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Health systems in transition
Portugal
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the process of adjusting prospective budgets for case-mix and other hospital
specificities, enabling a more equitable allocation of resources than would
otherwise be possible if only patient volume or information on the length of
stay were available.
Since 2003, DRGs have been used to set the totality of NHS hospitals and
inpatient funding; however, between 1997 and 2002 they have been introduced
smoothly. NHS inpatient care funding through DRGs represents around 75–85%
of NHS hospitals’ inpatient budget; the remaining percentage corresponds to
billing to third-party payers (Mateus, 2011). The DRGs are used to set the
budget given to the hospital, not to define a payment episode by episode. Some
other refinements of the budget computation have been implemented between
1997 and 2002, such as case-mix adjustment for ambulatory surgery and the
set-up of hospital peer grouping using a “grade of membership” model for
price setting (for further details, see Vertrees & Manton, 1986). In spite of
the formal sophistication of the payment model, the initial budget allocation
was more indicative than normative. Because budget overruns are covered by
supplementary allocations, the activity-based system had limited incentives to
encourage cost-containment or efficient practices. This system was abandoned
in 2001 in favour of a group classification derived from clusters based on
principal components analysis.
Health subsystems and private insurance schemes reimburse NHS hospitals
retrospectively on a case-by-case basis for inpatient care and ambulatory surgery
(according to a DRG price list), and on a fee-for-service basis for ambulatory
services provided to their beneficiaries. Private insurers may use different
modes of reimbursement. In some cases, patients are expected to pay and then
be reimbursed retroactively for the cost of services. The insurance companies
also define networks of preferred providers, at which the patient only pays the
co-payment (the remaining being settled directly between the provider and the
insurance company). This method acts as an incentive for such patients to seek
treatment from contracted providers.
Payment of primary care centres
Primary care centres are responsible for delivering primary care. They do not
yet have financial or administrative autonomy. The Ministry of Health allocates
funds to the RHAs, which in turn fund the global activity of each health centre
through the recently created groups of primary care centres (
Agrupamentos de
Centros de Saúde
, ACES). The contract (
contrato-programa
) of each ACES,
which is responsible for primary care delivery in a given geographical area, is
negotiated between the ACES and the RHA.