The Transformation of the Mexican Social Security Institute (IMSS): Progress and Challenges

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1 Health Systems & Reform ISSN: (Print) (Online) Journal homepage: The Transformation of the Mexican Social Security Institute (IMSS): Progress and Challenges José Antonio González Anaya & Regina García Cuéllar To cite this article: José Antonio González Anaya & Regina García Cuéllar (2015) The Transformation of the Mexican Social Security Institute (IMSS): Progress and Challenges, Health Systems & Reform, 1:3, , DOI: / To link to this article: Published online: 25 Jul Submit your article to this journal Article views: 1794 View related articles View Crossmark data Citing articles: 1 View citing articles Full Terms & Conditions of access and use can be found at Download by: [ ] Date: 09 January 2018, At: 23:21

2 Health Systems & Reform, 1(3): , 2015 Copyright Ó Taylor & Francis Group, LLC ISSN: print / online DOI: / Commentary The Transformation of the Mexican Social Security Institute (IMSS): Progress and Challenges Jose Antonio Gonzalez Anaya 1, * and Regina Garcıa Cuellar 2 1 General Director; Mexican Institute of Social Security; Mexico City, Mexico 2 Head of the Institutional Strategy Planning Unit; Mexican Institute of Social Security; Mexico City, Mexico CONTENTS IMSS s Silent Reform Results: First Two Years What s Next for IMSS and the Mexican Health System? References Abstract In 2013, the Mexican Social Security Institute (IMSS), the largest social security institution in Latin America, began a major transformation with two clear objectives: first, to improve the quality of its services in order to achieve better health outcomes and increase satisfaction among its 70 million beneficiaries and, second, to stabilize the Institute s finances. As in many other emerging economies, Mexico s demographic and epidemiological transitions, in conjunction with bureaucratic inefficiencies, left the Institute in a precarious financial situation. In 2012, the previous administration reported to the Mexican Congress that the Institute could remain financially self-sufficient until In the first year of this administration (2013), the deficit was reduced by half. By the second year (2014), the deficit was stabilized at the same level and the trend in the use of reserves consolidated. These results consolidated financial stability of the IMSS and, even better, were carried out while maintaining service quality and improving productivity. This article discusses how the IMSS transformation prioritized micro reforms over a macro approach to solve short-term problems by administering IMSS s limited resources in a more efficient and productive manner. The article also discusses the deep transformation that IMSS health care and resource management models will need to undergo in order to face pending medium and long-term challenges to ensure that IMSS can be sustainable in the long-term. Keywords: efficiency, health, IMSS, Mexican health system, Mexican Institute of Social Security, micro reform, transformation Received 26 May 2015; revised 5 June 2015; accepted 8 June *Correspondence to: Jose Antonio Gonzalez Anaya; josea. gonzalez@imss.gob.mx Color versions of one or more figures in this article can be found online at IMSS S SILENT REFORM Medicine, when used for the good of an individual s health is great, but when it toils in favor of the health of a nation it is simply grand. However, it also has to fit within the budget. [Phrase from legendary Mexican physician, Dr. Manuel Martınez Baez, adapted by Jose Antonio Gonzalez Anaya for his speech at the 105th IMSS General Assembly in October 2014.] The Mexican Social Security Institute (IMSS, or Instituto Mexicano del Seguro Social) is not only the largest social 189

3 190 Health Systems & Reform, Vol. 1 (2015), No. 3 security institution in Mexico; it is also the largest in Latin America. IMSS activities fall within three categories: (1) collector of employers contributions (IMSS collects 2% of gross domestic product, the second largest tax collector after the Mexican Internal Revenue Service), (2) insurer (including health, disability, life, workers compensation plans, and pensions), and (3) service provider (medical services, daycare centers, cultural and sports facilities, supermarkets, resorts, and funeral parlors) (Figure 1). Since its foundation in 1943, IMSS has been a leader among social security institutions across the developing world. During its more than 70 years of existence, IMSS has achieved remarkable medical success. IMSS surgeons were the first in Mexico to conduct a kidney transplant in 1963, a heart transplant in 1988, a pediatric liver transplant in 1994, a successful intrauterine surgery, a successful thoracic abdominal separation of conjoined twins in 2004, and a mechanical heart implant in IMSS has also been very successful in its provision of primary care services. Vaccination coverage of IMSS beneficiaries is over 96%, and IMSS annually provides approximately 30 million checkups and an average of two primary care consultations per beneficiary. Medical services constitute the bulk of IMSS s services as well as the main source of the Institute s expenses, accounting for 80% of total expenditure. Notwithstanding the medical accomplishments of IMSS, in recent years the Institution has faced four critical challenges: 1. Along with many other developing countries, Mexico is experiencing a radical change in the epidemiological and demographic profile of its citizens (and IMSS beneficiaries), defined by an aging population and a rapid, ongoing transition in disease burden. Noncommunicable chronic and degenerative diseases (NCDs), typically associated with developed countries, increasingly represent a great financial burden in Mexico and represent 81% of disability-adjusted life years lost (a summary measure of population health, integrating mortality with morbidity and disability information in a single unit). However, health issues that are common in many developing countries, such as respiratory and other infections as well as accidents, continue to remain the main sources of demand for first-time care and emergency services (Figure 2). Mexico s double morbidity burden competes for resources in health care services causing a gradual, but important, deterioration of IMSS s financial structure. 2. The health care model of IMSS was designed 70 years ago for the old epidemiological profile of the population and needs to be updated to meet the new epidemiological challenges that IMSS beneficiaries are facing. Under the old model, primary care and roles for physicians and nurses were designed to treat acute sicknesses. In this old model, when one or two visits per year were enough to treat most common illnesses, physicians played a relatively passive role in which they could wait for patients to attend their clinic. Nowadays, 80% of visits are taken by chronic patients, leaving little room for acute illnesses. Thus, many patients with acute illnesses end up having treatment in emergency care. The IMSS preventive program was created only 13 years ago and does not have strict guidelines for follow-up of patients who test positive at screenings and need more regular, structured care. Primary care physicians and nursing personnel have specific and separated roles and are not coordinated for treating NCDs. Doctors still have to do many tasks that nurses typically cover in other developed nations. 3. IMSS has an outdated model of physical and financial resource management that was based on centralized resource administration. This model does not include transfer prices for production or delivery of services or incentives (financial or nonfinancial) for quality of care, patient satisfaction, or the cost effectiveness of all services. Doctors and nurses are paid fixed salaries that are not tied to services provided, the quality of services, or any measure of performance or results. Union personnel receive some performance bonuses that are not related to their own performance. Hospitals and clinics are given historic budgets that grow too slowly, and there is no relation between budgets and services provided or the profile of the population of a facility s catchment area. 4. IMSS is confronting a financial sustainability crisis resulting from the above three challenges. When the new administration began in December 2012, the Institute was facing a critical financial situation. The Institute had gone from using almost no reserves [a] in 2007 to using over 24 billion pesos in The Report to the Mexican Congress stated that even using its reserves, the Institute can only extend the years of financial self-sufficiency to Moreover, the rate of the use of reserves was expected to continue to rise rapidly. One of our first priorities was to assess the financial situation and design and implement a strategic plan for the transformation and modernization of IMSS. The plan had to, in the short run, address the Institute s financial sustainability crisis with quickacting measures. Additionally, the plan needed to establish groundwork for advancing a solution to the medium- and long-

4 Gonzalez Anaya and Garcıa Cuellar: Transforming the IMSS 191 term challenges posed by the need to update the health care model to respond to Mexico s new epidemiological profile and modernize the resource management model. The objectives of the plan were to simultaneously improve service quality, health outcomes, and patient satisfaction while assuring IMSS s financial sustainability in the short, medium, and long run. At first glance these objectives seemed incompatible, even contradictory. To improve service quality, health outcomes, and patient satisfaction, it would seem necessary to devote a greater amount of resources. However, we found that these goals could be reconciled using the following strategies that proved particularly useful in the short run: improving service productivity and efficiency; strengthening transparency and competition in the procurement of goods and services; and encouraging compliance of obligations of all stakeholders. As the second largest purchaser of goods and services in the public sector and the second largest tax collector after the Ministry of Finance, these strategies had an important impact on IMSS s efficiency, quality, and finances. Additionally, restrictions inherent to IMSS and Mexico s public sector had to be taken into account when designing the strategic plan. First, IMSS has a hard budget constraint; its revenues are restricted by tax collection that depends on employment growth and firms compliance with payroll taxes. This creates an important challenge because the federal government does not contribute with more resources than those established by the Social Security Act. Second, IMSS has a rigid collective bargaining agreement. This means that there is little flexibility in terms of firing workers or changing workers activities as they are explicitly described in the labor contract. Additionally, modifying the agreement is difficult given the size of the workers union the second largest in the country with more than 400,000 members (including around 75,000 doctors and more than 120,000 nurses) plus 250,000 retirees. With these constraints in mind, the strategic plan was developed around three pillars: 1. Given the nonexistence of any performance or costeffectiveness incentives in management, a primary objective of the plan was to improve efficiencies in contracting and procurement to respond to the immediate financial crisis. This part of the plan has been implemented successfully through transparency enhancement, simplification of processes, and fostering compliance of obligations. As a result, IMSS s deficit has been reduced by half, producing annual savings of 12,980 million pesos (3.1% of the annual IMSS budget). 2. Due to the fact that IMSS s health care model was designed to serve a different population profile, a revision was needed. In particular, its screening programs and treatment of chronic diseases needed to be redesigned. Additionally, the combination of a growing population that lives longer and experiences higher incidence of chronic illnesses has imposed an increased pressure on the supply of services. Under the strategic plan, measures have been taken to improve the efficiency and productivity of services and health care workers in order to improve access to medical services. Lastly, through improvements in services and customer experience, the IMSS administration is aiming to improve patient satisfaction across all levels of care. All of these projects are currently being piloted, with promising initial results. In particular, results show that improvements to productivity have led to better access to services and some improvements in health care outcomes have been found. The next step will be to expand all these pilots to the national level. 3. Changes are being designed to modify the resource management model, including a gradual but increasing separation of functions between strategic purchasing and medical services providers, the transition to financing medical services based on results or services provided, a gradual decentralization of resource management, and a reinforcement of clinical operational excellence and efficacy. Specific activities for this pillar are now being designed. Some incentives to providers have been set up and results should be apparent by the end of This strategic plan has already seen some initial successes. The next part of this article analyzes the plan s impact on efficiencies of procurement and contracting processes that have reduced costs while simultaneously maintaining and, in most cases, improving services. Nevertheless, it will be imperative that this and future administrations continue implementing the IMSS strategic plan over the medium to long term. Without the continuing adaptation of the IMSS health care model and the modernization of the resources management model, the achievements described here will be unsustainable in the long run. Below, we discuss these plans and describe initial implementation efforts. RESULTS: FIRST TWO YEARS The new administration s efforts to stabilize the Institute s finances resulted in the Institute s ability to cut in half its use of reserves, from 24 billion pesos in 2012 to 12 billion pesos in 2014 (Figure 3). In addition, if we consider the inertial increases in IMSS workers pensions and payroll of seven

5 192 Health Systems & Reform, Vol. 1 (2015), No. 3 billion pesos that had to be paid over this time period, the fiscal effort totaled 19 billion pesos. By comparison, 19 billion pesos is equivalent to the collection of about half a percentage point of Mexico s value-added tax in a year. How Were These Results Achieved? A Micro Approach to a Macro Problem Efficiencies of Procurement and Contracting Processes Beginning in December 2012, the first measures taken were to improve the efficiency and transparency of procurement and contracting processes. Although almost a cliche, we found it to be true that the best way to increase efficiency and improve services is by eliminating red tape and by increasing the use of information technologies. Furthermore, simplification promotes formality and fosters compliance. Here are three examples of the measures taken and their impact in cost reduction and service improvement: 1. Previously, payroll taxes had to be paid monthly, in person, at a bank, via a floppy disk. Changes made under the strategic plan, starting in June 2013, allowed these taxes to be paid through the Internet. Today more than 600,000 firms out of a total of 860,000 have registered for this service and more than 90% of payroll tax collection is done through the Internet. The impact has been enormous. For example, if these employers had used their cars to go to the bank, the queue each month would have been as long as the distance from Mexico City to Los Angeles. These changes have saved nearly three million person-hours per year, not to mention other benefits such as increasing collection and reducing emissions. 2. In 2013, IMSS began an aggressive effort to switch to digital media to send billing statuses to employers. As a first step, we stopped printing statuses for the 150,000 bills for the largest firms, where each bill was approximately 50 pages long and used to be printed and mailed every two weeks. This simple change has allowed IMSS to reduce its spending on paper, mailing, and bank charges by about 170 million pesos. IMSS renovated its virtual private network, making it 12 times faster and 82% cheaper per byte transferred, and was therefore FIGURE 1. IMSS General Data

6 Gonzalez Anaya and Garcıa Cuellar: Transforming the IMSS 193 FIGURE 2. Mortality Rates by Selected Causes able to accomplish all of these efforts without spending a single extra peso on information technologies. 3. IMSS is the second largest purchaser of goods and services of public-sector institutions in Mexico, with medicines and medical supplies making up the largest category of purchases. At the time of reform initiation, IMSS had been refining its purchasing strategy for some years, but there were still areas of opportunity to improve purchasing conditions for the Institute and to enhance the supply of medicines. One of IMSS s most pressing demands is to obtain the necessary medicines for the population it serves. To do so, we developed a comprehensive procurement strategy that included elements to improve provision (including the elimination of emergency purchases, identification of optimal inventories, creation of medicine vouchers, etc.) and to improve competition. The strategy culminated with the greatest consolidated purchase of medicines and medical supplies in the history of the Mexican public health sector. In this consolidated purchase, almost all public health institutions participated. With the aid of bidding experts, some strategic changes were made to the tender process to improve competition. For example, the number of bids done through dynamic reverse tenders was increased. FIGURE 3. IMSS Annual Cash Flow Deficit (billion of 2014 pesos)

7 194 Health Systems & Reform, Vol. 1 (2015), No. 3 FIGURE 4. Consolidated Purchases Results (million medicines and million 2014 pesos). e/, expected This type of tender increases competition among providers and obtains better results in terms of prices as sellers are moved to reveal the true value of the product in order to win. Dynamic reverse tenders also increase transparency as the process is done electronically. As well as increasing the number of bids done by reverse tenders, some requirements for participation in tenders were eliminated, which resulted in greater national and international participation. Increased competition reduced the share of the 12 largest participants from 81% in 2013 to 58% in The results of the procurement process translated into 8.3 billion pesos of savings for the entire public health sector and 4.5 billion pesos in savings for IMSS. Moreover, IMSS was able to increase the number of medicine units purchased from 1.1 billion to 1.3 billion (Figure 4). To increase transparency, IMSS worked hand-in-hand with different agencies and institutions including the Ministry of Economy, the Mexican equivalent to the Government Accountability Office (Secretarıa de la Funcion Publica), the Mexican Anti-Trust Commission (COFECE, or Comision Federal de Competencia Economica), the IMSS internal audit (Organo Interno de Control del IMSS), and Transparencia Mexicana throughout the process of implementing the strategic plan. Additionally, IMSS signed memoranda of understanding agreements with the United States Agency for International Development and COFECE to guarantee and institutionalize transparency and competition procedures. Going forward, we plan to apply the same transparency and competition criteria to the purchasing of outsourced medical services (including, for example, purchases of dialysis and hemodialysis services, lab tests, and blood analysis). Improvements in the Health Care Model Medical services are IMSS s leitmotif. As described above, it is critical that the IMSS medical model change to respond to Mexico s new population profile and the increasing availability and accessibility of new technologies in order to provide better quality health services and achieve better health outcomes and higher satisfaction among IMSS beneficiaries. Mexico now has one of the highest rates of diabetes and obesity among Organization for Economic Cooperation and Development (OECD) countries. IMSS is spending more on NCD patients than ever before. Approximately 40% of IMSS s non-labor medical budget is spent on patients with chronic diseases, and 70% of this amount is spent treating complications presented by 15% of patients. Many of these complications could be avoided through better preventive efforts, earlier detection, and stricter patient follow-up. The IMSS treatment model has been shown to reduce NCD-related mortality more than the models from other public health care providers in Mexico, but there is still much room for improvement. 3 Thus, a new strategy for prevention, early detection, and improved treatment for patients with chronic diseases is needed, and IMSS is currently introducing two new programs. The first is a reformulation and expansion of IMSS s trademark prevention program (PrevenIMSS). PrevenIMSS has three main problems that must be overcome. The first one is that check-ups include an extensive list of required tests and procedures that differ by gender and age group but are the same for all people independent of their risk of developing a NCD. The second problem is a high rate of patient loss to follow-up due to the lack of a patient care coordinator. The third problem is the low PrevenIMSS coverage rate. Nearly 50% of PrevenIMSS beneficiaries do not

8 Gonzalez Anaya and Garcıa Cuellar: Transforming the IMSS 195 attend a clinic for their yearly check-up. Some people do not go because they have not heard of the program, but others especially workers and students do not go because they have no time to go to their clinic. To overcome these problems, we will stratify beneficiaries according to risk, based on personal and family history and basic health metrics. Check-up and follow-up of patients will be according to their risk category. In additional, we will extend these focused check-ups to workplaces, schools, and public spaces such as metro stations in order to improve accessibility, attract a larger number of patients, and increase coverage of the program. Second, IMSS designed a pilot program with an innovative pay-for-performance scheme that pays providers according to the results they achieve. Pay-for-performance mechanisms have been increasingly adopted in other countries and evidence shows encouraging results. 4 6 It would be the first pay-for-performance scheme in Mexico and the first internationally to be tendered in a public bid. Providers would be allocated a randomized set of patients who have been diagnosed with Diabetes Mellitus II in the past 15 years and who have no complications and would be paid a per capita fee and, every six months, an additional progress bonus based on their patients improvements in diabetes-related metrics. At the end of the 18-month pilot, providers would also be paid a control bonus for each patient whose diabetes is under control. 7 A previous pay-for-performance diabetes scheme implemented in Brazil, which paid incentives only for the patients whose diabetes was brought under control, found that the health of patients who were not initially close to controlling their diabetes deteriorated significantly. 8 Thus, the incentive structure, particularly the progress bonus, is designed to provide incentives to improve the metrics of all of their patients, not just those whose diabetes is close to being controlled. The results of this pilot will help evaluate which are the most successful and cost-effective interventions for treating diabetic patients in particular, and chronic patients in general. Additionally, we are implementing several programs to improve health care operations and improve patient satisfaction in primary care and hospitalization. One example is the Renewable Prescription Program. Data showed that a significant fraction of the nearly 500,000 doctor appointments that IMSS provides daily were scheduled for the sole purpose of renewing prescriptions for patients with controlled chronic conditions. To receive their prescriptions, these patients had to schedule a doctor appointment each month, which sometimes meant missing a day of work. In line with best medical practices, the Renewable Prescription Program allows doctors to fill a prescription for up to three months for certain controlled chronic conditions, improving patients experience and freeing seven million doctor appointment slots per year. For comparison, providing an additional seven million appointments would require the construction of approximately 500 doctors offices the equivalent to IMSS s expansion in doctors offices in a decade. More important, this program also improved health care outcomes. A study found that the Renewable Prescription Program improved treatment adherence. Because of the program, the number of days that people were without medication dropped by 30%. 9 Similarly, we are launching several programs to increase access to medical services and improve response capacity, as shown in Table 1. Many of these initiatives have been piloted in the first half of 2015 and achieved good results in process indicators. Improvement in Financial and Physical Resource Management IMSS was designed as a single vertically integrated system and has 430,000 employees, including 400,000 union members. All workers are paid a fixed salary with no performance incentives, and all hospitals and clinics are financed based on historical inertial budgets. External providers are paid fixed fee-for-service contracts that are not based on results or on the quality of services provided. In order to obtain better health outcomes with quality services that comply with patients expectations in a financially sustainable way, IMSS needs to ensure that resources are used in the most efficient way possible. This will require that IMSS modernize and create a new incentive framework that enhances efficiency and productivity. Health systems in the world are moving toward greater separation of functions to introduce competition and generate a more efficient and productive provision of health care services. 10 There is extensive evidence that there is no need to have a single insurance or single fund but there is need for single rules and protocols. For example, within a sample of 19 OECD countries, there is heterogeneity in the sources of financing as well as the number of funds from which funding comes. Only three countries (Canada, Denmark, and Spain) are financed with a single fund that comes from general taxes, and another three countries (Ireland, Norway, and the UK) are financed with a single fund that comes from mixed sources of financing. 11 However, the experience of other countries suggests that the separation of functions within a system is what truly improves the use of resources. Therefore, IMSS will start a

9 196 Health Systems & Reform, Vol. 1 (2015), No. 3 Strategy Motivation Objectives Roll-out date Preliminary results Bed management program Management of walk-in patients in primary care units (PCUs) Posttriage process in the emergency department (ER) Patient referral between PCUs and hospitals Model of care for patients with chronic diseases Hospital bed capacity was underutilized. On average, a bed remained empty for 20 hours from the time the patient was discharged to the time a new patient was admitted. This resulted in an overcrowding of the emergency department. Walk-in patients could only be seen by their assigned family doctor, which resulted in a two hours average waiting time. Additionally, the average time a patient had to wait to get a medical appointment was 34 days. Patients arriving at the ER have to fill out lengthy paperwork before receiving medical attention. Additionally, triage is done by doctors but lost along the way so patients are not seen according to their level of emergency. The referral process from PCUs to hospitals is highly complex. Patients can spend up to two hours for the referral process. Furthermore, they have to wait up to seven days to schedule an appointment with a specialist. The Institution does not have a program to systematically diagnose and give follow-up to patients with chronic diseases, which results in the development of complications that reduce the quality of life of patients and increase IMSS s expenses. The program seeks to increase coordination between hospital staff to decrease idle bed time and hence increase hospitals bed capacity and patient satisfaction. April 2014 The program allows walk-in April 2015 patients to be seen by any available doctor on a first come first serve basis. The program seeks to reduce waiting times and emergency care visits by allowing patients with nonurgent conditions to be seen in PCUs. The program will focus on applying triage to patients as soon as they arrive at the ER, on reducing time spent doing paperwork, and on targeting resources to critical patients. Additionally, the triage will be done by nurses instead of doctors. The program consists of an IT system that permits PCUs to manage specialized doctors agendas. The system seeks to reduce waiting time and increase patient satisfaction. The model seeks to empower nurses to coordinate early detection and diagnostic confirmation before patients visit their family doctor at their PCUs. The follow-up of patients will be systematic according to their disease control. This program will Implemented in three hospitals 30% increase in bed rotation 10% increase in hospital discharges Implemented in four PCUs Average waiting time of walk-in patients to be seen by a doctor decreased from up to seven hours to 31 min Percentage of walk-in patients who waited less than one hour: 82% Average number of days that patients waited to get a medical appointment decreased from 34 to 23 days June 2015 March 2015 Implemented in one hospital and 19 PCUs Average waiting time to schedule an appointment with a specialist: 56 minutes Percentage of patients who waited less than 30 minutes to schedule a medical appointment with a specialist: 64% July 2015 TABLE 1. Novel Strategies for Improved Health Care Operations and Patient Satisfaction (Continued) (Continued on next page)

10 Gonzalez Anaya and Garcıa Cuellar: Transforming the IMSS 197 Strategy Motivation Objectives Roll-out date Preliminary results Myocardial infarction program Myocardial infarction care requires prompt attention to prevent adverse outcomes such as complications or death and we identified an area of opportunity in reducing waiting times to receive treatment for myocardial infarction in the ER. also focus on starting treatment of prediabetic patients with pharmacologic and nonpharmacologic interventions to prevent the development of the disease. Lastly, the program has an important educational component. The program seeks to ensure the diagnosis and treatment of patients with myocardial infarction with angioplasty in the first 90 minutes or fibrinolytic therapy in the first 30 minutes after they arrive at the ER. Nowadays the average door-to-needle (fibrinolytic therapy) time is 118 minutes to receive fibrinolytic therapy and the average door-to-balloon (angioplasty) time is 152 minutes. To reduce these times, patients will not be asked to do lengthy administrative procedures before receiving medical attention; if the medical unit does not have adequate infrastructure to give proper treatment, they will send the patient in an ambulance to another hospital. With this program we will be able to reduce mortality and increase patient quality of life. February 2015 Implemented in one tertiary referral hospital and 9 hospitals Average door-to-needle (fibrinolytic therapy) time decreased from 118 to 69 minutes Average door-to-balloon time decreased from 152 to 92 minutes Reduction in nontreated patients: 41% Increase in patients treated with fibrinolytic therapy: 31% Increase in patients treated with angioplasty: 175% TABLE 1. Novel Strategies for Improved Health Care Operations and Patient Satisfaction gradual but increasing separation of functions between strategic purchasing and medical service provision. Payment to providers, both internal and external, will gradually shift to pay for results or pay for services. The first example will be the DiabetIMSS Externo pilot, but payment for services such as hemodialysis or lab tests will also begin to incorporate measures for quality. Internally, medical units will start to be paid for certain services. The first example is transplants: IMSS has 60,000 beneficiaries in renal therapy and conducts approximately 2,025 transplants per year. This administration set a goal to double the number of yearly transplants. Accomplishing this goal will require several changes, including giving incentives to groups of specialist doctors or to medical units to improve their productivity. The design of the bonus is still under construction but it will need to take into account the results of the transplant (including patient survival) as well as productivity (including number of transplants) and will be used to improve medical units equipment or general conditions. Currently, all medical units receive centrally determined, fixed budgets. In order to provide incentives to be more productive, medical units will need more financial autonomy.

11 198 Health Systems & Reform, Vol. 1 (2015), No. 3 Ideally, receiving payment for some services will provide medical units with incentives to become more productive and reinforce their clinical operations. An example of a program that has tried this approach is the Universal Pass program, which is expected to begin by the end of IMSS, along with the rest of the public health sector, will start a program to exchange prenatal, delivery, and postpartum care across institutions so that a woman can receive care in any public health institution. Institutions will be paid a single fee, which will lead to improvements in their clinical operation. Part of the payment for the Universal Pass will be delivered directly to the clinics. WHAT S NEXT FOR IMSS AND THE MEXICAN HEALTH SYSTEM? The Mexican health care system is composed of separate, vertically integrated sub-systems that function independently and have few interconnections. Health care for formal private-sector employees is provided by IMSS, whereas health care for public-sector workers is provided by the Institute for Social Security Services for State Employees (ISSSTE), and the unemployed, self-employed, rural workers, or otherwise nonsalaried informal workers have access to health services provided by state health ministries financed through Seguro Popular. IMSS and Seguro Popular each has more than 50 million beneficiaries, which is much more than many other health systems around the world. IMSS, ISSSTE, and Seguro Popular each have rigid labor contracts that make it difficult to adapt the labor force to respond to changes in demand. None of the sub-systems has price signals, the budget of each grows inertially and not according to services provided, and all workers are paid fixed salaries. Problems in each sub-system need to be addressed by institutionalizing a modern resource management model and separating functions before unifying the three systems. Unifying before these problems are addressed would only remove budget constraints without guaranteeing improvements in health benefits. Therefore, in order to consolidate the Mexican health sector and to use resources more effectively, Mexico needs to integrate public health care institutions through the exchange of services. Improved coordination among public sector institutions will help balance services, quality, and costs. It will introduce price signals and competition into the system. Exchanging services will gradually introduce the structural changes the system needs, such as transfer prices, separation of functions between payers and providers, and exchange of information across institutions. This first step is the muchneeded cornerstone to be able to grant effective health care access to all Mexicans regardless of their labor status. The success of a reform of this nature depends on the ability to provide institutions with an incentive framework and the tools to lead them to use their resources effectively. In the next years, the biggest challenge for IMSS as the largest health care provider in Mexico will be to consolidate the accomplishments achieved so far and entrench them into the Institution s culture and ways of working so that, in the years to come, IMSS can become an efficient provider able to deliver quality services that achieve good health outcomes while satisfying patient expectations in a financially sustainable environment. Transforming an institution like IMSS from morning to nightisliketryingtomovethetitanic inasinglehelmmovement. Changes have to be gradual so that all stakeholders can learn how to work within the new rules. Purchasers have to learn how much to pay for services, service providers have to learn how to become efficient in order to keep a certain margin, and medical units will even need to learn how to spend their resources. The goal of this administration is to establish the new rules and programs so that the resulting transformation is enduring and sustainable well into the future. DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST No potential conflicts of interest were disclosed. NOTE [a] Reserves are funds that IMSS must establish to ensure compliance with its obligations. Those reserves are operational reserves, financial and actuarial reserves, operating reserve for contingencies and financing, financial and actuarial general reserve, and the fund for legal or contractual labor obligations. REFERENCES [1] Instituto Mexicano del Seguro Social. Informe al ejecutivo federal y al congreso de la union sobre la situacion financiera y los riesgos del Instituto Mexicano del Seguro Social [Report to the President and Congress regarding the Financial Situation and Risks of the Mexican Institute of Social Security, ]. Mexico City: Instituto Mexicano del Seguro Social; [2] Instituto Mexicano del Seguro Social. Informe al ejecutivo federal y al congreso de la union sobre la situacion financiera y los riesgos del Instituto Mexicano del Seguro Social [Report to the President and Congress regarding the

12 Gonzalez Anaya and Garcıa Cuellar: Transforming the IMSS 199 Financial Situation and Risks of the Mexican Institute of Social Security, ]. Mexico City: Instituto Mexicano del Seguro Social; [3] Borja-Aburto VH, Gonzalez-Anaya JA, Davila-Torres J, Rascon-Pacheco RA, Gonzalez-Leon M. Evaluation of the impact on non-communicable chronic diseases of a major integrated primary health care program in Mexico. Fam Pract [4] Dudley RA. Pay-for-performance research: how to learn what clinicians and policy makers need to know. JAMA 2005; 294 (14): [5] Van Herck P, De Smedt D, Annemans L, Remmen R, Rosenthal MB, Sermeus W. Systematic review: effects, design choices, and context of pay-for-performance in health care. BMC Health Serv Res 2010; 10: 247. [6] Eijkenaar F, Emmert M, Scheppach M, Sch offski O. Effects of pay for performance in health care: a systematic review of systematic reviews. Health Policy 2013; 110(2): [7] American Diabetes Association. Standards of medical care in diabetes Diabetes Care 2015; 38(Suppl 1): S1 S93. [8] Borem P, Valle EA, De Castro MSM, Fujii RK, de Oliveira Farias AL, Gastal FL, Connor C. Pay-for-performance in Brazil: UNIMED-Belo horizonte physician cooperation. Bethesda, MD: Health Systems 20/20 project, Abt Associates, Inc; [9] Marquez-Padilla F. An apple every day: habit formation in medication adherence. Department of Economics, Princeton University Working Paper. [10] Restrepo, JH. Que ense~na la reforma colombiana sobre los mercados de salud? [What are lessons of the Colombian reform for health markets?]. Revista Gerencia y Polıticas de Salud 2004; 3(6): 8 34 [11] Paris V, Devaux M, Wei L. Health systems institutional characteristics: a survey of 29 OECD countries. OECD Health Working Papers No. 50. Paris: OECD; April 2010.