|Implemented in this survey?|
The main objective of this policy is to establish a public purchasing system with integrated and coordinated health care providers based on the covered population in some specific areas of
Catalonia. Then, the main goal is to transform individual contracts buying services to several providers for capitation based contracts with integrated health care organizations.
The pilot project is applied to five geographical areas covering 450.000 people in Catalonia (7.5% of the overall population). Integrated health services have to include at least primary care and hospital care. In all the areas included in the pilot project several providers with different ownership (public, non-profit and private for-profit) are present. In each area the public financing agency (Catalan Health Service) has signed an annual contract of coordination with the different providers. This contract has to specify the following items: services included in the contract, providers in the area involved in the contract, covered population, goals related with the coordination of health services, and the amount that will paid by the public sector.
The payment system is related with the number of residents in the area and payment per person based on the adjusted average public expenditure per person in Catalonia.
The main expected outcome is to increase integration and coordination between providers in primary care and hospitals belonging to different organisations.
The main incentive for coordination and clinical integration is that the different providers will have to share and re-distribute an overall public budget covering all health care costs of the resident population.
This very innovative policy measure in the Spanish health care area affects the public financer and also public and private providers contracted by the public sector in Catalonia. No similar measure has been observed in the rest of the country.
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
|Implemented in this survey?|
The idea generated in the public health care system Catalonia and was first presented by the Health Department and a very powerful association of public health care providers owned by local governments ("Consorci Hospitalari de Catalunya"). The idea is very new in the Spanish context and it appears as a natural evolution of the innovations introduced in the previous years in the public payment systems in Catalonia: from buying services to buying integrated care. Obviously, in the international context the idea is not new: it is inspired by integrated care systems in United States. In some related sense, small-scale examples may be found in PAMEM (a public insurer for local government officials) and the area of Baix Empordà (with a private provider under public contract being the main provider of hospital and primary care).
There has not been a policy paper clearly stating the objectives and process for this policy. The leadership role bringing forward this idea has been developed by the Health Department in Catalonia, however the public provider ("Institut Català de la Salut") and also some influential non-profit and private hospitals does not seem to provide strong support for this policy. One of the reasons may be that they probably suspect that the share of their budget will not increase with the integrated purchasing system, and/or that public management rules do not allow competing with other private or non-profit organisations with the same flexibility as other organisation do.
The idea led to a formal piece of legislation in May 2002, but only as a pilot project. In fact the original proposal has not been changed during the process but poorly developed.
Implementation of this policy involves all the different health care providers in the pilot area in Catalonia, including at least primary care and hospitals. In the initial phase of the implementation an important investment in the coordination of the different and disintegrated health information systems belonging to each provider is needed. However, a lack of investment in this and other critical areas for coordination is observed. Even, financial incentives to integrate services are very poor given that the public financer continues to allocate financial resources in a markedly retrospective way, and continues to allocate a separated budget to each provider in the area. At the other side, public providers under the "Servei Català de la Salut" are managed under very restrictive administrative conditions that do not allow to share and manage a common budget with other providers.
The pilot project includes the implementation of a mechanism to review the impact of this policy. However, the evaluation method has been poorly defined and no evaluation results are yet available (or are not known).