Primary healthcare in Portugal: 10 years of contractualization of health services in the region of Lisbon

Monteiro, Baltazar Ricardo; Pisco, Ana Maria Silva Azenha; Candoso, Fátima; Bastos, Sónia; Reis, Magda

doi:10.1590/1413-81232017223.33462016

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ARTICLE • Ciênc. saúde colet. 22 (3) • Mar 2017 • https://doi.org/10.1590/1413-81232017223.33462016 copy

Primary healthcare in Portugal: 10 years of contractualization of health services in the region of Lisbon

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Contractualization consists in the development and implementation of a documented agreement whereby one party (payer) provides compensation to the other party (provider) in exchange for a set of health services to a targeted population. We describe, through a case study, the history and the process of implementation of primary health care contractualization (since 1992) in Portugal, emphasizing the consolidation and future challenges of the primary healthcare reform started in 2005. This article resorts to a case study to reflect on the results obtained in the Cluster of Health Centers of the Northern West, Regional Administration of Lisbon and Tagus Valley, between 2009 and 2015, following implementation of contractualization. It was found that the incentive-related payments will have to be weighted considering the results obtained, strongly influenced by epidemiological and socioeconomic change.

Contractualization; Primary healthcare

	Residents	Population Density	Proportion of Women	Birth Rate	Mortality Rate	Dependence Rate	Aging Rate
Locations	Nº	/ km2	%	LB /1000 inhabitants	Deaths/1,000 inhabitants	/100 inhabitants [15; 65[Years	/100 inhabitants [0; 15[Years
Alcobaça	56.688	138,9	51,6	7	10,2	40,2	141,3
Bombarral	13.193	144,5	51,8	9,3	14,9	44,9	172,5
Caldas da Rainha	51.729	202,3	52,6	8,1	10,8	40,6	143,5
Nazaré	15.158	183,9	52,3	9,3	11,9	38,5	145
Óbidos	11.772	83,2	51,4	6,9	9,7	42,4	150,8
Peniche	27.753	357,9	51,6	7,9	12,2	39,6	138,4
ACES Northern West	176.293	166,8	51,9	7,8	11,2	40,6	144,6
ARS Lisbon and Tagus Valley	3.659.871	299,9	52,5	10,4	9,6	36,7	124,4
Continental Portugal	10.047.621	112,8	52,2	9,1	9,8	37,3	130,6

Indicator		Performed in 2015		Performed in 2014		Performed in 2013		Performed in 2012
		ACeS Northern West	ARSLVT	ACeS Northern West	ARSLVT	ACeS Northern West	ARSLVT	ACeS Northern West	ARSLVT
National level
Access	Rate of medical consultations use - 3 years	89,0%	78,9%	89,00%	79,9%	89,4%	80,3%	90,9%	79,6%
Access	Household nursing rate per 1,000 enrollees	151,4 ‰	124,9 ‰	158,2 ‰	127,6 ‰	155,5 ‰	127,2 ‰	136,2‰	105,8 ‰
Care performance	Proportion of participants > = 14 A, with smoking habits	53,6%	45,2%	46,60%	37,9%	34,9%	26,9%	25,2%	17,3%
	Adequate FP follow-up in WCA	0,6%	0,507%	0,561%	0,469%	33,1%	21,0%	14,7%	7,5%
	Proportion of low birthweight term newborns	3,04%	2,51%	2,17%	2,56%	1,70%	2,40%	3,04%	3,31%
	Proportion of young people aged 14 with current medical consultation and NIP	63,3%	48,0%	61,4%	45,1%	43,7%	36,1%	36,0%	28,4%
	CVD hospitalization rate among residents <65 years	8,8%	9,2%	6,74%	8,5%	9,0%	9,9%	7,8%	9,5%
	Incidence of major lower limb amputations (DM) in residents	0,3%	0,4%	0,45%	0,5%	0,5%	0,5%	0,9%	0,7%
	Proportion elderly, without anxiolytics / sedatives / hypnotics	67,2%	67,8%	66,50%	68,2%	65,7%	66,6%	64,6%	65,3%
	Proportion of face-to-face medical consultations with ICPC-2	92,2%	89,5%	84,60%	84,3%	82,8%	77,6%	74,3%	70,0%
	Proportion of prescription drugs that are generic	61,0%	59,4%	57,60%	55,7%	45,4%	43,0%	41,0%	38,7%
Efficiency	Billed drugs expenditure per user (PVP)	140,8 €	138,3 €	141,50 €	149,1 €	138,1 €	133,5 €	156,0 €	154,4 €
Efficiency	Billed MCDT expenditure, per SNS user (p. conv.)	51,6 €	--	49,30 €	63,4 €	42,3 €	52,7 €	44,7 €	54,8 €
Regional level
Care performance	Proportion of women [50; 70[years, w/ mammography (2 years)	63,1%	49,3%	63,20%	47,2%	58,3%	46,6%	54,3%	44,4%
	Proportion users [50; 75[years,w/ cancer screening CR	37,6%	36,6%	28,70%	31,2%	18,7%	23,6%	14,9%	18,8%
	Proportion of women [25; 60[ years, w/ colposcopy (3 years)	51,7%	37,7%	48,50%	35,9%	43,2%	33,3%	35,9%	28,5%
	Proportion DM2 in insulin therapy	78,1%	71,3%	73,20%	61,7%	4,8%	3,7%	4,5%	3,4%
Local level
Hypertension	Proportion of hypertensive with CV risk (3 years)	52,9%	35,4%	41,3%	26,8%	9,5%	7,7%	--	--
S. Adults	Proportionof hypocoagulated patients in the facility	49,3%	50,0%	43,7%	19,1%	18,0%	12,2%	--	--

Disease	ACeS Northern West			ARSLVT
Disease	2013	2014	2015	ARSLVT
Acute myocardial infarction	1,7	1,24	0,96	0,85
Stroke	3,1	2,8	1,72	1,71
Transient ischemic attack	0,6	0,45	0,38	0,38
Diabetes mellitus	15,6	13,2	8,19	7,61
Hypertension	42,3	37,1	21,5	20,6
Obesity	12,3	9,8	10,6	12,1
Lipid metabolism disorder	40,9	34,2	21,7	19
Tobacco addiction	22,6	26,6	16,2	14
COPD	2,1	2,17	1,99	2,06
Asthma	5,1	4,44	2,98	2,95
Anxiety disorder	4,4	5,17	5,98	3,73
Feeling of anxiety	1,8	2,26	2,51	2,3
Depressive disorders	6,1	6,6	8,95	5,56
Postpartum depression	0	0,03	0,03	0,02
Chronic alcohol abuse	0,6	0,62	0,75	0,71
Drug abuse	0,3	0,38	0,43	0,35

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[1] Collaborations

BR Monteiro was responsible for data collection, writing, critical review and version to be published; AMSA Pisco, for data collection, analysis and writing; F Candoso, for data analysis and paper critical review; M Reis for data collection and interpretation; and S Bastos for data analysis and interpretation.