The role of contractual arrangements in improving health sector ...

Lebanon
supervision of quality of care, and no way of enforcing certain standards or to link
hospitalization with preventive services. There is also bilateral distrust; the Ministry of Public
Health worries about abuse, while private hospitals see undue financial and regulatory pressures
by the Ministry at a time of fiscal difficulty. With the lack of sufficient political support for better
use of contractual arrangements to change the public health agenda, many see current
arrangements for hospitalization as facilitating public–private cash transfers that do not serve the
public in the long term.
The publicly insured population
Contractual arrangements for hospitalization are remarkably similar across the different
financing agencies, such as NSSF, CSC and others. These agencies contract with most private
hospitals licensed by the Ministry of Public Health (they do not use the Ministry’s accreditation
system). Interested hospitals apply to the concerned agency to provide services for beneficiaries.
Most of these hospitals are private, as public hospitals account for less than 5%. Site visits are
carried out to ensure eligibility. Hospitals sign standard contracts which stipulate responsibilities
of each party. Financing agencies have rotating or stationary supervising physicians who approve
indication for admission, assess appropriateness of care, and review bills either on-site (done by
the same supervising physician) or at central offices (done by different physicians). Some
agencies, like NSSF, use advisory committees to review applications for coverage of expensive
cases. Medical admissions are reimbursed on a fee-for-service basis. Different agencies have
different pay scales but all commonly use flat rates for many (but not all) surgical procedures and
fee-for-service for medical hospitalization.
The case of invasive interventions for coronary heart disease
Lebanon has undergone an epidemiological transition, and chronic diseases, especially
cardiovascular diseases, account for an important portion of mortality, morbidity and health care
expenditure. Coronary heart disease consumes considerable resources. Invasive interventions for
coronary heart disease, including coronary artery bypass surgery (CABG) and percutaneous
interventions (PCI) such as balloon angioplasty and stent implantation, account for a
considerable portion of the costs related to coronary heart disease. Nevertheless, coronary heart
disease is a medical, not surgical, disease and much can be accomplish to reduce related
mortality, morbidity and health care costs through well-proven and cost-effective secondary
prevention approaches. These approaches include medical therapies, such as aspirin, blood
pressure and cholesterol lowering agents, and behavioural and lifestyle modification, such as
smoking cessation and physical activity. Secondary prevention approaches are, however, grossly
underutilized in patients with coronary heart disease. This is especially striking considering the
well-described overuse of invasive interventions. Furthermore, lack of adequate emphasis on
secondary prevention leads to more costly invasive interventions in people with established
coronary heart disease. In addition to high costs and missed opportunities to improve health
outcomes, overuse of invasive interventions exposes potential conflict of interest in which the
health care facilities and physicians may be entangled to secure more lucrative benefits.
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