An Assessment of Health Services Contracting in Mexico's Seguro Popular de Salud, 2006–2014

Figures & data

FIGURE 1. Mexico's Seguro Popular de Salud (SPS) Organization by Government Level. Source: Elaborated by authors from Secretaria de Salud, 2006³⁶

TABLE 1. Elements to Ensure the Cost-Effective Contracting (Figueras et al.'s²² Framework). Source: Elaborated by authors with information from Figueras et al.²²

No.	Element	Description	Search Categories in Agreements and Contracts
1	Linking contracting with planning	Planning should take into account population dynamics, both demographic and epidemiological, as well as the resources available to meet the demand generated by these types of changes.	• Demographic/epidemiological dynamics
		The agreements should consider at least the types of services to contract; the types of providers to contract with; the payment mechanisms; and the time period (annually).	• Type of services to contract
			• Type of providers
			• Payment mechanisms
			• Time period
2	Basing contracts on available clinical and economic evidence	In the context of planning, contracting must be able to incorporate elements of the most recent sound scientific evidence on issues of clinical care for both traditional and emerging health problems.	• Clinical evidence (guidelines, official norms)
		This range of evidence would include the following:	• Economic evidence (capitation, pricing lists, others)
		• The development of clinical guidelines that take into account existing practices and potential change generated by demographic and epidemiological transitions and associated required resources.
		• The associated required resources to the interventions of the clinical guidelines.
		• A broad view of health improvement including prevention and treatment options.
3	Implement contracts with clearly defined costs and volume of services produced	Cost-and-volume contracts seem to have the most potential in signaling the appropriate incentives to providers. These contracts allow for purchasers to decide the following:	• Definition of costs of services
		• The volume of care required (in terms of Diagnosis Related Groups [DRGs], number of total or cases or bed days).	• Definition of volume of services to be contracted (in terms of DRGs, number of total, or cases or bed days).
		• Define the product and determine cost-effective forms of intervention.	• Measures of performance
		• Measures of performance
4	Driving pay-for-performance	Pay-for-performance describes health care payment systems that offer financial rewards to providers who achieve, improve, or exceed their performance on specified quality and cost measures, as well as other benchmarks. Pay-for-performance models are based on a common set of design elements performance measurement and incentive design.	• Fulfillment of goals
		Pay-for-performance has been an important innovation included in many recent health reforms. According to Alvarez,^35 an optimum payment system should induce providers to deliver the highest quality care, should be able to meet the needs of patients, and should achieve a high level of technical efficiency. However, the lack of clear consensus on the best ways to carry out pay-for-performance strategies is largely due to organizational variations of particular types of health systems.	• Design and payment of incentives
			• Other modalities of payment (budgets, capita, etc.)
5	Definition of quality of care standards	Promoting quality through contracting is a key goal, yet its achievement can be elusive. The quality promotion mechanisms can be specified before and/or after contracts are signed.	• Accredited or certified facility
		• Before: Through requiring the contracted facility (or the facility receiving financing from the system) to be accredited or certified.	• Quality assurance mechanisms
		After:	• Quality goals (process and outcome)
		• The establishment of evidence-based care standards
		• Quality assurance mechanisms
		• The definition of quality goals (process and outcome).
		Once quality guidelines are established in the contract, purchasers should closely monitor compliance with clearly defined quality standards.

TABLE 2. Evidence Level of Figueras et al.'s²² Framework in Managerial Agreements and Contracts Within Mexico's Seguro Popular de Salud^a

				Key Performance Features Included in Managerial Agreements and Contracts
Type of Managerial Agreement/Contract	Level	Agent	Number of Contracts/Agreements	Linking Contracting with Planning		Basing Contracts on Available Clinical and Economic Evidence		Implement Contracts with Clearly Defined Costs and Volume of Services Produced		Driving Pay-for-Performance		Definition of Quality of Care Standards
Coordination agreement for the execution of the Social Protection System in Health between the federal level and each state	Federal–state	Public–public	8	2006/2011	2012/2014	2006/2011	2012/2014	2006/2011	2012/2014	2006/2011	2012/2014	2006/2011	2012/2014
				+++	+++	+++	+++	NE	NE	NE	NE	+	++
Coordination agreement between the federal level and the states for the strengthening of health services infrastructure	Federal–state	Public–public	4	+++	+++	+++	+++	NE	NE	NE	NE	NE	NE
Framework agreement for the provision of medical services and economic compensation between 32 states and the federal level	Federal–interstate	Public–public	2	+++	+++	+++	+++	+	+	NE	NE	+	+++
Managerial agreement for the provision of medical services between REPSS and state health services (SESA)	State–state	Public–public	6	+++	+++	+++	+++	+	+	NE	NE	+	+++
Contract between REPSS and a private hospital	State–local	Public–private	2	+++	+++	+++	+++	+	++	NE	NE	++	+++
Collaboration agreement between REPSS and decentralized public hospital	State–local	Public–public	2	+++	+++	+++	+++	+	+	NE	NE	+	++
Managerial agreement between state health services and a decentralized public hospital	State–local	Public–public	2	+++	+++	+++	+++	+	+	NE	NE	+	+++
Coordination agreement between state health services and public hospital within the network	State–local	Public–public	2	+++	+++	+++	+++	+	+	NE	NE	+	+++
Contract between state health services and a private hospital	State–local	Public–private	2	+++	+++	+++	+++	+	++	NE	NE	++	+++

^a Scale: +++ = Level of evidence in contracts: high; = ++ level of evidence in contracts: medium; + = level of evidence in contracts: low; NE = no evidence in contracts.

Source: Elaborated by authors with agreements and contracts information.

Secretaría de Salud. Sistema de Protección Social en Salud. Elementos conceptuales, financieros y operativos [System of social protection in health. Conceptual, financial and operational elements]. 2a. Edición. Colección Biblioteca de la Salud. Payment systems for health care providers in Latin America and OECD countries. México DF: Fondo de Cultura Económica; 2006.

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