Mixed model performance contracting and casemix in limited settings – the case of Lebanon

Background Lebanon is an upper-middle income country with 4.5 million inhabitants (as well as more than 1.2 million refugees) and total health expenditures at 7.3% of the Gross Domestic Product. Lebanon has a mixed public and private healthcare sector. The Ministry of Public Health (MoPH) functions as ‘insurer of last resort’ for approximately 54% of the population that would otherwise lack hospitalization coverage. The MoPH contracts 26 public and 105 private hospitals and covers about 240,000 hospital admissions annually. Since 2001, hospital contracting is based on a link between reimbursement rate and accreditation. Accreditation has encouraged the development of a healthcare quality culture among providers, and has likely contributed to total quality management. Yet, the sole link between accreditation and reimbursement has imposed limitations that are apparent to both MoPH and the hospitals. To address this problem, since 2009, a MoPH cross-collaboration team (with membership that includes implementers, policymakers, and researchers) has worked to develop a system to capture additional dimensions of healthcare performance.