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

Lebanon
Correcting this imbalance by emphasizing secondary prevention should be a main focus of
public health action to control coronary heart disease.
In Lebanon there is a gross oversupply of high-tech facilities for performing invasive
interventions for coronary heart disease, and oversupply of super-specialists to perform them. As
a result, Lebanon has much higher than expected rates of CABG and PCI for coronary heart
disease.
• There are 35 centres for PCI and 22 centres for CABG. For CABG, this oversupply (1 per
180 000 population) contrasts with the availability of similar facilities in an industrialized
country such as France, where there is currently 1 CABG centre for each 700 000 population.
More recently, there is a move to consolidate centres in France to the ratio of 1 per 2 million
people. These large centres reduce costs and offer great opportunities for research and
development. The situation in Lebanon is not expected to change, even after the
implementation of the health map, due to the dominant effect of current oversupply.
• In Lebanon, 4000–4500 CABGs are carried out per year at a cost of around US$ 5500 per
procedure for the Ministry of Public Health, and up to US$ 10 000 for other financing
agencies. The Lebanese rate of CABG (1/900) exceeds that of France (1/1000). This is
surprising because France has a population that is considerably more aged than Lebanon, and
thus Lebanon would be expected to require CABG far less often (1/1300–1/1500).
The Ministry of Public Health and other financing parties can use the contract with
hospitals to encourage utilization of secondary prevention services to achieve several goals:
improve outcomes, improve quality of care, reduce costs, and link inpatient with outpatient care.
There are several steps that can be taken.
• An additional amount per patient can be appended to the hospital bill per CABG to ensure
follow-up of key risk factors such as cholesterol, blood pressure and smoking practices on
regular intervals during the first year (the most risky period) after hospitalization. Such
services can be added at bare cost price and would prove to be very cost-effective for
improving outcomes. This is especially important for citizens covered by the Ministry of
Public Health who lack insurance for ambulatory care. Alternative mechanisms for linking
hospitalization with care provided at primary care centres also need to be explored.
• The current oversupply of centres which offer CABG must be consolidated. For example, a
minimum number of CABGs per centre per year must be demonstrated before a hospital is
contracted for CABG services.
• Compliance in provision of secondary prevention care before the patient leaves the hospital
and after hospitalization needs to be demonstrated.
• The ability of the supervising physicians to ensure proper utilization must be improved.
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