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Abstract(s)
Em Portugal, existe a ideia generalizada de que o setor público da saúde é mal gerido e é
ineficiente. Apesar desta ideia, desconhece-se a extensão global do desperdício e não se sabe
se todas as organizações públicas prestadoras de cuidados de saúde são igualmente
ineficientes. A definição das medidas de gestão adequadas depende crucialmente desta
informação. Além disso, neste debate, os centros de saúde são normalmente relegados para
um segundo plano apesar de os cuidados de saúde primários serem chamados a desempenhar
um papel cada vez mais importante na procura de sistemas de saúde globalmente mais
eficientes.
Na literatura, existe uma discussão sobre a melhor forma de medir a eficiência das unidades
produtivas. Entre as críticas à aplicação dos métodos de fronteira de medição da eficiência,
refere-se frequentemente que a precisão das estimativas resultantes destes métodos depende
da utilização de modelos adequados e bem especificados.
Poucos são os artigos que estudam o papel de fatores exógenos, que fogem ao controlo das
unidades produtivas mas que influenciam fortemente o processo de produção. A maior parte
dos artigos que o fazem adota um procedimento em duas etapas que ignora a influência das
variáveis exógenas no momento em que a eficiência das unidades produtivas é medida.
Outros procedimentos calculam as estimativas de eficiência considerando simultaneamente os
fatores exógenos mas a aplicação destes procedimentos é uma abordagem pouco explorada.
Além disso, a abordagem paramétrica é de longe a abordagem menos utilizada para medir a
eficiência das unidades de saúde.
Neste trabalho, propomo-nos responder às seguintes perguntas de investigação:
1) Qual é o valor do desperdício do setor público da Saúde em Portugal? Quanto pode o
setor público da Saúde realmente poupar e simultaneamente continuar a prestar o
mesmo nível de cuidados?
2) Os cortes orçamentais devem ser proporcionalmente iguais em todas as unidades de
saúde? Em todos os hospitais e, ou, em todos os centros de saúde?
3) Qual é o custo mínimo de produção das unidades de saúde?
4) Agrupar os hospitais públicos portugueses pode torná-los mais eficientes?
5) Pode confiar-se nas estimativas dos métodos de fronteira de medição da eficiência,
designadamente nas estimativas dos métodos paramétricos? As estimativas são
sensíveis aos métodos de medição da eficiência? Estimamos as funções custo dos hospitais públicos portugueses e dos centros de saúde
portugueses e calculamos as suas estimativas de eficiência.
Estimamos as funções custo dos hospitais utilizando um modelo tradicional de fronteira
estocástica, um modelo de efeitos aleatórios, um modelo SUR, e um modelo com
heteroscedasticidade entre os hospitais. Estimamos as funções dos centros de saúde
utilizando um modelo tradicional de fronteira estocástica, um modelo SUR, e um modelo com
heteroscedasticidade entre os centros de saúde.
O cálculo dos níveis de eficiência decorre do pressuposto metodológico de que a diferença
entre os custos observados e os custos estimados resultam de choques aleatórios e de um
comportamento ineficiente.
Usamos dados longitudinais de 63 hospitais públicos portugueses do período 2002-2006 e
dados de corte transversal de 335 centros de saúde portugueses do ano de 2005. Optou-se por
utilizar dados destes períodos temporais em vez de utilizar dados de períodos mais recentes
porque estes períodos temporais possibilitam a recolha de informação homogénea.
Se, no período entre 2002 e 2006, o hospital médio da amostra tivesse sido totalmente
eficiente, ele teria gasto menos entre 24% e 33% do seu orçamento anual, i.e. entre 10.3 e
14.2 milhões de euros, sem reduzir o seu nível de prestação de cuidados de saúde.
Olhando para a globalidade da amostra dos hospitais, a poupança anual para o Serviço
Nacional de Saúde (SNS) português teria sido igual a entre 2.6 e 3.6 mil milhões de euros se
todos os hospitais da amostra tivessem sido eficientes.
Ao longo de todo o período entre 2002 e 2006, i.e. durante os cinco anos sob observação, o
SNS teria poupado entre 13 e 18 mil milhões de euros. Este valor corresponde a 1.6 e 2.3
vezes as transferências do Orçamento de Estado de 2016 para o SNS, que se prevê que sejam
iguais a 7.9 mil milhões de euros.
O indicador global de eficiência dos hospitais da amostra pertence ao intervalo 67%-76%. Isto
coloca os hospitais públicos portugueses a meio de uma tabela de hospitais internacionais
ordenados em função dos valores dos seus indicadores de eficiência. De acordo com a
literatura internacional, os hospitais localizados na Alemanha, nos Estados Unidos da América,
na Finlândia ou na Suíça, têm indicadores globais de eficiência iguais ou acima de 80%, e em
alguns casos, acima dos 90%. No grupo dos hospitais da amostra estão os hospitais espanhóis,
e dependendo do método de medição utilizado, os hospitais ingleses. Abaixo estão os
hospitais indianos com indicadores globais de eficiência na ordem dos 40%-50%. Se, no ano de 2005, o centro de saúde médio da amostra tivesse sido totalmente eficiente,
ele teria gasto menos entre 3% e 36% do seu orçamento anual, i.e. entre 0.2 e 2.4 milhões de
euros, sem reduzir o seu nível de prestação de cuidados de saúde.
Olhando para a globalidade da amostra dos centros de saúde, a poupança anual para o SNS
teria sido igual a entre 64 e 764 milhões de euros se todos os centros de saúde da amostra
tivessem sido eficientes.
Claramente, uns hospitais são mais eficientes do que outros e as diferenças de eficiência
entre eles podem ser muito significativas. Por exemplo, as estimativas da poupança potencial
do Hospital de São Sebastião variam entre 0% e 5% e as estimativas da poupança potencial do
Hospital Pulido Valente variam entre 40% e 46%. Isto também acontece com os centros de
saúde. Por esta razão, os cortes orçamentais não devem ser proporcionalmente iguais em
todos os hospitais e, ou, em todos os centros de saúde.
Com os mínimos e os máximos das estimativas de eficiência, e das estimativas de poupança
potencial das organizações de saúde, construíram-se intervalos de variação das estimativas.
Tendo em conta a grande dissemelhança dos métodos de medição da eficiência utilizados,
considera-se que os verdadeiros valores da eficiência, e os verdadeiros valores da poupança
que é possível realizar, estão necessariamente dentro dos limites destes intervalos.
O limite inferior dos intervalos diz-nos qual é o valor mínimo da poupança que é efetivamente
possível realizar. O limite superior dos intervalos diz-nos qual é o valor máximo a partir do
qual cortes orçamentais implicam forçosamente cortar na produção de cuidados de saúde. A
utilidade prática disto não é despicienda.
Além disso, observaram-se deseconomias de escala no hospital médio que tem 284 camas.
Uma vez que as elasticidades de escala de longo prazo não estão longe de 1, os efeitos de
escala não são expressivos e o hospital médio está perto da sua dimensão ótima. Concluiu-se
que, para a taxa de ocupação observada de 79.4%, a dimensão ótima do hospital médio é da
ordem das 250 camas.
Do ponto de vista dos custos médios, nem sempre é bom agrupar os hospitais. Só existe
vantagem em fazê-lo até ao ponto em que a soma das suas dimensões individuais é inferior à
dimensão para a qual existem deseconomias de escala. Por esta razão, é prejudicial agrupar
hospitais quando a soma das dimensões individuais dos hospitais é igual ou superior a 284
camas, mas é vantajoso fazê-lo se a soma das dimensões individuais dos hospitais for da
ordem das 250 camas. Este resultado é consistente com a literatura que utilizou dados de hospitais portugueses e é
consistente com a literatura internacional.
Finalmente, concluiu-se que as estimativas de eficiência são sensíveis aos métodos de
medição utilizados e que também são influenciadas pela escolha da tecnologia pré-definida.
In Portugal, there is the general perception that the public health care sector is poorly managed and that it is inefficient. Despite this perception, the global extent of waste is unknown and it is not known whether all public organizations that provide health care are equally inefficient. The definition of appropriate management measures depends crucially on this information. Moreover, in this debate, the primary health care centers are usually relegated to a second plane even though primary health care is called to play an increasingly important role in the quest for more efficient health systems. In the literature, there is a discussion about the best way to measure the efficiency of the production units. Among the criticisms of the application of frontier methods of efficiency measurement, it is often referred that the accuracy of the estimates of such methods depends on the use of appropriate and well-specified models. Few articles explore the role of exogenous factors, which are beyond the control of the production units but strongly influence the production process. Most articles that do so adopt a two-step procedure that ignores the influence of exogenous variables at the time the efficiency of the production units is measured. Other procedures compute the efficiency estimates while considering the exogenous factors but the application of these procedures is little explored. In addition, the parametric approach is far less used to measure the efficiency of health care organizations. In this work, we intend to answer the following research questions: 1) What is the value of waste in the public health care sector in Portugal? How much can the public health care sector in Portugal actually save and simultaneously continue to provide the same level of care? 2) Should the budget cuts be proportionally equal in all health care units? In all hospitals and, or, in all primary health care centers? 3) What is the minimum production cost of the health care organizations? 4) Would grouping Portuguese public hospitals together make them more efficient? 5) May one rely on the estimates of the frontier methods of efficiency measurement, including the estimates of the parametric methods? Are the estimates sensitive to the methods of efficiency measurement? We estimate the cost functions of the Portuguese public hospitals and the Portuguese primary health care centers, and compute their efficiency estimates. We estimate the cost functions of the hospitals using a traditional stochastic frontier model, a random effects model, a SUR model, and a model with heteroscedasticity among hospitals. We estimate the functions of the primary health care centers using a traditional stochastic frontier model, a SUR model, and a model with heteroscedasticity among primary health care centers. The computation of the efficiency estimates relies on the methodological assumption that the difference between the observed costs and the estimated costs is due to random shocks and inefficient behavior. We use longitudinal data from 63 Portuguese public hospitals covering the period 2002-2006, and cross-sectional data from 335 Portuguese primary health care centers of the year of 2005. We decided to use data from these periods of time instead of using data from more recent periods because these periods of time make it possible to collect homogeneous information. If, between 2002 and 2006, the average hospital of the sample had been fully efficient, it would have spent less between 24% and 33% of its annual budget, i.e. between 10.3 and 14.2 million euros, without reducing its level of care. Looking at the whole sample of hospitals, the annual savings for the Portuguese National Health Service (NHS) would have been equal to between 2.6 and 3.6 billion euros if all the hospitals in the sample had been efficient. Throughout the period between 2002 and 2006, i.e. during the five years under review, the Portuguese NHS would have saved between 13 and 18 billion euros. This corresponds to 1.6 and 2.3 times the transfer from the 2016 Portuguese state budget to the Portuguese NHS, which is expected to be equal to 7.9 billion euros. The indicator of overall efficiency of the hospitals in the sample belongs to the range 67% - 76%. This places the Portuguese public hospitals in the middle of a ranking of international hospitals ordered according to the values of their indicators of efficiency. According to the literature, the hospitals located in Germany, the United States, Finland or Switzerland, have indicators of overall efficiency that are equal to or above 80%, and in some cases above 90%. In the group of the hospitals of the sample are the Spanish hospitals, and depending on the measurement method used, the English hospitals. Below are the Indian hospitals with global efficiency indicators in the order of 40% -50%.If, in 2005, the average primary health care center of the sample had been fully efficient, it would have spent less between 3% and 36% of its annual budget, i.e. between 0.2 and 2.4 million euros, without reducing its level of care. Looking at the whole sample of primary health care centers, the annual savings for the Portuguese NHS would have been equal to between 64 and 764 million euros if all the primary health care centers in the sample had been efficient. Clearly, some hospitals are more efficient than others and the efficiency differences among them can be very significant. For example, the estimates of potential savings of the Hospital São Sebastião vary between 0% and 5% and the estimates of potential savings of the Hospital Pulido Valente vary between 40% and 46%. This also happens with the primary health care centers. For this reason, the budget cuts should not be proportionally equal in all hospitals and, or, in all primary health care centers. With the minimum and maximum values of the efficiency estimates, and the estimates of potential savings of the health care organizations, we built variation ranges of the estimates. Considering the wide dissimilarity of the methods of efficiency measurement used, we consider that the true values of efficiency, and the true value of savings that can be made, are necessarily within the limits of these ranges. The lower limit of the intervals tells us what is the minimum amount of savings that is actually possible to achieve. The upper limit of intervals tells us what is the maximum value from which budget cuts imply necessarily cut in the production of health care. The practical utility of this is not inconsiderable. Furthermore, we observed diseconomies of scale in the average hospital that has 284 beds. Since the long-term scale elasticities are not far from 1, the scale effects are not significant and the average hospital is close to its optimal size. We concluded that for the observed occupation rate of 79.4%, the optimal size of the average hospital is of the order of 250 beds. From the point of view of average costs, it is not always good to group hospitals together. There is only advantage in doing so up to the point where the sum of their individual sizes is less than the size for which there are diseconomies of scale. For this reason, it is detrimental to group hospitals together when the sum of the individual sizes of hospitals is equal to or above 284 beds, but it is advantageous to do so if the sum of the individual sizes of hospitals is of the order of 250 beds. This result is consistent with the literature that used data of Portuguese hospitals and it is consistent with the international literature. Finally, we concluded that the efficiency estimates are sensitive to the methods of measurement used and that they are also influenced by the choice of the pre-defined technology.
In Portugal, there is the general perception that the public health care sector is poorly managed and that it is inefficient. Despite this perception, the global extent of waste is unknown and it is not known whether all public organizations that provide health care are equally inefficient. The definition of appropriate management measures depends crucially on this information. Moreover, in this debate, the primary health care centers are usually relegated to a second plane even though primary health care is called to play an increasingly important role in the quest for more efficient health systems. In the literature, there is a discussion about the best way to measure the efficiency of the production units. Among the criticisms of the application of frontier methods of efficiency measurement, it is often referred that the accuracy of the estimates of such methods depends on the use of appropriate and well-specified models. Few articles explore the role of exogenous factors, which are beyond the control of the production units but strongly influence the production process. Most articles that do so adopt a two-step procedure that ignores the influence of exogenous variables at the time the efficiency of the production units is measured. Other procedures compute the efficiency estimates while considering the exogenous factors but the application of these procedures is little explored. In addition, the parametric approach is far less used to measure the efficiency of health care organizations. In this work, we intend to answer the following research questions: 1) What is the value of waste in the public health care sector in Portugal? How much can the public health care sector in Portugal actually save and simultaneously continue to provide the same level of care? 2) Should the budget cuts be proportionally equal in all health care units? In all hospitals and, or, in all primary health care centers? 3) What is the minimum production cost of the health care organizations? 4) Would grouping Portuguese public hospitals together make them more efficient? 5) May one rely on the estimates of the frontier methods of efficiency measurement, including the estimates of the parametric methods? Are the estimates sensitive to the methods of efficiency measurement? We estimate the cost functions of the Portuguese public hospitals and the Portuguese primary health care centers, and compute their efficiency estimates. We estimate the cost functions of the hospitals using a traditional stochastic frontier model, a random effects model, a SUR model, and a model with heteroscedasticity among hospitals. We estimate the functions of the primary health care centers using a traditional stochastic frontier model, a SUR model, and a model with heteroscedasticity among primary health care centers. The computation of the efficiency estimates relies on the methodological assumption that the difference between the observed costs and the estimated costs is due to random shocks and inefficient behavior. We use longitudinal data from 63 Portuguese public hospitals covering the period 2002-2006, and cross-sectional data from 335 Portuguese primary health care centers of the year of 2005. We decided to use data from these periods of time instead of using data from more recent periods because these periods of time make it possible to collect homogeneous information. If, between 2002 and 2006, the average hospital of the sample had been fully efficient, it would have spent less between 24% and 33% of its annual budget, i.e. between 10.3 and 14.2 million euros, without reducing its level of care. Looking at the whole sample of hospitals, the annual savings for the Portuguese National Health Service (NHS) would have been equal to between 2.6 and 3.6 billion euros if all the hospitals in the sample had been efficient. Throughout the period between 2002 and 2006, i.e. during the five years under review, the Portuguese NHS would have saved between 13 and 18 billion euros. This corresponds to 1.6 and 2.3 times the transfer from the 2016 Portuguese state budget to the Portuguese NHS, which is expected to be equal to 7.9 billion euros. The indicator of overall efficiency of the hospitals in the sample belongs to the range 67% - 76%. This places the Portuguese public hospitals in the middle of a ranking of international hospitals ordered according to the values of their indicators of efficiency. According to the literature, the hospitals located in Germany, the United States, Finland or Switzerland, have indicators of overall efficiency that are equal to or above 80%, and in some cases above 90%. In the group of the hospitals of the sample are the Spanish hospitals, and depending on the measurement method used, the English hospitals. Below are the Indian hospitals with global efficiency indicators in the order of 40% -50%.If, in 2005, the average primary health care center of the sample had been fully efficient, it would have spent less between 3% and 36% of its annual budget, i.e. between 0.2 and 2.4 million euros, without reducing its level of care. Looking at the whole sample of primary health care centers, the annual savings for the Portuguese NHS would have been equal to between 64 and 764 million euros if all the primary health care centers in the sample had been efficient. Clearly, some hospitals are more efficient than others and the efficiency differences among them can be very significant. For example, the estimates of potential savings of the Hospital São Sebastião vary between 0% and 5% and the estimates of potential savings of the Hospital Pulido Valente vary between 40% and 46%. This also happens with the primary health care centers. For this reason, the budget cuts should not be proportionally equal in all hospitals and, or, in all primary health care centers. With the minimum and maximum values of the efficiency estimates, and the estimates of potential savings of the health care organizations, we built variation ranges of the estimates. Considering the wide dissimilarity of the methods of efficiency measurement used, we consider that the true values of efficiency, and the true value of savings that can be made, are necessarily within the limits of these ranges. The lower limit of the intervals tells us what is the minimum amount of savings that is actually possible to achieve. The upper limit of intervals tells us what is the maximum value from which budget cuts imply necessarily cut in the production of health care. The practical utility of this is not inconsiderable. Furthermore, we observed diseconomies of scale in the average hospital that has 284 beds. Since the long-term scale elasticities are not far from 1, the scale effects are not significant and the average hospital is close to its optimal size. We concluded that for the observed occupation rate of 79.4%, the optimal size of the average hospital is of the order of 250 beds. From the point of view of average costs, it is not always good to group hospitals together. There is only advantage in doing so up to the point where the sum of their individual sizes is less than the size for which there are diseconomies of scale. For this reason, it is detrimental to group hospitals together when the sum of the individual sizes of hospitals is equal to or above 284 beds, but it is advantageous to do so if the sum of the individual sizes of hospitals is of the order of 250 beds. This result is consistent with the literature that used data of Portuguese hospitals and it is consistent with the international literature. Finally, we concluded that the efficiency estimates are sensitive to the methods of measurement used and that they are also influenced by the choice of the pre-defined technology.
Description
Keywords
Serviço Nacional de Saúde - Eficiência - Portugal Serviço Nacional de Saúde - Avaliação de desempenho - Portugal Serviço Nacional de Saúde - Gestão financeira - Portugal