The collaboration of private Hospitals with the Public Health System: the case of La Rioja, Spain (1986-2019).

1. Introduction

Hospital care is an essential part of the healthcare system. The study of the historical development of hospital systems and the dependence on private and public hospital infrastructure for care provision has become a topic of renewed interest in international academic circles due to its relevance to healthcare and the economic cost it entails [1]. The National Health System, which serves almost all Spaniards and residents in Spain, is the result of a complex historical process and has transitioned from a Social Security-based model financed by contributions to a tax-funded system inspired by National Health Services, with a focus on the population’s health [2]. The National Health System is a universal healthcare system fully decentralized and adapted to the State of Autonomies. Each Autonomous Community has legislative capacity for its organization and management. Universal healthcare models, also known as National Health Services, are characterized by universal coverage, public financing, and predominantly public provision of services. Equity is established as the general principle of the National Health System, understood as the guarantee that access to and the provision of health services are carried out under conditions of equality.

La Rioja is an unprovincial Autonomous Community of Spain located in the North of the Iberian Peninsula. It covers part of the Ebro Valley in its northern zone and the Iberian System in the south. With an area of 5,045 km², it is a small region compared to the whole of Spain, with a population of 315,931 inhabitants [3]. In the analysis of demographic evolution in La Rioja, the two most relevant features of the Riojan population are aging and immigration, which has defined the demographic structure of this territory. The evolution of sociodemographic characteristics has influenced the change in the patient profile in La Rioja, which includes older age, greater comorbidity and complexity, chronicity, and dependence [4].

In the regulatory framework, it is worth noting the application of three regulations: First, Law 14/1986 of April 25, General Health Law, which established the National Health System, encompassing health services provided by the State Administration and the Health Services of the Autonomous Communities [5]. Second, Royal Decree 1473/2001 of December 27 transferred health responsibilities and services from the National Health Institute to La Rioja, granting the Autonomous Community authority in health matters [6]. Third, Law 2/2002 of April 17 [7] defined the Public Health System of La Rioja as the set of organizational means, resources, and actions to ensure individuals' right to health protection. The Riojan Health Service, established in 1991, is the public entity under the Ministry for Health of the Government of La Rioja responsible for overseeing healthcare services and benefits provided by Public Health Facilities in La Rioja. The existing Spanish historiography on the history of hospitals lacks comprehensive and long-term interpretations that allow us to understand the obstacles faced in the development of hospital services, both public and private, the key elements of the process, and the stages of modernization or involution in their political, economic, and social context [8,9]. There are no comprehensive reviews of public and private hospitals in La Rioja for the 1986–2019 period, which serves as a case study reflecting what has happened in other regions.

This study began in 1986 with the approval of the General Health Law and ended in 2019 to delimit a period of homogeneous healthcare activity without the particularities derived from hospital care during the exceptional situation experienced during the coronavirus SARS-CoV-2 (COVID-19) pandemic. This study aims to review the strategy of public–private collaboration among hospitals in La Rioja and takes into account the patrimonial dependence of hospitals and the purpose and impact of each of them. We have reviewed the evolution of hospitals: how and why some were closed and others were opened.

2. Source and Methods

A local study and interpretation were conducted on a long-term basis and within a national context to analyze the development of private hospital supply and its relationship with public hospital resources, which is crucial for understanding the hospital development of La Rioja. Through a documentary study, we analyzed the framework of hospitals in La Rioja and each hospital's regulation and specific sources. Additionally, we analyzed data comparing hospitals in La Rioja to those in other Autonomous Communities within the National Health System. Three main moments have been considered: heuristic (documentation search), hermeneutic (interpretation of data in its context), and critical (evaluation of documentation). Primary and secondary documentary sources from the National Health Management Institute archives and the Government of La Rioja, including the General Archives of La Rioja and the Institute of Riojan Studies, have been reviewed. Municipal archives from La Rioja, Logroño, Haro, and Calahorra have also been studied. Information from hospital catalogs and censuses from the Department of Health and the Ministry of Health, data from the National Institute of Statistics and the Institute of Statistics of La Rioja, and other documents, such as institutional reports, have also been utilized.

3. Results

The Public Network of the National Health System comprises publicly funded and private hospitals that have a substitute agreement or belong to a Public Utilization Network; that is, they are funded with public funds. Throughout the 1986–2019 period, the proportion of public hospitals was 56.22% (on average) in La Rioja and 44.62% in Spain. At the beginning of this study (1986), La Rioja had seven hospitals, of which 43% were private; this percentage remained unchanged at the end of the study period. In 2000, the proportion of public hospitals increased to 80%, and that of private hospitals decreased to 20%. This pattern changed in La Rioja in 2013 (public hospitals: 39.67%; private hospitals: 55.13%) (Figure 1). Likewise, the proportion of public beds throughout the 1986–2019 period was 87.75% (La Rioja) and 68.25% (Spain as a whole) on average, and the proportion of private beds was 12.25% (La Rioja) and 31.75% (Spain as a whole) on average. From 2013, there was a growing trend in the proportion of private beds (22%), and the proportion of public beds decreased to 78% (a more pronounced pattern than at the national level) (Figure 2). At the end of this study (2019), 57% of hospitals were private.

Overall, hospitals in La Rioja during the study period (1986–2019) are segmented by type: General Hospitals, Psychiatric Hospitals, and Sociosanitary Convalescence Hospitals (Table 1). Private hospitals included Sanatorio Velázquez, Policlínico Quirúrgico “Nuestra Señora del Carmen”, Policlínico Riojano “Nuestra Señora de Valvanera”, Clínica Los Manzanos, Centros Sociosanitarios de Convalecencia “Los Jazmines”, and “Nuestra Señora Virgen del Carmen”. In addition, the Calahorra Hospital Foundation, a publicly managed hospital that was established in 2000, is included. This hospital adhered to the non-profit healthcare organization model outlined in Royal Decree 29/2000 of January 14, which introduced new management methods for the National Health Institute (INSALUD), the former public entity responsible for the healthcare provision and management until the current National Health System was configured. After the study period and per Law 1/2022 of February 23, the Calahorra Hospital Foundation was transformed into a Public Health Foundation and became part of the Riojan Health Service.

3.1. Sanatorio Velázquez

The Sanatorio Velázquez or Velázquez Clinic was owned by Sociedad Anónima Velázquez and was established in 1965. It was a privately owned center located in Logroño that contained approximately fifty beds and had an agreement with the Public Health System of La Rioja. It was a General hospital with departments for Medicine, Surgery, Obstetrics and Gynecology, and Pediatrics (classified in Group IV, Surgical, type IA, the first level of complexity) [10]. The center closed its doors in April 1990. This privately contracted clinic ceased operating on patients covered by Social Security on January 1, 1986, when the Incompatibilities Law in the public sector was enacted [11]. This decision resulted in a significant reduction in its activity.

3.2. Policlínico Médico Quirúrgico "Nuestra Señora del Carmen"

The Policlínico médico quirúrgico "Nuestra Señora del Carmen", a local facility in Calahorra, was established in 1968, contained approximately fifty beds, and was contracted with the Public Health System of La Rioja. It was founded by Dr. Victorino Imaz Jiménez, Dr. José Piñeiro Esparza, and Dr. Esteban Lana Beaumont. In the first phase (1968–1989), its activity was focused on acute patient care. In the second phase (1990–1997), assistance was reoriented, mainly towards chronic patients. For contracts, it was classified as a General Hospital, with departments for Medicine, Surgery, Obstetrics and Gynecology, Pediatrics, and Emergency Services (classified in Group IV, Surgical, type IA) [10]. One of the most valued areas was Obstetrics, as, without the Polyclinic, women from the Lower Rioja region had to travel to other cities, such as Logroño or Pamplona, to give birth. There was an upward trend in activity from patients referred by the INSALUD to the Polyclinic from 1989 to 1991. Gradually, especially from 1992 onwards, the INSALUD began to limit the referral of chronic patients and long hospitalizations. In April 1997, the existing agreement was denounced with the establishment of the Calahorra Specialties Center, the embryo of the Calahorra Hospital Foundation [12], and this fact partly conditioned the future of the Polyclinic, which closed its doors on April 30, 1997.

3.3. Policlínico Riojano “Nuestra Señora de Valvanera”

The Policlínico Riojano "Nuestra Señora de Valvanera" was a private Center in Logroño belonging to gynecologists, Drs. Barquín and Maguregui. It was established in 1969 as a General Hospital. From the beginning, it maintained an agreement with the Public Health System of La Rioja. Initially classified as a non-beneficent and Surgical Private Hospital in 1986, it became a General Hospital in 2006 (classified in group IV, level IA) [10]. The hospital’s activity gradually focused on convalescence (medium stay) and evolved into a Sociosanitary Center. The Polyclinic had a Singular Agreement. The complementary provision modalities corresponded to the medical and surgical areas [13]. It was acquired by the company Viamed Salud, one of the leading Hospital Groups in the Spanish market created in 2001, which is owned by MEIF Amistad Holding Sociedad Limitada and belongs to Macquarie Assets Management. In 2013, it moved to a location near Hospital San Pedro. In 2007, the opening of the San Pedro Hospital was completed, with the start-up of the High Resolution Center for Healthcare Processes, which led to an adjustment in the activity carried out in the Polyclinic due to changing healthcare needs. Like the case of the Sanatorio Velázquez, the Polyclinic ceased to operate on patients covered by Social Security on January 1, 1986, when the Incompatibilities Law in the public sector came into effect. This decision resulted in a significant reduction in its activity.

3.4. Clínica Los Manzanos

The Los Manzanos Clinic was built in 2004 in Lardero, a municipality located 5 km from Logroño, by the Viamed Salud Group [14]. It is a General Hospital with Medical–Surgical specialties. It was classified as a non-beneficent private institution with a hospitalization capacity of approximately 50 beds [15]. From its inception, it had an agreement with the Public Health System of La Rioja. The Public Administration and Finance Department awarded the Management of Public Service contract to the Los Manzanos Clinic for providing healthcare services for surgical and interventional diagnostic and therapeutic procedures [16]. The hospital's billing to the Health Department showed an upward trend from 2016 to 2018. However, it decreased thereafter until the Government of La Rioja suspended the contract in 2021.

3.5. Centro Sociosanitario de Convalecencia "Los Jazmines"

The Centro Sociosanitario de Convalecencia "Los Jazmines" is located in Haro and was established in 2005. The project was carried out by order of a Temporary Union of Companies. The managing entity was FIRSA II-Inversiones riojanas Sociedad Anónima, which brought together several companies, including Viamed Salud Sociedad Limitada [17]. It was classified as a non-beneficent private hospital specializing in Geriatrics and/or long-term care. Healthcare was provided to patients from Rioja Alta who simultaneously required healthcare and social attention. The center had 140 places, of which 115 were for assisted residents and 25 for Alzheimer's and other dementia patients. It was built through a public works concession contract. A sociosanitary agreement was established between the Government of La Rioja and this center for beneficiaries of the National Health System, whose activity increased over time. This hospital, owned by the Government of La Rioja, had a dual function: first, its role as a convalescence and medium-stay center, attending to patients who had suffered cardiovascular accidents, fractures, and chronic illnesses. Second, as a nursing home, it had 109 publicly owned places: 25 dedicated to high-dependency residents and the rest to severe-dependency residents [18].

3.6. Centro Sociosanitario de Convalecencia "Nuestra Señora Virgen del Carmen"

This hospital began its journey in Calahorra in 2013 with 75 beds. The Government of La Rioja awarded the Policlínico de Valvanera Society, belonging to Viamed, the construction, and management of this center through a public works concession contract for 25 years. The center was classified as a non-beneficent private hospital specializing in Geriatrics and/or long-term care. The center’s objective was to provide healthcare to patients from Rioja Baja who simultaneously required healthcare and social attention. The activity and economic amount show an upward trend. The start-up represented a total investment of approximately EUR 7 million and created 70 direct jobs and another 50 indirect jobs. With the creation of this center, the Riojan government completed its network for long-term patient care. Together with the 29 places in the Los Jazmines residence in Haro and the 75 in the Valvanera Polyclinic in Logroño, they added up to 176 places [19].

3.7. Fundación Hospital Calahorra

The Fundación Hospital Calahorra was established by the National Health Institute in 2000. It had a Collaboration Agreement formalized on April 5, 2001, signed between the Ministry of Health and Social Services of the Government of La Rioja and the hospital. Each year, the Department of Health signed an Additional Clause. The purpose of the Agreement was to provide healthcare to beneficiaries of the Public Health System of La Rioja [20].

4. Discussion

4.1. Evolution of Private Hospitals in La Rioja

Throughout the years, there was a promotion of the development of public hospitals and the establishment of a greater number of medical and surgical specialties, aiming to reduce the dependence of hospitals on neighboring Autonomous Communities, which resulted in a decrease in the referral of patients to Navarra, Cantabria, Aragón, and the Basque Country, compared to the previous period [21]. Additionally, agreements were developed with private hospitals. In general, these agreements were contracts between a healthcare facility (private or public) and the organization responsible for managing the Social Security healthcare services, by which the characteristics and rates of each contracted healthcare service are determined under certain conditions. In some cases, the relationship between the hospital and the Managing Entity is governed by a Linking Agreement or a Singular Agreement [22]. The public and private hospitals in La Rioja adapted according to political decisions and the evolution of the demographic and epidemiological patterns of disease and disability processes, as well as the expectations of the user collective and the system's resources. Here, we have focused on privately owned dependency hospitals. Throughout this study, two privately owned General Hospitals closed: the Sanatorio Velázquez (1965–1990) and the Policlínico Médico Quirúrgico “Nuestra Señora del Carmen” (1968–1997). Some of the factors involved were the changes associated with transformations in disease diagnosis and treatment, surgical methods, and the modernization of medicine in general, particularly hospital care, as they proved demanding in financial, logistical, and human capital terms. The effects of the economic crisis led to a reduction in private demand, the absence of generational family succession, and the reduction in agreements with Social Security, which undoubtedly contributed to the survival of these hospitals. An example of a change in mission and adaptation of the service portfolio was the Policlínico Riojano “Nuestra Señora de Valvanera”, which, although born as a General hospital, transformed into a Sociosanitary Convalescence Center due to the reduction in agreements and demographic epidemiological, and social changes. Those dedicated to sociosanitary care stand out among the private hospitals in La Rioja. We have observed a process of specialization of private hospitals in the sociosanitary space. As already mentioned, the purpose of sociosanitary agreements was to provide healthcare to patients who, having passed the acute phase, required simultaneous and synergistic attention from health and social services at the Viamed-Haro, Viamed-Valvanera in Logroño, and Viamed-El Carmen de Calahorra Centers (Table 2).

4.2. Public–Private Collaboration in La Rioja

A characteristic element of La Rioja has been the promotion of public–private collaboration. Private initiatives have increased in the Autonomous Community of La Rioja and have been focused on service agreements and concession contracts. From the Government of La Rioja, the arguments put forward to justify public–private collaboration are threefold: financial, efficiency, and risk transfer. In practice, the model of the hospital system in La Rioja is characterized by a predominance of public hospitals and beds over private ones, which increased from 2000 with the opening of the Fundación Hospital Calahorra. There was an upward trend in the proportion of private beds during the study period due to the incorporation of two convalescent sociosanitary hospitals. This is reflected in the evolution of the budget allocated to agreements in the Ministry of Health's budgets. This evolution is presented in La Rioja and at the national level. In 2002, the percentage of healthcare spending dedicated to agreements in Spain quadrupled that of La Rioja (Spain: 10.27; La Rioja: 2.64). The difference decreased throughout the study (2002–2019), although it remained higher in Spain. In 2019, the proportion in Spain was 8.85, and in La Rioja, it was 7.45 (Figure 3) [23].

The chosen formulas for sociosanitary agreements in La Rioja have been the Management Services Contract and the Work Concession. Regarding the Management Services Contract, on the one hand, in the sociosanitary field, it was the case of Nuestra Señora de Valvanera, with a term of 10 years, which ended in 2024. As for the Sociosanitary Centers “Los Jazmines” (Residence with Convalescence Unit) and “Nuestra Señora del Carmen” (Convalescence Unit), since they were newly constructed, the Government of La Rioja opted for the Work Concession, in which the work and service were contracted. The duration was up to 40 years. When the Concession ends, the centers will become the property of the Department of Health (in the case of “Nuestra Señora Virgen del Carmen”, it expires on December 31, 2037). In La Rioja, until 2004, patients requiring cardiac surgery had to be referred to other Autonomous Communities such as Cantabria. Therefore, once resources were maximized, the competent Health Department of the Government of La Rioja established contracts called "Concerts or Singular Linking Agreements." On the other hand, a Management Services Contract was established with Clínica Los Manzanos to provide healthcare for surgical procedures and diagnostic and therapeutic interventional procedures to beneficiaries of the Public Health System of La Rioja.

This study also has some limitations. Although there was continuity in data collection between 1986 and 2019, obtaining information regarding private hospitals has been challenging. Research could be expanded in the future to understand the impact of the COVID-19 pandemic on La Rioja's healthcare system. Additionally, comparative studies on different hospital management models could be conducted to study their impact on healthcare activity, patient and worker satisfaction, and the region's economy.

5. Conclusion

The development of the hospital system in La Rioja during this contemporary period, spanning from 1986 to 2019, has been determined by the presence of a mixed public–private hospital system and a reduced dependence on specialized hospitals from other Autonomous Communities in the past. The hospital system of La Rioja, thanks to collective effort, has united public and private initiatives to provide comprehensive care to the citizens of La Rioja.