Privately managed public hospitals: Is a Torrejón case possible in Catalonia?

BarcelonaNeglecting to treat sick people in order to earn more money goes against the ethical principles and professional conduct of doctors, and yet this is what was allegedly happening in at least one hospital in the Community of Madrid for months. These past few weeks have set off alarm bells throughout the public healthcare system as a result of... the Torrejón de Ardoz Hospital scandalA publicly owned but privately managed center, where the directive was allegedly to reject unprofitable patients or procedures in order to lengthen waiting lists and increase profits. This information has ignited yet another political battle between the governments of Isabel Díaz Ayuso and Pedro Sánchez, but it has also reopened the debate about the provision of services in the public healthcare system.

The Ministry of Health has stated that it is thoroughly investigating the Torrejón center—managed by the controversial Ribera Salud group—and the other privately managed Madrid hospitals belonging to the Quirón Group, which have substantially increased their government funding in recent years. The Ministry has presented a report on the economic growth of the private network of state hospitals, which has seen its funding increase significantly over the last decade. It has increased by 85%.In fact, the document details that the number of private hospitals integrated into the public system has increased from 106 in 2011 to 145 in 2023, and in this regard, Minister Mónica García warned of a "growing dependence" and asserted that Torrejón is not an isolated case. "It is onemodus operandi"which is trying to parasitize our public system through the profit and loss accounts of private companies," she stated.

The minister's accusations have been met with dismay by the various entities and providers of the Catalan healthcare system, who fear that it could damage the reputation of the publicly subsidized and private sectors in a region with a business-oriented model. Those in Catalonia consulted by ARA – La Unió, the Catalan Health and Social Consortium (CSC), and the Catalan Association of Health Entities (ACES) – have closed ranks and made it very clear that what happened in Torrejón cannot be replicated here. "Catalonia is not Madrid. The minister has stirred up all this controversy and is now casting doubt on our system, but the Catalan model does not favor speculative, profit-driven entities," argues Roser Fernández, general director of La Unió.

It is true that private entities play an essential role in the state's public healthcare system and, as the Ministry confirms, are gaining increasing importance. However, the regional models differ, and each territory structures its system differently. If we look at the Catalan and Madrid models, both are part of the National Health System (NHS), meaning they must guarantee universal coverage—age, income, and pre-existing conditions do not exclude anyone from receiving care—and that their funding comes primarily from taxes. But their organizational structure and service delivery methods are very different.

Two different models

In Madrid, the outsourcing of hospital management plays a significant role: it is mostly based on concessions to private groups to which the regional government pays a fixed annual fee based on the population they serve. Therefore, the hospital receives the same amount of money regardless of the number of operations or diagnostic tests it performs. Furthermore, the management companies are primarily large, for-profit groups. As for Catalonia, healthcare has historically been based on a mixed model, in which public and private-public partnership hospitals coexist within the Catalan Integrated Public Healthcare System (Siscat)—as is the case with two large hospitals like the Hospital Clínic and Hospital Sant Pau, both in Barcelona—and with regional management bodies.

The main difference with Madrid lies in the contracting model, which in Catalonia is focused on achieving activity targets. In other words, centers commit to performing a certain number of services, operations, and tests per year, and if they fall short, they are penalized. For example, a district hospital agrees with the Health Department to perform 200 hip surgeries, and if it performs fewer, it will be penalized. will punish for breaching the agreement. It's a strategy designed to reduce long waiting lists and prevent perverse incentives that could violate patients' rights.

Publicize or privatize

Given the differences in healthcare models across the autonomous communities, the three employers' associations have criticized the ministry's report, which ACES's director general, Anna Zarzosa, has labeled a "bombshell" against private healthcare. In her opinion, private centers are key to reducing waiting lists, so she doesn't understand why the minister is framing the Torrejón case as a systemic problem. "The Madrid model has nothing to do with Catalonia's public-private partnership model," argues Francesc José María Sánchez, director general of the Catalan Health and Social Consortium, who points out that Madrid's problem is "the lack of oversight" regarding the concessions granted to companies for center management. The three Catalan employers' associations maintain that "the rules of the game" are the same for all centers, regardless of the qualifications of those managing them. "There's no room for speculation in healthcare service contracts; instead, the benefits go back to the system," Fernández asserts, and José María maintains that generating surpluses "isn't bad if it comes from quality care and innovation," but it is bad if it "cuts working conditions and worsens the city's healthcare."

The ministry's report aligns with the 100% public model that the minister has defended on several occasions, and with a very common demand in healthcare demonstrations, regardless of their scope, where one of the most frequent chants is "Public and quality healthcare." Employers' associations view the report with suspicion because they believe it could fuel these narratives to the detriment of the Catalan healthcare model, and Fernández, from La Unió, is very emphatic. "Wanting to make everything public is not the Catalan model, nor is it the solution. The contracted-out model must be managed with a public service approach, as it has been until now," he argues. CSC and ACES also criticize the fact that the minister's accusations could affect the sector. "We are starting from many ideological preconceptions that have no basis," argues José María, and Zarzosa believes that the report is counterproductive for the healthcare system as a whole. "We're putting crutches in our own wheels, and instead of facilitating the work, we're hindering it."

From Madrid, Ángela Hernández, surgeon and general secretary of the Madrid Association of Doctors and Higher Graduates (AMYTS), asserts that the case of Torrejón Hospital "has been repeating itself for fifteen years" and that it has generated "an ecosystem that is very difficult to reverse." "Scams and patronage networks have been created, the profit motive has become entrenched in the system, and the mechanisms for comparison and transparency are failing," she laments.

"Inconvenient" Doctors

Hernández explains that in these hospitals, surgeons are pressured to prolong non-urgent treatments in order to maximize profits according to the fixed annual fee contracted with the administration. He explains that these are "very complex" contracts, with numerous clauses, that benefit the companies, which hold all the cards when negotiating with the administration for the provision of a public service. Aside from the citizens receiving the care, those who suffer the most are the professionals, according to Hernández. "With all this chaos, we doctors are the ones who are inconvenient for the companies, because we continue to prioritize patients. This leads, for example, to unfair dismissals being very common in these companies [in Madrid]," he laments.

Despite the obvious differences, the Metges de Catalunya union sees similarities in this area and also believes that it is the professionals who ultimately pay the price for the system's shortcomings, such as the fact that extremely high patient volume is managed by understaffed and poorly paid teams. "The perversion of our system is this. The company agrees with the department on how much work it will do and then can decide whether to hire one doctor or fifty to carry out this work," explains Josep Maria Serra, vice president of Doctors of Catalonia and head of the private healthcare sector within the union. In his opinion, what these companies in Catalonia do to save money is "reduce the number of professionals and create an overload on the staff," since this way they have to pay lower salaries to perform the same level of care.

For the union, the only way to reverse this situation is for doctors to report to the Department of Health, as is the case with teachers and Education, and for the administration to determine who works at each center. This would "eliminate territorial and inter-center inequity," as well as help "reduce waiting lists in those areas with fewer available professionals," argues Serra.

"Serious illegalities" according to the Ombudsman's Office

Another element to consider is that this year the Catalan Audit Office has detected "serious irregularities" in the financing of acute hospital and specialized care in contracted hospitals by the Catalan Health Service (CatSalut) in 2022. Specifically, it has detected "serious problems of non-compliance with the law regarding expired hospitals throughout Catalonia." Serra criticizes the lack of transparency in all processes affecting the system, which he acknowledges is not perfect. He also agrees with employers' associations that a case like Torrejón is unlikely to be replicated in Catalonia, but insists that It is necessary to change the model to protect the most important part of the systemThe professionals, and that they be under the department's umbrella. However, he acknowledges that achieving this will not be easy: "We have some major competitors: the companies."