Relações de agência em contratos de gestão de hospitais públicos: um estudo da medida da internação como mitigadora do risco moral

Abstract

The challenge of the complexity of the relationship between the State as a contractor and hospital management service providers is presented in this study in light of the Agency Theory in its various dimensions. Besides the configuration of the elements that characterize the agency relationship between the parties, the process of hospital admission has specificities that potentialize this problem, related to the level of uncertainty, the prerogatives of the service providers, the intensity of informational asymmetry and the impossibility of monitoring behavior. In this context, the establishment of results contracts is the strategy adopted in two of the models of management of public hospitals in Bahia (management by Social Organization and Public-Private Partnership) to restrict the possibilities of moral hazard incidence and preserve the efficiency of service provision, measured through the "hospital outflow" indicator. The ownership of management contracts in the mitigation of moral hazard, especially the measure of hospitalization adopted in these instruments, was evaluated in a comparative manner among the management models, using the descriptive qualitative research approach and having as sources the documents that regulate this service provision and the production of hospitalizations registered in the Hospital Admission System (SIH/SUS) in 2019, of three hospitals representing the different management models, including direct management, not linked to the management contract. The lower result in the ratio of admissions per bed and the longer stay in the direct management model suggest that the "out-of-hospital" indicator is potentially related to the efficiency of the service, which is corroborated by the analysis of the characteristics of the contracts based on the theoretical reference. However, the higher frequency of low complexity admissions and the significant differences for shorter average length of stay in the OS management model suggest that the inability of the "out-of-hospital" indicator to differentiate admissions is related to the higher incidence of moral hazard. As a strategy to mitigate this risk, the study aimed to propose a quantitative indicator for management contracts, which takes into consideration the different types of hospitalization, based on the variables available at SIH / SUS. Aspects related to the quality and sufficiency of SIH/SUS have limited the specificity of the proposed indicator and its potential for risk mitigation. Nevertheless, it is believed that its implementation will mean an improvement in the system for evaluating hospital management contracts, helping to qualify SIH/SUS data, which will make it possible to conduct other studies necessary to improve the measurement of hospital admission in hospital management contracts.