Comparative study among different remuneration models practiced in a private hospital

Abstract

Objective  To compare the remuneration models practiced in relation to cholecystectomy and bariatric surgeries in two units of a private hospital.

Methods  This is a quantitative, comparative and retrospective study covering the remuneration models for cholecystectomy (elective and emergency) and bariatric surgeries practiced in units I (mixed and fee for service) and II (bundle) of a private hospital from healthcare service providers’ perspective. For variables with statistically significant difference (ANOVA test p<0.05), the Games-Howell test was used for post-hoc comparison two by two.

Results  In cholecystectomy surgeries, the mean total revenue (R$14,557.73), mean surgery revenue (R$11,090.67), mean hospitalization revenue (R$3,467.07), mean total cost (R$10,135.58) and mean surgery cost (R$7,777.42) were higher in the fee for service model. The bundle model showed a shorter operating room time of 51.17 minutes, a lower mean daily hospitalization (1.05 days), and no records of surgical complications. In bariatric surgeries, the mean total revenue (R$29,425.62), mean surgery revenue (R$24,175.33) and mean hospitalization revenue (R$5,250.33) were also higher in the fee for service model. The mean operating room time and hospitalization days were shorter in the bundle model (72.67 minutes and 1.1 days of hospitalization, respectively), and more complications were found in the fee for service and bundle models (14% and 12%, in that order). In both surgeries, the fee for service model was the most profitable model (R$4,422.15/cholecystectomy and R$10,199.22/bariatric) and the bundle resulted in the lowest mean total cost (R$5,520.47/cholecystectomy and R$15,498.27/bariatric).

Conclusion  The fee for service remuneration model presented better financial results for hospital billing and the bundle model presented the lowest mean total costs, with more favorable care results regarding room time, number of hospitalization days and complications associated with the aforementioned surgeries.

Keywords
Hospitals, private; Hospital costs; Health care costs; Insurance health; Remuneration; Fee-for-service plans

Resumo

Objetivo  Comparar os modelos de remuneração praticados em relação às cirurgias de colecistectomia e bariátricas em duas Unidades de um hospital privado.

Métodos  Estudo quantitativo, comparativo e retrospectivo abrangendo os modelos de remuneração de cirurgias de colecistectomia (eletivas e de urgência) e bariátricas praticados nas Unidades I (Misto e Fee for service) e II (Bundle) de um hospital privado, na perspectiva do prestador de serviços de saúde. Para as variáveis com diferença estatística significante (teste ANOVA p<0.05), utilizou-se o teste de Games-Howell para a comparação post-hoc, dois a dois.

Resultados  Nas cirurgias de colecistectomia, a receita total média (R$ 14.557,73), receita média da cirurgia (R$ 11.090,67), receita média de internação (R$ 3.467,07), custo total médio (R$ 10.135,58) e o custo médio da cirurgia (R$ 7.777,42) foram maiores no modelo Fee for service. O modelo Bundle apresentou menor tempo de sala cirúrgica com 51.17 minutos, menor média de diária de internação (1,05 dias), sem registros de complicações cirúrgicas. Nas cirurgias bariátricas, a receita total média (R$ 29.425,62), receita média da cirurgia (R$ 24.175,33) e receita média com internação (R$ 5.250,33) também foram maiores no modelo Fee for service. A média de tempo de sala cirúrgica e diárias de internação foram menores no modelo Bundle (72,67 minutos e 1,1 dias de internação, respectivamente), foram encontradas mais complicações nos modelos Fee for service e Bundle (14% e 12%, nessa ordem). Em ambas as cirurgias, o modelo Fee for service foi o modelo mais lucrativo (R$ 4.422,15/colecistectomia e R$10.199,22/bariátrica) e o Bundle resultou no menor custo total médio (R$ 5.520,47/colecistectomia e R$15.498,27/bariátrica).

Conclusão  O modelo de remuneração Fee for service apresentou melhores resultados financeiros para o faturamento hospitalar e o modelo Bundle os menores custos totais médios, com resultados assistenciais mais favoráveis quanto ao tempo de sala, número de diárias de internação e complicações associadas às cirurgias supracitadas.

Descritores
Hospitais privados; Custos hospitalares; Custos de cuidados de saúde; Seguro saúde; Remuneração; Planos de pagamento por serviço prestado

Resumen

Objetivo  Comparar los modelos de remuneración practicados con relación a cirugías de colecistectomía y bariátricas en dos unidades de un hospital privado.

Métodos  Estudio cuantitativo, comparativo y retrospectivo que incluye los modelos de remuneración de cirugías de colecistectomía (electivas y de urgencia) y bariátricas, practicados en la Unidad I (Mixto y Fee for service) y II (Bundle) de un hospital privado, bajo la perspectiva del prestador de servicios de salud. Para las variables con diferencia estadística significativa (prueba ANOVA p<0.05), se utilizó la prueba de Games-Howell para la comparación post-hoc, por pares.

Resultados  En las cirugías de colecistectomía, los ingresos totales promedio (R$ 14.557,73), los ingresos promedio de la cirugía (R$ 11.090,67), los ingresos promedio de internación (R$ 3.467,07), el costo total promedio (R$ 10.135,58) y el costo promedio de la cirugía (R$ 7.777,42) fueron mayores en el modelo Fee for service. El modelo Bundle presentó menor tiempo de quirófano con 51,17 minutos, menor promedio de días de internación (1,05 días), sin registros de complicaciones quirúrgicas. En las cirugías bariátricas, los ingresos totales promedio (R$ 29.425,62), los ingresos promedio de la cirugía (R$ 24.175,33) y los ingresos promedio de internación (R$ 5.250,33) también fueron mayores en el modelo Fee for service. El tiempo promedio de quirófano (72,67 minutos) y de días de internación (1,1 días) fueron menores en el modelo Bundle. Se observaron más complicaciones en los modelos Fee for service (14 %) y Bundle (12 %). En ambas cirugías, el modelo Fee for service fue el modelo más lucrativo (R$ 4.422,15/colecistectomía y R$ 10.199,22/bariátrica) y el Bundle resultó ser el de menor costo total promedio (R$ 5.520,47/colecistectomía y R$ 15.498,27/bariátrica).

Conclusión  El modelo de remuneración Fee for service presentó mejores resultados financieros para la facturación hospitalaria y el modelo Bundle los menores costos totales promedio, con resultados asistenciales más favorables respecto al tiempo de quirófano, cantidad de días de internación y complicaciones asociadas a las cirugías mencionadas.

Descriptores
Hospitales privados; Costos de hospital; Costos de la atención en salud; Seguro de salud; Remuneración; Planes de aranceles por servicios

Introduction

Healthcare services are increasingly incorporating the concepts of economic assessment, given that budgetary and resource restrictions require managers, administrators and healthcare professionals to make complex decisions.(¹)

In Brazil, despite the public Unified Health System (In Portuguese, Sistema Único de Saúde - SUS) with universal access, most financial resources have been invested in the Supplementary Health System (SHS), which is accessed by around 23% of the population. The portion allocated to funding the SUS corresponds to just under 50% of the gross domestic product and contrasts with investments in countries that have efficient health systems with universal access, such as the United Kingdom (94.2%), Sweden (84%) and France (81%), and is close to that observed in the United States of America (47%), where the private system is prioritized.(²)

The Brazilian National Supplementary Health Agency reported that there are over 50.3 million beneficiaries with private health insurance plans in Brazil, 40 million of whom are covered by group corporate or membership plans. The number of beneficiaries generated revenues of R$106 billion in compensation up to the third quarter of 2015, and healthcare expenses accounted for R$90 billion (76.5% of total expenses). In 2000, after reaching 2,004 Health Insurance Companies (HIC) in operation, 2017 ended with 1,290 HIC, of which 1,076 had beneficiaries, and the majority (82.5%) were concentrated in 168 of the 780 HIC. While the three largest HIC have 9.6 million beneficiaries, the 515 smallest have 4.8 million.(³)

In the context of the Brazilian SHS, the need for continuous improvement of management processes and administration of services provided and the difficulties faced by HIC require that healthcare professionals acquire knowledge regarding the different remuneration models, enabling an increase in quality and costs, benefiting insurers, HIC, health providers and patients/clients.(⁴)

Discussions regarding the payment policy for service providers are associated with the care model and expected health outcomes, making it increasingly evident that the remuneration model impacts the care provided and its results.(⁵)Among the remuneration models adopted by private healthcare services, this study will address fee for service (payment per service) and bundle (payment per bundle).

In fee for service, everything required for the healthcare process (test, procedure, material, daily rate and hospitalization) is listed in a detailed invoice sent to HIC. In this model, the values charged for the same types of procedure vary widely between different providers and payers, and remuneration depends on the volume of service provided and the materials consumed.(⁶)

This model encourages an increase in the number of processes, the volume and complexity of services, with an emphasis on production (the higher the number, the higher the payment received) without taking into account quality, which should be the focus of every provider. In the logic of production, this model has encouraged HIC to gloss over items in hospital bills, based on technical or administrative resources.(⁷,⁸)

In a Bundle, providers receive a previously defined amount agreed upon with payers for the services provided to patients throughout the entire treatment of a specific condition. The amount is bundled, including all the care that patients may need during their treatment, and providers are responsible for the entire treatment cycle. This model takes into account the improvement of treatment performance, both in terms of savings and quality, requiring a database on patients and population history. Thus, the risk falls on providers and is not shared by payers,(⁵-⁷) and its implementation involves detailed assessment of risk actions and careful selection of the payment amount.(⁹)

A private hospital in greater São Paulo (HP-SP), recognized as one of the largest high-complexity hospital institutions in the country, with two units, referred to in this study as I and II, was a pioneer in adopting the bundle with the aim of offering an experimental cost predictability model.

For some years, digestive diseases were the main focus of this hospital’s activities, attracting a leading medical team to the market, which resulted in a high number of digestive system surgeries in both units, where care in the operating room has a favorable impact on economic and financial aspects.

Currently, digestive system surgeries continue to occur in greater numbers in units I and II of HP-SP, with a high number of cholecystectomy surgeries (elective and emergency) and bariatric surgeries, which are very significant for hospital revenue.

Unit I predominantly practices the fee for service remuneration model, which, for some accredited HIC, is in the transition phase to the bundle, which is referred to in this study as the mixed model, and unit II as the bundle.

Considering the above, the objective was to compare the remuneration models practiced in relation to cholecystectomy and bariatric surgeries in two units of a private hospital.

Methods

This is a quantitative, comparative and retrospective study covering the remuneration models practiced in units I (opened 120 years ago) and II (opened seven years ago) of HP-SP, which operates in circulatory, digestive, oncological, musculoskeletal and elderly care diseases. In both units, the hospital adopts absorption costing, widely used in health organizations in the country because it is the only one accepted by Brazilian legislation in the calculation of Income Tax.(¹⁰)

Using absorption costing, units I and II of HP-SP are structured into a set of cost centers classified as productive or final (which provide healthcare services), auxiliary (which support productive cost centers) and administrative (which provide administrative support to productive and auxiliary cost centers).(¹¹)

Using this costing method, cost centers are identified and all production costs (direct, indirect, fixed and variable) are allocated to the costs of the organization’s products and services. It allows knowing the value that each cost center absorbs from other cost centers or external suppliers, and the sum corresponds to the cost center value under consideration. Thus, production centers’ direct and indirect costs are added to the allocation of auxiliary and administrative cost centers, obtaining the total cost.(¹¹)

In unit I, the fee for service (open account, no bundled items) and mixed (number of defined hospitalization days and no risk included [rehospitalizations and/or surgical complications], including orthoses, prostheses and special materials (OPSM)) models were analyzed; and in unit II, the bundle model was created (no defined number of hospitalization days, risk included [rehospitalizations and/or surgical complications], including OPSM).

It is important to note that the bundles were assembled by the coordinators of care teams at unit II, who have specific technical knowledge of the procedures performed. Through meetings, comparisons of techniques and alignment with the different surgical teams, the materials, medications, OPSM, equipment, fees related to physical space (use of surgical room, outpatient room) and medical fees were listed. After the bundles were assembled, the procedures were priced by HP-SP’s Product and Pricing Sector, considering the risks incorporated (surgical complications, increased hospitalization period, readmissions, loss of material and/or medications, among others), the safety margin and the values practiced by the market.

From 2018 to 2021, 2.834 cholecystectomy (elective and emergency) and bariatric surgeries were performed. Adopting a 95% confidence level and a 5% margin of error, the sample size obtained was 357 surgical procedures and their outcomes. After the total calculation, it was necessary to weight stratified values through several percentage calculations of how much each account meant in relation to the population. Thus, the samples were established as follows: 30 cholecystectomy surgeries paid by fee for service and 150 in mixed, for unit I, and 24 in bundle, for unit II; and 24 bariatric surgeries paid by fee for service and 70 in mixed, for unit I, and 58 in bundle, for unit II. For sample calculation, all cholecystectomy surgeries (elective and emergency) and bariatric surgeries performed in the two units during the aforementioned period were considered.

Data collection and analysis

Data collection took place through access to electronic records (medical records and accounts for surgeries and hospitalizations) made available by HP-SP from July 2023 to June 2024. For any doubts or conflicts of information, clarifications were requested from the managers responsible for the Commercial and Products and Pricing sectors.

The data were organized in electronic spreadsheets according to the following topics: costs and revenues; length of hospital stay; readmissions; and complications related to surgery and/or hospitalization.

For the analyses, the Jamovi statistical software (Version 2.4) was used.(¹²) Continuous numerical variables were presented as “mean ± standard deviation (SD)” and minimum and maximum values, and categorical variables as frequency and percentages (%). P-values <0.05 were considered statistically significant.

For variables with a statistically significant difference (p<0.05) in the comparison of the three groups (remuneration models) using the ANOVA test, the Games-Howell test was used for the post-hoc comparison two by two.

The development of this study complies with national and international standards of ethics in research involving human beings. The research project was approved by the HP-SP Research Ethics Committee, through Substantiated Opinion 3.975.774 (Certificate of Presentation for Ethical Consideration 28550620.8.0000.0070).

Results

In the sample of cholecystectomy surgeries (elective and emergency), females predominated; the mean age for the mixed model was 51.15 years (SD±14.96), fee for service was 48.9 years (SD±15.52) and bundle was 47.2 years (SD±10.71); the diagnosis of gallbladder stones was the most frequent in the three models (73%, 63% and 71%, respectively), followed by cholecystitis (11%, 17% and 2%, in that order). Considering the main surgical procedures, in the three models, cholecystectomy with videolaparoscopic cholangiography predominated (86% in the mixed, 83% in the bundle and 73% in the fee for service). The operating room time was longer in the mixed, with a mean of 63.82 minutes (SD±28.72); the bundle presented the shortest time (51.17-SD±15.23 minutes). In the three models, the mean daily hospitalization was one day, being the shortest in the bundle model (1.05 - SD±0.210). There were no surgical complications recorded in the bundle model. In the fee for service model, 10% of patients had some complication, and in the mixed model, 4%.

Table 1 shows the comparison between the models, using the ANOVA statistical test, in relation to the revenue and cost values attributed to cholecystectomy surgeries. There was a statistically significant difference between all revenue and cost variables assessed, except hospitalization cost. For the post-hoc comparison, two by two were considered: mixed versus fee for service: (there was a statistical difference for surgery revenue, total revenue and profit); mixed versus bundle (there was a statistical difference for all variables, except hospitalization cost and profit); and fee for service versus bundle (there was a statistical difference for all variables, except hospitalization cost).

Table 1
Comparative distribution of values, in reais, of revenue, cost and profit related to cholecystectomy surgeries (elective and emergency) performed in units I and II according to the remuneration model (Mixed, Fee for service and Bundle)

Values in reais (R$)	Unit I						Unit II			Statistical tests
	Mixed			Fee for service (FFS)			Bundle (B)
	n	Mean±SD	Minimum-Maximum	n	Mean±SD	Minimum-Maximum	n	Mean±SD	Minimum-Maximum	ANOVA (p)	Mixed x FFS*	Mixed x B*	FFS x B*
Surgery revenue	150	7.037.71 ±874.62	3.384.00 – 8.506.00	30	11.090.67 ±2.147.26	7.935.00 – 17.679.00	24	4.330.58 ±825.24	3.267.00 – 6.667.00	<0.001	<0.001	<0.001	<0.001
Surgery cost	150	5.783.49 ±2.860.22	158.33 – 2.2766.00	30	7.777.42 ±5.381.83	2.831.00 – 23.055.00	24	2.538.90 ±774.42	1.202.00 – 3.742.00	<0.001	0.135	<0.001	<0.001
Hospitalization revenue	150	2.169.25 ±1.535.85	346.00 – 11.090.00	30	3.467.07 ±3.460.51	657.00 – 18.652.00	24	1.230.17 ±394.54	463.00 – 2.047.00	<0.001	0.125	<0.001	0.004
Hospitalization cost	150	2.717.50 ±1.738.71	115.09 – 12.435.00	30	2.358.16 ±2.047.01	42.00 – 11.331.00	24	2.734.77 ±2.743.42	77.00 – 11.619.00	0.671	0.644	1.000	0.842
Extra revenue	32	2.194.88 ±2.558.88	87.00 – 10.686.00	0	NaN ±NaN	-	19	1.816.68 ±989.80	562.00 – 3.358.00	0.359
Extra cost	31	2.111.19 ±3.144.12	53.00 – 15.003.00	0	NaN ±NaN	-	19	311.74 ±427.42	16.86 – 1.364.00	0.007
Total revenue	150	9.675.21 ±2.098.86	7.308.00 – 19.848.00	30	14.557.73 ±4.911.30	9.355.00 – 36.331.00	24	6.998.96 ±1.096.92	5.223.00 – 8.581.00	<0.001	<0.001	<0.001	<0.001
Total cost	150	8.937.30 ±4.659.82	273.42 – 36.698.00	30	10.135.58 ±5.547.70	3.378.00 – 24.265.00	24	5.520.47 ±3.243.18	1.534.00 – 15.175.00	<0.001	0.515	<0.001	0.001
Profit	150	737.90 ±3.587.17	-19.352.00 – 8.840.58	30	4.422.15 ±5.415.67	-11.566.00 – 12.103.00	24	1.478.49 ±3.384.47	-9.025.00 – 6.114.00	0.004	0.003	0.590	0.047

• * Games-Howell Post-Hoc test.

The total mean revenue was higher for the fee for service model (R$14,557.73-SD±4,911.30), followed by the mixed (R$9,675.21-SD±2,098.86) and bundle (R$6,998.96-SD±1,096.92) models. There was a greater statistical difference in the mean revenue for surgery, with the highest remunerations in the fee for service (R$11,090.67-SD±2,147.26) and mixed (R$7,037.71-SD±874.62) models. In the bundle model, the lowest mean total cost was obtained (R$5,520.47-SD±3,243.18), the highest mean cost with hospitalization (R$2,734.77-SD±2,743.42) and the lowest mean surgery revenue (R$4,330.58-SD±825.24).

Considering the mean revenue for hospitalization, the fee for service model also presented the highest value (R$3,467.07-SD±3,460.51) and the bundle model the lowest (R$1,230.17-SD±394.54). Only in the fee for service model was the cost lower than the revenue. In the sample of bariatric surgeries, females also predominated in the three models (mixed=73%, fee for service=63% and bundle=71%); the mean age was 41.44 (SD±11.37), 47.04 (SD±10.76) and 38.02 (SD±9.67) years, respectively, with a diagnosis of obesity, with videolaparoscopic gastroplasty for morbid obesity (mixed=79%, fee for service=88% and bundle=54%). The mean operating room time was similar in the mixed and fee for service models, and shorter in the bundle (72.67-SD±24.53 minutes). The number of hospitalization days was 1.63 (SD±0.71) in the fee for service model, 1.50 (SD±0.63) in the mixed model, and 1.16 (SD±0.37) in the bundle model. Although there was no statistically significant difference regarding the postsurgical complications recorded in the medical records, the percentages were higher in the fee for service and bundle models (14% and 12%, in that order). Table 2 shows that there was a statistically significant difference in most of bariatric surgery sample revenue and cost variables, except for hospitalization cost.

Table 2
Comparative distribution of values, in reais, of revenue, cost and profit related to bariatric surgeries performed in units I and II according to the remuneration model (mixed, fee for service and bundle)

Values in reais (R$)	Unit I						Unit II			Statistical tests
	Mixed			Fee for service (FFS)			Bundle (B)
	n	Mean±SD	Minimum-Maximum	n	Mean±SD	Minimum-Maximum	n	Mean±SD	Minimum-Maximum	ANOVA (p)	Mixed x FFS*	Mixed x B*	FFS x B*
Surgery prescription	70	19.734.46 ±3.028.54	12.823.00-34.931.00	24	24.175.33 ±6.813.41	14.051.00-39.785.00	58	12.148.71 ±1.548.45	10.075.00- 20.149.00	<0.001	0.013	<0.001	<0.001
Surgery cost	70	15.988.13 ± 5.483.37	5.562.02 -40.378.00	24	15.679.27 ±4.739.81	11.595.57-32.592.00	58	10.332.49 ±2773.03	329.19- 17.281.00	<0.001	0.962	<0.001	<0.001
Hospitalization prescription	70	3.873.46 ±2.856.50	1.356.00-24.097.00	24	5.250.33 ±2.491.22	2.173.00-13.152.00	58	3.130.07 ±759.27	1.356.00- 4.838.00	<0.001	0.074	0.098	0.001
Hospitalization cost	70	3.812.44 ±1.938.35	1.220.00-17.573.00	24	3.547.12 ±1.446.27	1.761.00-8.116.00	58	4.640.76 ±5.449.81	84.22- 35.058.00	0.361	0.760	0.517	0.340
Extra revenue	6	6.615.67 ±4.926.32	463.00-12.589.00	0	----	----	35	2.551.09 ±1.236.97	1.199.00- 5.778.00	<0.001
Extra cost	6	4.580.89± 4.765.72	347.23-11.679.27	0	----	----	35	870.02 ±1394.47	51.00- 5.279.00	<0.001
Total revenue	70	24.174.97 ±4.386.19	19.094.00-40.193.00	24	29.425.62 ±8.233.10	20.675.00-46.433.00	58	16.818.22 ±1.916.85	14.913.00- 22.993.00	<0.001	0.016	<0.001	<0.001
Total cost	70	20.488.57 ±6.153.12	13.248.00-46.231.00	24	19.226.39 ±5.572.16	13.804.96-36.650.00	58	15.498.27 ±5.926.24	527.29- 43.295.00	<0.001	0.623	<0.001	0.025
Profit	70	3.686.40 ±6.140.11	-16.873.00-11.149.00	24	10.199.22 ±5.205.53	3.021.00-25.917.92	58	1.319.96 ±6.155.47	-28.382- 17.049.71	<0.001	<0.001	0.081	<0.001

• * Games-Howell Post-Hoc test.

Concerning the similarity of the sample of cholecystectomy surgeries, in bariatric surgeries, the mean total revenues were higher in the fee for service (R$29,425.62-SD±8,233.10) and mixed (R$24,174.97-SD±4,386.19) models, and the bundle presented the lowest mean revenue (R$16,818.22-SD±1,916.85). The mean revenue from bariatric surgeries was higher in the fee for service (R$24,175.33-SD±6,813.41) and lower in the bundle (R$12,148.71-SD±1,548.45).

In relation to the mean revenue from hospitalization, the fee for service (R$5,250.33-SD±2,491.22) and bundle (R$3,130.07-SD±759.27) models showed a statistically significant difference. The lowest mean total cost was obtained in the bundle (R$15,498.27-SD±5,926.24), but the mean hospitalization cost was higher in this model (R$4,640.76-SD±5,449.81). Regarding profit, the fee for service model, compared to the mixed and bundle models, showed a statistically significant difference, indicating better financial results, in the samples of cholecystectomy and bariatric surgeries.

Discussion

Different remuneration models practiced in two units (I and II) of a Health Center in São Paulo were comparatively analyzed from healthcare service providers’ perspective. In the fee for service model, applied in unit I, healthcare service providers are paid per service or procedure performed, according to the quantity of services provided, which may encourage the provision of additional and unnecessary care.(⁵,⁷) In this case, all financial risk is borne by HIC, since there is no control or predictability of costs related to the procedures performed, and healthcare service providers obtains greater profitability. As previously mentioned, the transition process between the fee for service model and the bundle model, which does not include risk and the daily hospitalization rates are predetermined, was called the mixed model.

In the bundle model applied in unit II, instead of paying for services rendered, a global payment is made to cover all services required to treat a specific condition or perform a given procedure, covering all costs associated with the expected care. The main objective of this model is to encourage coordination of care and reduce overall costs, promoting efficiency and quality of care provided. However, the success of the bundle depends on the payment bundle value, whose adequate implementation requires a detailed assessment of values and risks.(⁵-⁷,⁹)

In the sample of cholecystectomy surgeries, the fee for service model, despite the higher costs, was the model that generated, as expected, the highest revenue and profit for HP-SP, while the mixed model generated the lowest profit. The bundle model presented the lowest mean total costs and, if the principles of this model were replicated in unit I, the profitability of HP-SP would be even better, as it would have the opportunity to increase its financial results in relation to the costs of the surgeries studied.

The bundle model was the one that best contributed to the financial sustainability of HIC, as it generated the lowest total revenue, providing better sustainability in the relationship established healthcare service providers and financiers. It is worth noting that unit II, which uses the bundle remuneration model, obtained the best results regarding room time, number of hospitalization days and complications associated with cholecystectomy surgeries.

In the sample of bariatric surgeries, the fee for service model also corresponded to the best revenue for HP-SP. However, the bundle provided greater benefits to HIC by enabling the performance of the same surgical procedure with a smaller budget.

It is important to highlight that the success of the bundle depends on the payment bundle value, and its implementation requires a detailed assessment of values and risks and rigorous monitoring, bundle review, price and constant analysis of procedure costs. In view of these points, it is understood that, given the similarity of results of cholecystectomy surgeries, unit I has the opportunity to review bariatric surgery costs, considering what is practiced in unit II and, in this way, increase its profitability.

A systematic review that analyzed, based on 20 studies, the effects of bundled payments on health costs, use of services and quality of care in three programs of the Centers for Medicare and Medicaid Services, indicated that this model resulted in a reduction in Medicare payments in six of 16 articles that analyzed the costs involved. There was a significant reduction in length of hospital stay in eight of 13 studies that analyzed this outcome and a one-third drop in the readmission rate of studies that addressed this outcome.(¹³)

However, a study that compared changes in quality of care for 103,251 (100.0%) patients hospitalized with heart failure according to the hospital’s participation or not in the Bundled Payments for Care Improvement (BPCI) program (8.45% in 23 BPCI hospitals and 91.55% in 224 non-BPCI hospitals) of the Centers for Medicare and Medicaid Services, indicated that hospital participation in the aforementioned program was not associated with improvements in care processes and readmission rates.(¹⁴)

There is no doubt that the complex financial situation of SHS requires a review and discussion of the remuneration models used by healthcare service providers and HIC. In this regard, a study that analyzed the form of remuneration chosen by a Brazilian private healthcare institution highlights that the model adopted by the institutions plays a fundamental role in the design, dynamics and efficiency of their flows and results. It showed that the model constructed was priced in bundles by procedure, taking into account surgical times with good practice protocols for each specialty, but did not faithfully follow any other existing model. It concluded that this design provides predictability and cost control to funders.(¹⁵)

In the United States of America, a study on bundled payments in spinal surgeries reports that this model is an alternative to replacing fee for service, which can lead to cost reduction and greater accountability of surgeons, not only for the results, but also for the costs and care provided to patients.(¹⁶)

A systematic review that analyzed the fee for service and Diagnosis Related Group (DRG) remuneration models (which stipulates a single payment from the diagnosis, encompassing the entire set of care required) in appendectomy surgeries indicated that the fixed payment model resulted in shorter hospital stays, but with higher hospital readmission costs. The increase in early readmission rates suggests that the fixed payment model (DRG) may accelerate negative practices, such as early discharge. However, the authors state that the bundled model has the potential to significantly impact reimbursements of private health systems, as it provides better control over cost variability and better coordination of healthcare.(¹⁷)

It is known that the private healthcare market has been seeking to transition to new remuneration models that recognize providers, services and technologies in delivering results that add value to patients. From this perspective, value-based healthcare has been conceived as a solution to offer better healthcare services to patients and, at the same time, generate predictability about the costs involved. Achieving a redefinition of value that represents all actors in the chain and applying it is highly complex, but very necessary to contribute directly to financial sustainability. Therefore, including and engaging all SHS actors to promote a joint vision of value and efficiency is a conditioning factor for the successful implementation of value-based healthcare models.(¹⁸)

Recurrent searches in national and international literature revealed a lack of studies that comparatively addressed remuneration models practiced in hospital institutions that are part of SHS. Thus, the contribution of this study is to generate new knowledge on the comparison between different remuneration models from healthcare service providers’ perspective. The methodology adopted can be replicated in other private hospitals, aiming to understand the repercussions of the models adopted on their billing and on the quality of care processes.

The limitations of this study are: a) its conduct in a single hospital; b) only two types of digestive system surgeries were considered; and c) the lack of separation in terms of time of surgical techniques related to bariatric surgeries.

Conclusion

The comparative analysis between the fee for service, mixed (in unit I) and bundle (in unit II) remuneration models, from healthcare service providers’ perspective, indicated that there was a statistically significant difference in most revenue and cost variables, except hospitalization cost, in the samples of cholecystectomy and bariatric surgeries. It was found that fee for service corresponded to the best revenue for HP-SP and bundle to the lowest mean total costs, with more favorable results regarding room time, number of hospitalization days and complications.

Acknowledgements

This work was carried out with the support of the Brazilian National Council for Scientific and Technological Development (In Portuguese, Conselho Nacional de Desenvolvimento Científico e Tecnológico - CNPq.

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Edited by

• Associate Editor:
  Alexandre Pazetto Balsanelli (https://orcid.org/0000-0003-3757-1061) Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brasil

Publication Dates

• Publication in this collection
  07 Nov 2025
• Date of issue
  2025

History

• Received
  10 July 2024
• Accepted
  22 Apr 2025