As public health systems globally confront the challenges of aging populations, rising healthcare costs, and increasing patient complexity (1, 2), the question of whether outsourcing healthcare services to private organizations can improve outcomes remains deeply contested (3). The sustainability of healthcare systems is under pressure worldwide, and the privatization of healthcare delivery has become a central issue in political and policy debates. For those investing in public health, understanding the effects of privatization—especially within modern care models like value-based healthcare—is crucial for shaping equitable and effective policy (4, 5).

Despite the long-standing trend toward increased private sector involvement, there is still limited and inconsistent evidence comparing the quality of care between publicly and privately managed hospitals. While some existing evidence from high-income countries leans in favor of public management (3, 6, 7), other findings challenge this narrative (8–10). Many existing studies have methodological limitations, including the inclusion of diverse healthcare systems and inconsistent adjustment for contextual variables such as socioeconomic factors, regional healthcare models, and population needs. These factors complicate cross-study comparisons and have led to conflicting conclusions in the literature. The currently inconclusive results highlight a core public health insight: healthcare outcomes are not determined solely by the ownership model but by how systems are designed, governed, and implemented (4).

Spain’s National Health Service, organized under the Beveridge model, offers universal healthcare via 17 autonomous regional health authorities. One of the largest is Madrid’s Regional Health Service (SERMAS), which serves over 6.5 million people—13% of Spain’s population—through a comprehensive network of primary care centers and more than 25 hospitals, including eight tertiary-level institutions. Since 2010, the Madrid health system has allowed residents to choose their healthcare providers, including both publicly and privately managed hospitals. While most hospitals in the region are publicly managed, five—including the Fundación Jiménez Díaz University Hospital—are privately operated under a value-based healthcare (VBHC) model (11, 12). For public health stakeholders, the core concern is whether outsourcing within a VBHC model supports or undermines equity, access, and health system resilience. While VBHC principles align with many public health goals (13)—such as improving efficiency, outcomes, and patient experience—the interaction between private management and VBHC has yet to be fully explored in terms of its broader population health impact.

As systems around the world seek to modernize while preserving the principles of universal access, evidence is crucial to ensure that policy decisions enhance—not erode—public health outcomes. To fill this knowledge gap, the current study analyzes data from 2023 across eight tertiary hospitals in the Madrid region. The analysis focuses on key indicators of care quality, patient safety, functioning and accessibility, and patient satisfaction to assess how a privately managed hospital performs relative to publicly managed institutions in a value-based care context. For those in public health, this research offers important insights into how management models intersect with care quality and equity.

This work analyzes recently reported annual official public indicators from the Madrid Health Service for the year 2023. The study includes eight tertiary hospitals located in the Madrid region and aimed to evaluate the results of a public hospital outsourced to a private provider following a value-based strategy (study hospital). The comparative analysis of healthcare indicators does not support the hypothesis that outsourcing is associated with worse healthcare indicators. On the contrary, our findings highlight that, at least in this case, there is a substantial improvement in most healthcare indicators when compared to publicly managed hospitals. These findings validate other previous publications demonstrating the benefits of the value-based model and encourages the progressive migration of the rest of hospitals to this model, which improves patient outcomes.

In the year 2023 the study hospital reported 1,376,626 care episodes, representing a 15.32% of the total number of care episodes from tertiary hospitals, and a similar case-mix complexity compared to the control group. These observations are concordant with an average value of 15.53% of total care episodes recorded from the study hospital together with a similar case mix-complexity, both registered for the period from 2015 to 2022 (extracted from past published official annual data).

Of note, the study hospital showed a significant lower hospital mortality ratio compared with each of the rest tertiary hospitals (Table 1), consolidating the data reported in 2022, when it had the second-best score for this indicator (data not shown). These findings are in contrast with literature in which outsourcing was associated with increased mortality rates (7), but in accordance with another Spanish study in which mortality rates after coronary surgery were lower in outsourced hospitals (10). Regarding patient safety, our study validates the positive trend observed for the study hospital in surgical and medical complications in the past decade (Figure 1), placing it at the top of the tertiary hospitals in Madrid in the year 2023 (Table 2). This finding is similar to that of a previous study in which independent management was associated with lower case-mix adjusted complications for hip replacement, cataract surgery and hernia repair (15). Of note, the Figure 2 shows that the study hospital had a lower rate of hospital-acquired infections than the control group in all years except 2021, when no differences were observed. This finding could be influenced by the COVID pandemic, and a very marked improvement was seen in 2022. In this sense, the 2023 data validate the very significant improvement seen in this indicator in 2022. This finding is in contrast with another study in which outsourcing cleaning facilities was associated with higher hospital acquired infections (16).

We also analyzed potential differences in functioning and accessibility indicators average inpatient length of stay, CMAILS, and mean surgical backlog. Although a progressive reduction in average inpatient length of stay can be observed between 2021 and 2023 in all tertiary hospitals, the study hospital stably maintains the best data with respect to this indicator (Supplementary Table S3). Additionally, the study hospital showed significantly shorter CMAILS than expected during 2023, with much better results than the control group. These findings are in line with previous studies reporting improved efficiency indicators after increased outsourcing, including higher accessibility to care and lower healthcare-related expenditure (17–19).

Regarding patient care indicators, overall satisfaction with the care received allows us to assess the quality of care provided, identify potential areas for improvement, and align best practices with patient priorities and preferences. This indicator shows the percentage of patients satisfied with the care received at the hospital, in the areas of inpatient care, outpatient consultations, ambulatory surgery, and emergency services. In a value-based model where the patient is at the center of care, these indicators demonstrate that the model works and, notably, the study hospital had the best scores (Table 5). Furthermore, the free-choice results confirm the overall satisfaction results and highlight that this type of strategy has clear positive effects not only on clinical outcome indicators but also on patient perceptions. Thus, the free-choice results were overwhelmingly in favor of the study hospital, with an incoming patient flow 10 times greater than the outgoing patient flow in the analyzed series (Table 6). Our results are concordant with findings from another study demonstrating higher patient satisfaction with privatized care (9).

Overall, the results observed in 2023 are in line with those observed in previous years, increasing in some cases the positive trend shown by the study hospital as well as the differences with respect to the control group. However, an important limitation of our study is that being retrospective it cannot confirm the causality between the results and the value-based model. In addition, our results are context-specific and may not be applicable to different health systems in other countries or those lacking similar digital or policy frameworks. Another relevant limitation is that our study includes only one study hospital, which makes independent validation of the results necessary. Finally, we did not adjust our findings for variables such as patient socioeconomic status, infrastructure or healthcare staffing that could represent potential confounding factors.

The findings described in our study validate the study hospital’s commitment to the value-based strategy, which has been deepened with the progressive implementation of numerous initiatives at the study hospital, and which have made this hospital a reference center for VBHC in Spain (11, 12, 20–24). The results of these initiatives have been driving their adoption in other public hospitals, which demonstrates how outsourcing to private health providers that follow a value-based model not only offers and demonstrates better results but also serves to improve the entire public health system, which is adopting these initiatives due to their association with better results for patients, as well as the quality and functioning and accessibility of the healthcare delivered. In summary, the value-based model represents a very important change with respect to the traditional way of providing healthcare, since it is a model based on processes and not on acts, which promotes proactive medicine rather than reactive medicine, and which places the patient at the center of the healthcare process, in which they become a proactive protagonist. Healthcare policy makers should consider outsourcing to value-based providers as a sustainable strategy for health systems worldwide.