ABSTRACT

The state of São Paulo has adopted a financial incentive program for philanthropic hospitals. The objective of this study was to analyze the performance of the hospitals participating in this program in 2012. Performance indicators were analyzed according to hospital size and municipal size, using the Proadess performance model (Evaluation of Health System Performance). There was a difference in the performance of the hospitals according to the size: small hospitals presented unfavorable results in relation to the indicators of access, efficiency and effectiveness. This result corroborates the need to reassess financial incentive programs for small hospitals configured as general hospitals.

KEYWORDS
Hospital administration; Health services; Service indicators; Health management; Hospital services

Introduction

In the state of São Paulo, philanthropic hospitals and, in particular, Holy Houses of Mercy are responsible for an important portion of hospital care offered to the Unified Health System (SUS)¹1 Bittar OJNV, Mendes JDV, Magalhães A. Rede Hospitalar no Estado de São Paulo: mapear para regular [monografia]. São Paulo. SESSP; 2011. 54p.. In 2012, of the total number of hospitals that provided care to SUS, more than 66% of the institutions were of a philanthropic nature, according to data from the National Registry of Health Establishments (CNES) ²2 Ramos MCA, Cruz LP, Kishima VC, et al. Avaliação de desempenho de hospitais que prestam atendimento pelo sistema público de saúde, Brasil. Rev. Saúde Pública. Universidade de São Paulo, 2015..

The increase of costs in hospital care (due to the demographic and epidemiological transitions), the technological advance and the need to improve the quality of care provided by the Holy Houses and philanthropic hospitals led to the proposal of a program of financial support to these institutions ¹1 Bittar OJNV, Mendes JDV, Magalhães A. Rede Hospitalar no Estado de São Paulo: mapear para regular [monografia]. São Paulo. SESSP; 2011. 54p.. This program was settled and approved by the Bipartite Interagency Commission (BIC) of the state of São Paulo, in 2007 and 2009, with the objective of financially supporting philanthropic entities responsible for hospital health services of regional reference of the SUS and improving regional organization and quality of hospital care. The number of participating hospitals was established according to the population size of each Health Region (HR): up to 80.000 inhabitants, one hospital; from 80.000 to 200.000 inhabitants, two hospitals; from 200.000 to 400.000 inhabitants, three hospitals; and more than 400.000 inhabitants, four hospitals, regardless of whether they are under state or municipal management ³3 São Paulo (Estado). Deliberação CIB nº 232, de 27 de novembro de 2007. Aprovar o Programa Pró-Santa Casa - 2008. Diário Oficial do Estado. 2017 Dez. 11.^,44 São Paulo (Estado). Deliberação CIB nº 51, de 17 de setembro de 2009. Nota Técnica sobre o Programa Pró-Santa Casa 2. Este programa substitui o atual Programa Pró-Santa Casa. Diário Oficial do Estado. 2009 Set. 23.. The total value of the incentive to be granted was also set based on the same population criteria: regions with up to 80 thousand inhabitants, R$30.000,00 monthly; regions with between 80 and 200 thousand inhabitants, R$100.000,00 monthly; regions with between 200 and 400 thousand inhabitants, R$200.000,00 monthly; and regions with more than 400 thousand inhabitants, R$450.000,00 per month ³3 São Paulo (Estado). Deliberação CIB nº 232, de 27 de novembro de 2007. Aprovar o Programa Pró-Santa Casa - 2008. Diário Oficial do Estado. 2017 Dez. 11.^,44 São Paulo (Estado). Deliberação CIB nº 51, de 17 de setembro de 2009. Nota Técnica sobre o Programa Pró-Santa Casa 2. Este programa substitui o atual Programa Pró-Santa Casa. Diário Oficial do Estado. 2009 Set. 23..

It was agreed that these Philanthropic Hospital Units (PHU) should present minimum criteria to be covered by this financial incentive: more than 30 hospital beds, demonstrate regional or micro-regional coverage and compliance with standards and procedures with surveillance instances, auditing and other. Hospitals that provided predominant care for chronic and psychiatric patients and those who only provided ambulatory care were excluded from the program. They were established as mandatory conditions for the inclusion of hospitals in the program the availability of 100% of the SUS beds to the competent regulatory body and other outpatient procedures defined and prioritized by the corresponding Regional Interagency Committee (RIC) ³3 São Paulo (Estado). Deliberação CIB nº 232, de 27 de novembro de 2007. Aprovar o Programa Pró-Santa Casa - 2008. Diário Oficial do Estado. 2017 Dez. 11.^,44 São Paulo (Estado). Deliberação CIB nº 51, de 17 de setembro de 2009. Nota Técnica sobre o Programa Pró-Santa Casa 2. Este programa substitui o atual Programa Pró-Santa Casa. Diário Oficial do Estado. 2009 Set. 23..

The financial values to be transferred would be shared among the managers: 70% of the state manager and 30% of the municipal managers. The selection of the PHU beneficiaries was delegated to the RIC, as well as the definition of the corresponding incentive values within the limit established by HR ³3 São Paulo (Estado). Deliberação CIB nº 232, de 27 de novembro de 2007. Aprovar o Programa Pró-Santa Casa - 2008. Diário Oficial do Estado. 2017 Dez. 11..

Figure 1 shows the distribution of selected hospitals, according to HR and the Regional Health Department (RHD), for 2012.

The description and analysis of the hospital performance indicators of these PHUs contemplated by the financial incentive would contribute to directing the reformulation of the adopted election criteria. It is, therefore, opportune to investigate the performance of these institutions, to recognize qualifying elements, and to promote adjustments to subsidize the formulation of new incentive policies.

The objective of this study was to analyze the performance of hospitals participating in the financial incentive program to philanthropic hospitals in the state of São Paulo, in 2012.

Methods

A cross-sectional descriptive study with secondary data was performed. In 2012, the state of São Paulo was organized in 64 HR, all of them with constituted RIC. All HR indicated philanthropic hospitals to participate in the financial assistance, except for the Metropolitan Region of São Paulo, where only one of the six RICs indicated a hospital unit.

The present study contemplated the description of the indicators of all PHU included in the financial incentive program in 2012.

The selected performance indicators and the variables of hospital size and municipal size were described. The hospital size variable was organized according to the stratum of number of beds by PHU, adopting to the composition of the strata the orientation indicated by the Ministry of Health (MH) ⁵5 Brasil. Coordenação de Assistência Médica e Hospitalar. Secretaria Nacional de Ações Básicas de Saúde. Conceitos e Definições em Saúde. Brasil. Brasília, DF: Ministério da Saúde; 1997.^,66 Brasil. Secretaria Nacional de Ações Básicas de Saúde. Coordenação de Assistência Médica e Hospitalar. Portaria no 2.224, de 6 de dezembro de 2002. Conceitos e Definições em Saúde. Diário Oficial da União. Brasil. Brasília, DF: Ministério da Saúde; 1977.: small size, less or equal to 50 beds; medium size, from 51 to 150 beds; and large size, with more than 150 beds (GM Ordinance nº 2.224, December 2002). The variable municipal size was organized according to the stratum of number of inhabitants per municipality: small size - less than 50.000 inhabitants; medium size - from 50.000 to less than 100.000 inhabitants; large size - 100.000 inhabitants or more.

The performance indicators described were selected according to the quality criteria established by McGlynn ⁷7 Mcglynn EA. Selecting Common Measures of Quality and System Performance. Medical Care, California.2003; 41(supl.):39-47.: reliability, feasibility, uses and limitations. The indicators were classified according to the sub-dimensions, adapted from the model proposed by the Performance Evaluation of the Brazilian Health System (Proadess) ⁸8 Viacava F, Almeida C, Caetano R, et al. Uma metodologia de avaliação do desempenho do sistema de saúde brasileiro. Ciênc. Saúde Colet. Associação Brasileira de Saúde Coletiva. Rio de Janeiro. 2004; 9(3): 711-724.. The sub-dimensions adopted for analysis of the performance dimension were access, adequacy, effectiveness and efficiency. The indicators used were: access - number of outpatient procedures per month, number of hospitalizations and number of deliveries per month; efficiency - hospital occupancy rate, average length of stay, proportion between the value of the incentive program and the amount paid for SUS production; effectiveness - percentage of Hospitalizations for Conditions Sensitive to Basic Care (ICSAB); and adequacy - hospital mortality rate and cesarean rate (chart 1).

The main sources of data were: CNES ⁹9 Cadastro Nacional de Estabelecimentos de Saúde [internet]. Departamento de Informática do SUS (Datasus) [acesso em 2012 dez 5]. Disponível em: http://www.cnes.datasus.gov.br/.
http://www.cnes.datasus.gov.br/... , Outpatient Information System of SUS (SIA/SUS) ¹⁰10 Ministério da Saúde (Brasil). Tabnet [internet]. Departamento de Informática do SUS (Datasus). [acesso em 2017 jun 10]. Disponível em: http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sia/cnv/qisp.def.
http://tabnet.datasus.gov.br/cgi/deftoht... , Hospital Information System of the SUS (SIH/SUS) ¹¹11 Ministério da Saúde (Brasil). Tabnet [internet]. Departamento de Informática do SUS (Datasus). [acesso em 2017 jun 10]. Disponível em: http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sih/cnv/qisp.def.
http://tabnet.datasus.gov.br/cgi/deftoht... . Demographic data were obtained from the Brazilian Institute of Geography and Statistics (IBGE) ¹²12 Ministério da Saúde (Brasil). Tabnet [internet]. Departamento de Informática do SUS (Datasus). [acesso em 2012 dez 10]. Disponível em: http://tabnet.datasus.gov.br/cgi/deftohtm.exe?ibge/cnv/popsp.def.
http://tabnet.datasus.gov.br/cgi/deftoht... .

The statistical measures used to describe the indicators were: median, 25h percentile (P25), 75th percentile (P75). The analysis of the indicators was performed according to hospital size and municipal size.

The data used in this study were obtained from the official information systems, available for public access. Data on the institutions that make up this financial aid program were provided by the State Department of Health of São Paulo (SESSP) ¹³13 São Paulo. Secretaria de Estado da Saúde de São Paulo. Matriz de Indicadores de Saúde do Estado de São Paulo, 2012 [internet]. [acesso em 2017 maio 5]. Disponível em: http://www.saude.sp.gov.br/ses/perfil/gestor/informacoes-de-saude/matriz-de-indicadores-de-saude-atualizado/.
http://www.saude.sp.gov.br/ses/perfil/ge... , also with public access.

Results

Of the total of 112 PHU, 13 (12%) were small size, 72 (64%) were medium size and 27 (24%) were large size (table 1). The indicators were analyzed by dimension according to hospital size and municipal size. It was observed that a small PHU was indicated by the RIC in a large municipality, and a large PHU, located in a small municipality. In the group of municipalities of medium size no small hospital was found benefited.

In the analysis of the performance indicators, it was observed that the three access indicators (number of outpatient procedures per month, number of hospitalizations per month and number of deliveries per month) had a positive relation with the size of the PHU and the size of the municipality: the larger the indicator, the larger the hospital size (table 2). This relation was maintained after a stratified analysis by municipalities (table 3): large size hospitals in large size municipalities presented a number of hospitalizations per month 8.5 times greater, and a number of births per month 8.9 times higher.

The percentage of ICSAB, an indicator of effectiveness, was 1.7 times higher in PHU of small size (27.7%) than in large ones (16%). In the analysis stratified by municipality, these small PHUs in small municipalities presented a percentage 8 times greater of ICSAB in relation to large hospitals in large municipalities. In large municipalities, the performance of ICSAB has remained worse in small PHUs.

In the efficiency sub-dimension, the occupancy rate was higher in PHU of large size (79.6%), and the performance of the small PHU was 2.1 times smaller. Regarding the averages of permanence, the differences according to the size were not as expressive: the larger PHU presented 1.5 times more average of permanence than the smaller ones, a result that was not modified by the analysis stratified by size of municipality. The median of the proportion of the benefit value in relation to the output approved by the SUS production of the hospital was four times higher in small hospitals compared to large hospitals. It is noteworthy that in a quarter of small hospitals this figure was higher than 55%. After stratifying the analysis by size of municipalities, this difference remained, and it was observed that a small PHU located in a large municipality had a higher percentage - 57.4%.

Regarding adequacy indicators, the hospital mortality rate observed in the small and medium-sized group of hospitals increases by 2.5 times when these hospitals are located in larger municipalities. This same relation was not verified for the group of large hospitals. The median cesarean rate presented a smaller variation in relation to the hospital size, with a 51.5% increase in small size, to 57.5% in large size. It was possible to observe that the largest cesarean rate occurred in a large PHU in a small municipality (86.5%).

Discussion

The aim of this incentive program for philanthropic hospitals was to provide financial support to philanthropic entities that provided health services, such as general hospitals, which constituted regional references, as well as to improve the territorial organization and quality of hospital care. The selection strategy of these hospitals that would be contemplated by the incentive was given by the indication of the RIC, with the use of election criteria agreed in BIC. The distribution according to the hospital size of the PHU contemplated by the financial incentive program showed that the indication prioritized the medium and large hospitals. However, approximately 12% were small PHUs. The PHUs of small hospital size presented an unfavorable performance, especially in the indicators of access, effectiveness and efficiency. In Brazil, and also in the state of São Paulo, studies have indicated worse performance evaluations among small hospitals ¹1 Bittar OJNV, Mendes JDV, Magalhães A. Rede Hospitalar no Estado de São Paulo: mapear para regular [monografia]. São Paulo. SESSP; 2011. 54p.^,22 Ramos MCA, Cruz LP, Kishima VC, et al. Avaliação de desempenho de hospitais que prestam atendimento pelo sistema público de saúde, Brasil. Rev. Saúde Pública. Universidade de São Paulo, 2015.^,1414 Mendes JDV, Cecilio MAM, Osiano VLRL. Hospitais de Pequeno Porte no SUS do estado de São Paulo. Boletim Epidemiológico Paulista. São Paulo. 2014; (11):127-128.^,1515 Cunha LF, Bahia L. Construção de hospitais de pequeno porte como política de saúde: um caso emblemático no estado de Maranhão, Brasil. Journal of Management and Primary Health Care, América do Norte. 2014; 6(2): 248-254..

The observed performance of the access indicators was positively related to hospital and municipal transport, that is, the larger the size, the better the performance. This result is expected and determined by the existing hospital structure, that is, by the installed capacity of the larger PHUs and by the greater demand in municipalities with larger population sizes ¹⁶16 Souza RR, Mendes JDV, Barros, coordenadores. Pactuação em saúde. In: Vinte anos do SUS São Paulo. São Paulo. Secretaria de Estado da Saúde; 2008. p. 69-80.^,1717 Bittar OJNV. Produtividade em hospitais de acordo com alguns indicadores hospitalares. Revista de Saúde Pública. Faculdade de Saúde Pública. Universidade de São Paulo. 1996; 30(1):53-60. However, it should be noted that the small general PHUs presented a very restricted service offer, which could be better organized in the regional health service system. As has been pointed out in other publications, these hospitals do not present economies of scale, and there is a direct relationship between quality and quantity of procedures ¹1 Bittar OJNV, Mendes JDV, Magalhães A. Rede Hospitalar no Estado de São Paulo: mapear para regular [monografia]. São Paulo. SESSP; 2011. 54p.^,22 Ramos MCA, Cruz LP, Kishima VC, et al. Avaliação de desempenho de hospitais que prestam atendimento pelo sistema público de saúde, Brasil. Rev. Saúde Pública. Universidade de São Paulo, 2015.^,1414 Mendes JDV, Cecilio MAM, Osiano VLRL. Hospitais de Pequeno Porte no SUS do estado de São Paulo. Boletim Epidemiológico Paulista. São Paulo. 2014; (11):127-128.^,1515 Cunha LF, Bahia L. Construção de hospitais de pequeno porte como política de saúde: um caso emblemático no estado de Maranhão, Brasil. Journal of Management and Primary Health Care, América do Norte. 2014; 6(2): 248-254..

The effectiveness indicator, percentage of ICSAB, was higher in small size hospitals, even when located in larger municipalities. This result was similar to that found in 2013 in the universe of hospitals in the state of São Paulo with less than 50 beds, in which the percentage of ICSAB was 29% ¹⁴14 Mendes JDV, Cecilio MAM, Osiano VLRL. Hospitais de Pequeno Porte no SUS do estado de São Paulo. Boletim Epidemiológico Paulista. São Paulo. 2014; (11):127-128.. The provision of services in small general hospitals contributes to unnecessary hospitalizations ²2 Ramos MCA, Cruz LP, Kishima VC, et al. Avaliação de desempenho de hospitais que prestam atendimento pelo sistema público de saúde, Brasil. Rev. Saúde Pública. Universidade de São Paulo, 2015.. This high proportion of hospitalizations of simpler cases, often unnecessary, may indicate that the urgent care of cases with low complexity, which should be resolved in the basic care network, was performed by these small hospitals. In addition, the high percentage of ICSAB may indicate a lack of quality and a lack of articulation in the Regional Health Care Network (RRAS) ¹⁸18 Nedel FB, Facchini LA, Martín-Mateo M, et al. PSF e condições sensíveis à atenção primária. Revista de Saúde Pública. Faculdade de Saúde Pública. Universidade de São Paulo. 2008; (42):1041-1052..

In relation to the indicators of occupancy rate, efficiency indicator, the performance of all PHU was lower than that found for all hospital units with SUS service in the state in 2013 (67%). Regarding small hospitals, performance was similar ¹¹11 Ministério da Saúde (Brasil). Tabnet [internet]. Departamento de Informática do SUS (Datasus). [acesso em 2017 jun 10]. Disponível em: http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sih/cnv/qisp.def.
http://tabnet.datasus.gov.br/cgi/deftoht... . The result of the poorer performance of this indicator in small hospitals, as compared to large ones, corroborates the findings in other studies conducted in the state of São Paulo ¹1 Bittar OJNV, Mendes JDV, Magalhães A. Rede Hospitalar no Estado de São Paulo: mapear para regular [monografia]. São Paulo. SESSP; 2011. 54p.^,22 Ramos MCA, Cruz LP, Kishima VC, et al. Avaliação de desempenho de hospitais que prestam atendimento pelo sistema público de saúde, Brasil. Rev. Saúde Pública. Universidade de São Paulo, 2015.^,1414 Mendes JDV, Cecilio MAM, Osiano VLRL. Hospitais de Pequeno Porte no SUS do estado de São Paulo. Boletim Epidemiológico Paulista. São Paulo. 2014; (11):127-128.. The apparent idleness of beds, demonstrated by occupation rates below 80%, should be examined considering the differences between the different clinics, which reflect the changing demographic and epidemiological profiles and the existence of great regional inequalities, not only in the supply of beds, but also in its complexity and resolubility. Economies of scale can be found in hospitals with more than 100 beds, due to the direct relationship between quality and quantity ¹⁶16 Souza RR, Mendes JDV, Barros, coordenadores. Pactuação em saúde. In: Vinte anos do SUS São Paulo. São Paulo. Secretaria de Estado da Saúde; 2008. p. 69-80.^,1919 Bittar OJNV. Indicadores de qualidade e quantidade em saúde. São Paulo. Revista de Administração em Saúde. Associação Brasileira de Medicina Preventiva e Administração em Saúde. São Paulo. 2001 Jul-Set; 3(12):21-28..

The cost of financing small size hospitals is disproportionately high compared to their low efficiency ¹1 Bittar OJNV, Mendes JDV, Magalhães A. Rede Hospitalar no Estado de São Paulo: mapear para regular [monografia]. São Paulo. SESSP; 2011. 54p.^,1515 Cunha LF, Bahia L. Construção de hospitais de pequeno porte como política de saúde: um caso emblemático no estado de Maranhão, Brasil. Journal of Management and Primary Health Care, América do Norte. 2014; 6(2): 248-254.. Another efficiency indicator used was the amount of value allocated by the incentive program on the financial value received by the SUS production, which was much higher for small PHUs compared to large PHUs - four times higher. In 25% of small-scale UHFs, this resource accounted for more than half of the financial value received by SUS production, a result that indicates difficulties in the sustainability of these PHUs and their dependence on the incentive program to maintain their operation. In addition, the distribution of the proportions found evidences the need to revise the current criterion: the proportional distribution of the number of hospitals contemplated according to the size of the regions, a factor that could have led to distortions in the indication of hospitals. In one of the HR, a small philanthropic hospital was indicated, even though there were other larger public hospitals in the region, only to complete the PHU quota contemplated by HR. This result points to the fragility of the PHU election criterion benefited by this program.

Regarding the adequacy indicators, the worst performance in a small PHU in a large municipality was noticed. The institutional mortality found was twice as high in small PHU, located in a larger municipality, in relation to the PHU located in a small municipality. This result was not as expected. In the evaluation of hospital mortality, the concern should be focused on identifying the deaths that could be avoided by the hospital, but also reflects the severity of demand. In hospitals that are more complex, this rate could be high due to the severity of the cases treated ²⁰20 Travassos C, Noronha JC, Martins M. Mortalidade hospitalar como indicador de qualidade: uma revisão. Ciênc. Saúde Colet. Associação Brasileira de Saúde Coletiva. Rio de Janeiro. 1999; (4):367-381., however, such an analysis should be carried out with caution, since only a single small PHU was contemplated with the incentive program in one large municipality. Institutional mortality rates can be considered as a possible indicator to discriminate services with different performance in the quality of the patient care process ²⁰20 Travassos C, Noronha JC, Martins M. Mortalidade hospitalar como indicador de qualidade: uma revisão. Ciênc. Saúde Colet. Associação Brasileira de Saúde Coletiva. Rio de Janeiro. 1999; (4):367-381.^,2121 Martins M, Blais R, Leite IC. Mortalidade hospitalar e tempo de permanência: comparação entre hospitais públicos e privados na região de Ribeirão Preto, São Paulo, Brasil. Cad. saúde pública. Escola Nacional de Saúde Pública Sergio Arouca. Rio de Janeiro; 2004; 20(supl.2):S268-S282..

Medium size and large size hospitals showed a higher cesarean rate, regardless of the size of the municipality. One of the large PHUs located in a small township presented a caesarean rate approximately six times higher than what is recommended by the World Health Organization ²²22 World Health Organization. Appropriate technology for birth. Lancet. 1985; 326(8452):436-437..

Therefore, one may raise some limitations related to the data sources used. The largest of these refers to the CNES. This data source does not always accompany the changes, which occur in institutions, which, as a consequence, can cause distortions in some of the selected performance indicators ²³23 Escrivão JRA. Uso da informação na gestão de hospitais públicos. Ciênc. Saúde Colet. Associação Brasileira de Saúde Coletiva. Rio de Janeiro. 2007; 12(3):655-666..

Another limitation concerns the production data used that were approved by the SIA and SIH system, and there may be differences between the procedures presented by the supplier and those approved, that is, it is possible that the production was higher than the one obtained ²⁴24 Rede Interagencial de Informações para a Saúde - RIPSA. Indicadores Básicos para a Saúde no Brasil. 2.ed. Brasília, DF. 2008..

Meeting the health needs of the population must always be the central objective of a health system. Health services are an integral part of the system, whose performance influences the living conditions and determinants of health ²⁵25 Buss PM, Pellegrini Filho A. Saúde e seus Determinantes Sociais. Physis. Instituto de Medicina Social. Universidade do Estado do Rio de Janeiro. 2007; 17(1):77-93.. The confrontation of a health condition must be done by providing people with the complete cycle of care for them, that is, in a health care network ¹⁶16 Souza RR, Mendes JDV, Barros, coordenadores. Pactuação em saúde. In: Vinte anos do SUS São Paulo. São Paulo. Secretaria de Estado da Saúde; 2008. p. 69-80.. Financial aid to health services needs to consider the regional context, existing health services, and how they are organized. The hospital is a point of attention for these networks, and it is up to public managers to define the role of the institution in the network and to monitor their performance.

A program of financial assistance to health services should aim to improve the health of the population, always considering the characteristics of the territory in which the service is located. The role it should and would have to play would be based on a regional planning that would take into account, in addition to its physical and human resources structures, the range of health services in the territory, the conditions of access and the regional context. Thus, as proposed by the incentive program, the indication of the institutions to be covered by this financial aid should continue to be attributed to the RIC. However, the criteria for indication and financial figures to be given to each hospital, as well as the appropriateness of funding for small hospitals, would need to be reviewed.

Conclusions

This result corroborates the need to reassess financial incentive programs, especially for small hospitals configured as general hospitals. The financial incentive program should be directed to PHU that present good performance and articulation with the other points of attention of the network, in a more favorable relation of investment and quality of care.

Acknowledgements

To the Professors Dr. José Nogueira Viana Bittar, Oziris Simões and Arnaldo Sala for the fundamental contributions added to this work.

References

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History