Sistemas de pago a prestadores de servicios de salud en paises de America Latina y de la OCDE / Payment systems for health services providers in countries of Latin America and of the OECD

RESUMEN

Ademas de ser uno de los componentes mas importantes de las relaciones contractuales entre los agentes de los sistemas de salud, el sistema de pago a prestadores es relevante para algunos de los principales criterios de valoracion de un sistema de salud, como la eficiencia y la calidad. En este articulo tratamos de proporcionar un marco analitico sencillo para comprender la naturaleza de los distintos sistemas de pago, que ilustramos con una revision de las formulas de pago utilizadas en dos grupos de países 10 de la Organizacion de Cooperacion y Desarrollo Economico (OCDE) y cuatro de America Latina cuyas experiencias consideramos representativas. Primero presentamos un modelo basico para caracterizar las diferentes formas de pago, basado en dos dimensiones la unidad de pago y la distribucion de riesgos financieros entre el que vende y el que compra. Cada sistema de pago tiene ventajas e inconvenientes que deben evaluarse en funcion de los objetivos que se pretenda alcanzar. En un extremo tenemos la remuneracion fija, que representa el pago prospectivo mas puro, sin ajustes, como el pago capitativo, en el que los prestadores soportan todo el riesgo financiero derivado de la variabilidad de costos. En el otro extremo se situa el pago retrospectivo o por acto, con el que el riesgo incurrido por los prestadores es nulo y es el financiador quien soporta todo el riesgo derivado de la variabilidad de costos. Como suele ocurrir, los extremos no parecen optimos y la cuestion consiste en escoger un sistema de remuneracion intermedio. Para ello, es necesario seleccionar, por una parte, la unidad de pago optima segun los objetivos del financiador y, por otra, una distribucion de riesgos que atribuya al prestador los riesgos derivados del mayor o menor grado de eficiencia que consiga en la prestacion de los servicios

ABSTRACT

The system used to pay health services providers is one of the most important components of the contractual relationship between persons who receive health services and the individual practitioners and institutions that provide those services. That payment system is also relevant in assessing a health system, including its efficiency and quality. In this article we present a simple analytical framework for various payment systems. We also provide an overview of the payment approaches used in two groups of countries whose experiences we consider representative 10 nations of the Organization for Economic Cooperation and Development (OECD) and four countries of Latin America. We present a basic model to characterize the different forms of payment based on two dimensions. One of the dimensions is the payment "unit," which is used to measure the amount of health care services provided or promised. The other dimension is the distribution of financial risks between the service provider and the service purchaser. Each payment system has advantages and disadvantages that should be evaluated in relation to the intended objectives. On one extreme of the approaches is fixed remuneration, without any adjustments; it represents the purest prepayment approach. One example of fixed remuneration is capitated payment, in which providers carry all the financial risks coming from the variability in the cost of providing services. On the other extreme is fee-for-service payment, where service providers are not at financial risk; the insurer or other financing institution carries all the risk from variable costs. Neither of the extremes appears to be the best choice, and so the issue becomes one of selecting a remuneration system that falls between those extremes. Therefore, it is necessary to choose, on the one hand, the optimal payment unit according to the objectives of the financing entity and, on the other hand, a risk distribution approach that allocates to the service provider the risks coming from greater or less efficiency in delivering services