Lebanon - What is GIS - World Health Organization

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Lebanon Role of contractual arrangements in improving health system performance 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.
Lebanon Role of contractual arrangements in improving health system performance 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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Lebanon - What is GIS - World Health Organization

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