25 Mar Carta enviada a la comisión de expertos de la UE en respuesta al informe sobre el modelo PPP
For the attention of Mr Jan De Maeseneer
DG Health & Consumers
Expert Panel on effective ways on investing in health (EXPH)
Directorate D: Health Products and Systems
Unit D3 – eHealth and Health Technology Assessment
Office B232, 08/036
Valencia, March 25th 2014
Dear Mr De Maeseneer,
I have received and read the report “Health and Economic Analysis for an Evaluation of the Public-Private Partnerships in Health Care Delivery across Europe”, published by the DG Health & Consumers of the European Commission. I would hereby like to declare that I am in complete disagreement with some of the conclusions of the report that call into question the efficiency of the public-private partnership healthcare model.
I would like to place on record the following statements:
- The report is biased and insufficient and contains false information, common errors and subjective interpretations. This is the result of analysing the model without the necessary rigour. As an example the report states that the duration of the Alzira concession is of 25 years with an extension to 35 years whereas it is a 15-year contract, extendable up to 5 years. Little credibility can be lent to the rest of the report when such an elementary point is mistakenly given.
- No expert in the PPP model has been involved in the drafting of the report as the only Spanish representative in the “expert panel” held a position of responsibility in the previous government of Spain and was Castilla-La Mancha Government Minister of Health in the previous administration. Mr Fernando Lamata is a manager with knowledge of the conventional public system who holds a clear stance against new management models in general and particularly against the concession model.
- The report itself acknowledges that it does not have sufficient information to draw definite conclusions. However, no data have ever been requested from Ribera Salud Grupo or the Health Ministry of the Generalitat Valenciana (Government of the Valencia Region) in spite of having chosen the La Ribera Hospital as an example in the evaluation.
- The report includes false information, among them the cost of treatments and referrals of patients. The services portfolio of the La Ribera Hospital includes units such as Heart Surgery or Comprehensive Cancer Treatment. Thus, like the rest of public hospitals, only certain cases such as transplants are transferred to referral units. Prices are public as they require approval by the Valencia Parliament and are included in the Tariffs Law, published yearly by the Valencia Government.
- The report provides biased conclusions derived from other reports such as the National Competition Commission report. It makes sense that there is very little competition in this kind of tenders, due to the sector is new and there are few specialized companies with the sufficient knowledge to carry out these projects with all the guarantees required.
- Another mistake committed in the report is the erroneous interpretation of “rescue”. Once again we would like to explain that the increase in the capitated fee was due to the inclusion of new services and new investments in the new contract, as it comprised the management of Primary Care, besides Specialized Care. This comprehensive model of Primary and Specialized Care management was implemented in 2003 in the Alzira health department as a pilot experience for the subsequent establishment in the whole Valencia Region. Therefore, the private concession had to be rescued and a new call for public tender was made. In order to reach a mutual agreement on the concession rescue, payment to the concessionaire was incorporated for the non-amortized investment to date plus loss of earnings as the 10-year business plan foreseen by the company could not be met. Such rescue did not imply any outflow of public funds from the Valencia Government as the new tender’s terms of reference included as mandatory for the new concessionaire to assume this cost via a €72 million canon. Hence, this operation did not imply any cost for the Valencia Government; instead it meant a €4 million income.
- The report overlooks the fact that the profit margin for the company has been limited as per contract in the Valencia region at 7,5 % IIR. It profits surpass 7,5% the Administration will decide upon its return to the Administration itself, an increase of the investment plan or a decrease of the capitated fee.
- The report distorts a recent statement by Mr Alberto Fabra, President of the Valencia Government, in which he referred to not initiating new projects under a public-private model “during this legislative term”, which comes to an end in may 2015.
- It is untrue that there are no reports supporting the public-private model’s performance. As an example, the IASIST report “Evaluation of results of Spain’s hospitals according to their management model” (document available in Spanish at http://www.iasist.com.es/files/Modelos_de_gestion.pdf) considers private management more efficient. It is worth recalling that in the Valencia Region, the Ministry of Health each year establishes the Objective Plan (Acuerdos de Gestión), the ranking between all public health departments (direct management and concessions) that features over 100 indicators related to care quality, safety and efficient resource management including waiting lists, delay, mortality rates, readmissions and patient satisfaction, among other. The health concessions occupy the top positions, as an example the Torrevieja and Vinalopó departments ranked first and second in 2013 (http://cuidados20.san.gva.es/documents/504963/508166/Objetivos+2013).
- As a company that for sixteen years has been solely and exclusively dedicated to the health concessional model, we condemn the recurrent publication of reports like this one that are not supported by objective and reliable data, where appropiate sources have not been approached and data have not been collated or analysed in sufficient depth and yet partisan, biased and subjective conclusions are drawn.
- Finally, as we have always expressed, we reiterate the full readiness of Ribera Salud Grupo to collaborate with any organisation or institution interested in learning about our data. We hereby call on all public bodies to definitively create an independent observatory in Spain that may analyse all management models, including direct management. It is our aim for a serious and rigorous analysis on the different existing health management models to be undertaken.
We hereby expressely demand the modification of the terms and conclusions regarding the Alzira Model. In addition, we reserve the right to undertake the legal action that Ribera Salud Grupo may deem appropriate.
Alberto de Rosa Torner
Ribera Salud Grupo