Mechanisms of microregulation of private hospitals by health plan operators

To analyze the mechanisms employed by health plan operators for microregulation of clinical management and health care qualification within care-providing hospitals.

A nation-wide cross-sectional study was carried out. The universe consisted of hospitals which provided care to health plan operators in 2006. A sample of 83 units was selected, stratified by Brazilian macroregion and type of hospital. Data were obtained by means of a questionnaire administered to hospital managers.

Microregulation of hospitals by health plan operators was minimal or almost absent in terms of health care qualification. Operator activity focused predominantly on intense control of the amount of services used by patients. Hospitals providing services to health plan operators did not constitute health micro-systems parallel or supplementary to the Sistema Unico de Saúde (SUS - Brazilian National Health System). The private care-providing hospitals were predominantly associated with SUS. However, these did not belong to a private care-provider network, even though their service usage was subject to strong regulation by health plan operators. Operator intervention in the form of system management was incipient or virtually absent. Roughly one-half of investigated hospitals reported adopting clinical directives, whereas only 25.4% reported managing pathology and 30.5% reported managing cases.

Contractual relationships between hospitals and health plan operators are merely commercial contracts with little if any incorporation of aspects related to the quality of care, being generally limited to aspects such as establishment of prices, timeframes, and payment procedures.