest of them. Despite the concrete results of the illustrative exercise, it is the robustness of the method to compare different Health Authorities the main result of the study. This robustness lies on the possibility of comparing Health Authorities and their populations, adjusting them by their risks and casemix.

Regulación del financiamiento a hospitales: yardstick competition aplicada a los hospitales públicos en Chile / Hospital Financing regulation: yardstick competition in Chilean Public Hospitals

El financiamiento de los hospitales públicos requiere de unos incentivos adecuados para conseguir una mayor eficiencia en el uso de los recursos. El sistema de pago actual muestra insuficiencias para acotarlas tasas de crecimiento de los costos de los prestadores de atención de salud, requiere una nueva regulación y presenta riesgos de desequilibrar el financiamiento. En el artículo se propone desarrollar un modelo de competencia por comparación o “yardstick competition”, que genere incentivos al mejoramiento de la eficiencia en el tiempo basado en lo que los hospitales son, o su estructura y en lo que hacen o su casuística, medida con GRDs. El modelo provee incentivos a los hospitales para asignar mejor recursos en un contexto de un mecanismo más global, de asignación poblacional que se apliquen a los Servicios de Salud a los cuales pertenecen.

Public hospital financing requires appropriate incentives in order to improve efficiency in resources allocation. The payment mechanisms currently in place present serious defi- ciencies in the provision of health as regards cost containment; they also require a new regulation as they represent a risk of financial imbalance. We present a model of competition based on comparison, or yardstick competition intended improve efficiency in the model is based on hospital current structure and activities, measured through DRGs. As a result, the model provides incentives for a better allocation of resources within the hospital, in a wider context related to population based resource allocation to the Health Authorities, of which hospitals are a part.