Hospital utilization and reimbursement method in Brazil

Abstract

Urban private hospital discharges in Brazil increased enormously during the last decade. Several measures were taken in an effort to slow the rate of increase in hospital admissions and the escalation of hospital costs, which were out of control by the end of the last decade. The introduction of a new case-based reimbursement method, late in 1983, not only contributed to increased hospitalizations, but to changed hospital case mix, as private hospitals shifted from more costly to less costly patients. This occurred especially in the most developed areas of the country, where the concentration of profit-making hospitals is very high. The case-based prospective payment method can be seen as a good managerial tool for use in comparing hospital performance. However, it seems not to be a good mechanism for controlling health care expenditures, especially when profit-making hospitals dominate the provision of hospital care. Any decrease in hospitalization by private hospitals in Brazil has been caused by the severe economic recession, which hit the Brazilian economy hard, and by the shift in hospital admissions from private to public hospitals, not by the introduction of the new reimbursement method which has changed the unit of payment from 'patient day' to case or procedure.

Motivation, money and respect: A mixed-method study of Tanzanian non-physician clinicians

“…Some researchers have argued that non-financial motivators such as "a sense of achievement" and "recognition" are more important than salary in low-income country settings (Alihonou, Soude, & Hounye, 1998;Mathauer & Imhoff, 2006;Stilwell, 2001). However, others point out that in environments where salaries are very low, low motivation is to be expected (Ferrinho, Van Lerberghe, Fronteira, Hipolito, & Biscaia, 2004) and financial incentive schemes have had some success in improving healthworker motivation and performance in low-income country settings (Biai, Rodrigues, Gomes, Ribeiro, Sodemann, Alves et al, 2007;Mliga, 2003;Rodrigues, 1989). Herzberg categorised salary as a "dissatisfier" rather than a "satisfier" (Herzberg, Mausner, & Snyderman, 1959), arguing that low salaries have the potential to demotivate workers but that salary in itself does not motivate workers.…”

Institutional features of health insurance programs and their effects on developing country health systems

“…From the late 1960s until the early 1980s, the number of private hospital beds increased by over 40 per cent, and the hospital industry grew faster than the rest of the economy (Rodrigues, 1989). The fee-for-service reimbursement system encouraged hospitals to increase both the number of patients and the amount of services provided per patient as a means of generating profits.…”

“…Largely as a result of the incentives of the curative care reimbursement system, health expenditures increased by more than 20 per cent annually during the 1970s, and public sector health expenditure as a share of GDP rose from 1 per cent in 1949 to 3.7 per cent in 1975and 5.6 per cent in 1982(World Bank, 1988a. From the late 1960s until the early 1980s, the number of private hospital beds increased by over 40 per cent, and the hospital industry grew faster than the rest of the economy (Rodrigues, 1989). The fee-for-service reimbursement system encouraged hospitals to increase both the number of patients and the amount of services provided per patient as a means of generating profits.…”

“…There are few empirical data with which the impact of INAMPS reforms on health care cost escalation since 1983 can be analysed. A study of Brazilian hospitalization during the 1980s (Rodrigues, 1989) concluded that the change to case-based reimbursement did not appear to be effective in controlling health care costs because it created an incentive for private hospitals to increase certain types of admissions. In addition, although a system of prospectively set reimbursement rates encourages providers to economize on the level of resources allocated to the care of an individual patient, such a system also provides incentives for hospitals to maximize the volume of profitable admissions.…”

“…With a limited number of case payment groups, there will be patients of varying severity within each category. INAMPS reportedly set payment rates based on average reimbursement within a category (Rodrigues, 1989). One way that hospitals could minimize their resource inputs per case would be to treat the less severe patients within a category and try to shift sicker patients to public hospitals.…”