PROVIDER-PAYMENT MECHANISM:

- In the 4-way flow: the financial intermediaries adopt several methods to reimburse
providers of care. Providers: physicians, centers, hospitals, pharmacies…
- It is the way that health purchasers pay health care providers to deliver services.
- Each payment system is based on one or more provider payment methods or mechanisms.
Hybrid mechanisms of paying providers.
- Each method creates a different set of incentives and may be appropriate in different
contexts.
 Each payment mechanism will affect the behavior of the provider and the behavior of
the patient.
 For the provider, it might induce them to increase or decrease services and demands.

These are all provider-payment methods that could be adopted by HIP to pay or reimburse
providers.
1. An allocation that HIP gives to a provider at the beginning of the year or over a specific
period of time in a fixed amount. It is a budget. Every year, they define a budget for each
provider. This budget is usually set according to historical data (how much was the
hospital bill in the last year, how many patients they admit and the type of services
provided…) and the accommodate a small percentage for inflation.
2. Same concept but here they divide the budget into line-item. Instead of setting an overall
amount, they set a fixed amount for each line-item. They cannot transfer money within
items.

3. The most recent form of methods. You pay the provider per capita. Per capita is per head.
HIP registers a specific number of beneficiaries with a particular provider. For example, a
primary health care center in Beirut. They tell this center that they will register 2000
beneficiaries in the area to the center and whenever this beneficiary comes to seek
services at your center, you have to cover it. For each person, per head, we will pay you
an X amount per year prospectively. They will pay them an X amount per head and these
are the heads registered in your center. They will pay them X amount of money, whether
the beneficiary seeks services or not.

1. Based on diagnosis. All surgical and medical procedures have been categorized. Each
diagnosis has been codified; it has a medical code. HIP took each diagnosis and
established a clinical protocol for the diagnosis. What services should be provided if
someone is diagnosed with X. if a patient is diagnosed with X and needs to be admitted to
the hospital, what services will be provided? Then, they set a fixed price for this protocol.
 An average is fixed price: this is the amount the hospital will pay no matter what happens
during surgery or stay at hospital. Example, a patient diagnosed with X is admitted to the
hospital. When he is discharges, HIP will pay 200$. Whether the hospital performed the
whole protocol on the patient or not, the amount will be paid. If the hospital had to do
more, HIP will still pay the same amount which is 200$.

2. Every single service or medication or supply that is used is costed. There is a fee for each
supply and it is reimbursed. It the only payment method that is retrospective. It is similar
when you go the supermarket, fill it, and pay for every single item. You pay for the
medication and consultation. HIP pays the whole bill.

3. Same concept as case-based. It is a payment per day of hospitalization, it is not by

diagnosis. A patient is admitted to the hospital, he stays there 3-4 night and per day HIP
will pay the provider a 100$. Depending on the ward the patient has been admitted to,
there is a different rate, but whatever happens during the day of hospitalization, they will
still pay on 100$. It is common in long-term facilities.

4. Per admission: the admission of the patient o the hospital or a visit. Same concept as per
diem. Instead of payment per day or per diagnosis. The patient is admitted and no matter
how many days and the diagnosis, the amount will be the same 1000$.

 Case-based, per diem, and per admission are

 Also, capitation, but is paid no matter what happens.
 The only retrospective one is free-for service.
 The patient has to pay 10% of the total thing.

LEBANESE HEALTH CARE SYSTEM:

- Composed of 6.849 million people (World Meter, 2020)
- Classified as an upper middle-income country; however, the severe financial crisis of
2020 has had major impact on the economy
- Total expenditure on health was estimated to be 8.2% in 2018 (World Bank, 2019) 
public and private expenditure.

WHERE DOES THE MONEY COME FROM IN LEBANON?

 Salary Taxes
contributions
Premiums
Donations
Out-of-pocket

- Premiums are paid for private insurance companies.

HOW IS THE MONEY POOLED IN LEBANON?

Sources of revenues

Governing Ministry

Financial
Intermediaries

- It is the ministries that manage and control the financial intermediaries.

 Taxes

Ministry of Office of
Ministry of Ministry of
Public the Prime
Interior Defense
Health Minister

Cooperative Internal
of Civil Security Army
Servants Forces

State
Security

General
Security

- Taxes are channeled through several ministries and intermediaries. It is one of the aspects
that contributes to the fragmentation and inefficiency to the Lebanese financing system.
Budgets of taxes are allocated to the ministry of public health, office of the prime
minister, ministry of interior, and ministry of defense.
- The ministry of public health is also an intermediary.
- Office of the prime minister governs the cooperative of civil servants. ‫تعاونية الموظفين‬. It is
used to cover the civil staff that work in the public sector. Director general of the ministry
and the high-level staff of the ministry. ‫موظفين الدولة‬.
- Ministry of interior covers several funds that are related to security forces. Internal
security force ‫امن الداخلي‬, state security ‫امن الدولة‬, and general security ‫امن العام‬
- Ministry of defense: specific to the army.
 Salary
Contributions
Premiums

Ministry of Ministry of
Labor Economy

National Private
Social Insurance
Security Fund Companies

Premiums

Ministry of
Agriculture

Mutual
Funds

- Private insurance plan: for profit, while mutual funds: non-profit organizations. Sectors
that come together.
- When we say they are governed by ministry of economy it doesn’t mean they control
them or have a say, rather they are protected by it.
DISTRIBUTION OF RESIDENTS BY TYPE OF FUNDS:

- MOH: ministry of public health. It covers mainly anyone that doesn’t have any type of
insurance.
- Army: all security forces. Internal, general, and state security.

BENEFIT PACKAGE, COST SHARING & ELIGIBILITY:

- Who is eligible or could be enrolled in this? And what are the benefits with the cost
sharing (how much the population pays in terms of beneficiary when they seek the
service, what do they cover, and what is the source of the money).
- It shows us how the system is fragmented and how there is some duplication of effort. It
shows the inequity in the system mainly in the benefit package due to the variance.
HEALTH EXPENDITURES VS BASIC HEALTH STATUS INDICATORS:
 - The fragmentations and inefficiency is affecting health outcome.
- Other countries are performing better for the same amount of money or even less amount
(UAE and Qatar) and yet they are doing much better.
- Even though they are gold countries with rich people and many resources, still, they are
just a proportion.
- Qatar spend much less and have same indicators as Lebanon. Although Qatar has purely
public system and universal coverage. This is explained by the behavior of people,
promotion, prevention…
 Health outcomes are affected by the resources we put and also by the organization of
the system (at the process level)
 The fragmentation and inequity is affecting the health indicators.

HEALTH INDICATORS OF LEBANON IN 2016:

- We have a lack of data  it is an issue in Lebanon and most Arab countries.

- In Lebanon, we have a problem in the denominator, we haven’t calculated it since the late
20s and this is due to political reasons.
 It affects establishing and determining health needs and inputs needed in the system.
PROVIDER PAYMENT MECHANISM:
 PUBLIC & PRIVATE HOSPITALS:
They are paid depending on the funds.
Public (NSSF and MOPH) they are paying flat rates, based on diagnose, case
payment and there are global budgets.