Los problemas de la Reforma a la Salud

Should Health Be a Business?

Introduction to the Health Debate

• The question of whether health should be a business raises concerns about prioritizing profits over patient care. Everyone has the right to medical attention, but this issue is complex.

• Since the Colombian government proposed health reform in Congress, discussions have intensified, often exaggerated. Critics label EPS (Health Promotion Entities) as mere intermediaries profiting from patients' suffering.

Understanding Colombia's Health System

• This video aims to explore Colombia's health system and proposed reforms from an economic perspective, emphasizing that financial resources are crucial for maintaining healthcare services.

• Access to quality medical care shouldn't depend on one's ability to pay; average costs for serious conditions can be prohibitively high without a supportive system.

The Role of Insurance Models

• A model of insurance allows pooling resources through monthly payments, ensuring that those who need care can access it without facing crippling costs.

• Colombia's Law 100 established two groups: formal workers in the contributory regime and others in the subsidized regime, both accessing similar healthcare services despite different payment structures.

Funding and Resource Allocation

• The state supplements insufficient contributions with tax revenue, creating a substantial budget (80 trillion pesos for 2023) aimed at guaranteeing healthcare for all Colombians.

• Ensuring healthcare for 50 million people requires significant logistical planning regarding professionals' availability and necessary medical supplies.

Functioning of EPS within the System

• EPS were created under Law 100 in 1993; they manage economic and administrative aspects rather than providing direct medical care like IPS (Institutions Providing Health Services).

• EPS are responsible for paying for medical services received by patients while also auditing service quality and managing costs effectively.

Economic Risk Management by EPS

• The state pays EPS a fixed amount per enrolled member (approximately 100,000 pesos monthly), which incentivizes them to negotiate effectively with IPS while managing their budgets.

• While IPS provide services funded by the state, organizations like EPS take on financial risks associated with patient coverage within limited resources.

Balancing Costs and Patient Care

• Law 100 intended for EPS to become adept at resource management—deciding how many doctors are needed or when airlifting patients is more cost-effective than transporting them via ground transport.

Evaluating the Performance of Health Care Providers in Colombia

The Importance of Effective Management by CPS

• Health care providers (CPS) must manage their operations effectively, not only for ethical reasons and public health but also to protect their financial interests.

• Despite negative anecdotes, surveys indicate that a majority of users are satisfied with their CPS, with 80% willing to recommend them to friends or family.

Coverage and Spending Insights

• Colombia has achieved a 99% health coverage rate among its citizens, recognized by the OECD as one of the best systems among member countries.

• On average, Colombians spend only 15% out-of-pocket for additional services outside the public health system, significantly lower than neighboring countries where this figure is around 38%.

Challenges and Improvements Over Time

• While there are notable challenges such as specialist shortages and service quality disparities between urban and rural areas, significant improvements have been made over the past 30 years.

• The Colombian health system has consistently provided treatments for complex diseases to low-income individuals due to ongoing public-private partnerships.

Proposed Reforms: Centralization Concerns

• Current reform proposals suggest centralizing the health system under state control; however, it’s crucial to consider successful elements of the existing model before making drastic changes.

• Initial discussions included eliminating CPS entirely but shifted towards redefining their roles amidst public backlash.

Infrastructure and Resource Allocation Issues

• The proposal includes establishing a health center for every 20,000 inhabitants; however, this raises concerns about cost efficiency and resource allocation.

• Building new infrastructure poses significant financial burdens; adapting existing facilities is complex and may not meet urgent needs efficiently.

Staffing Shortages Complicate Solutions

• Even if new centers were established quickly, staffing remains a critical issue. Many regions lack sufficient healthcare professionals to meet demand.

• A rigid model requiring each center to operate independently could lead to inefficiencies in resource distribution based on varying local needs.

Logistical Challenges in Complex Care

Challenges in the New Health Care Model

Issues with Patient Transfers

• In the new health care model, primary care centers are responsible for finding specialized clinics for patients they cannot treat. This poses a risk if nearby clinics are full, leading to difficulties in locating appropriate care.

Financial Oversight Concerns

• When patients reach these specialized clinics, there is no oversight on complex procedure costs. The current system requires prior authorization, but under the new model, treatments would be administered at discretion and billed later to the state.

Incentives Leading to Budget Mismanagement

• The lack of pre-authorization creates an incentive to exhaust health budgets quickly. This situation mirrors behaviors seen when using company credit cards irresponsibly or overindulging at buffets due to absence of limits.

Absence of Checks and Balances

• Without financial oversight, there's a tendency for excessive spending as everyone competes for their share of the health budget before it runs out. This issue highlights systemic problems rather than individual moral failings.

Home Visits and Preventive Medicine

• A proposal includes sending doctors directly to homes to promote preventive medicine. However, this raises concerns about limited resources and whether enough professionals exist to support such a model effectively.

Structural Concerns in Health System Financing

Payment Delays Risks

• There are significant worries regarding timely payments for treatments under the proposed system. The bureaucratic challenges could hinder financing capabilities for healthcare providers (IPS).

Direct Payments vs Intermediation Issues

• While removing intermediaries might seem beneficial by streamlining payments from ADRES (the payment entity), it complicates expense management and could lead to larger systemic issues.

Microtransactions Burdening ADRES

• ADRES would face an overwhelming number of small transactions instead of fewer large payments, which may exceed its operational capacity given current delays in processing existing payments.

Corruption Risks in Healthcare Reform

Increased Corruption Potential

• The reform could exacerbate corruption risks since monitoring public spending becomes more challenging without clear expenditure tracking per patient.

Historical Context of Corruption

• Previous models aimed at simplifying control mechanisms have shown that corruption can thrive within complex systems where accountability is diluted.

Vulnerability of Oversight Mechanisms

• Current oversight mechanisms are not robust enough to prevent corruption entirely; thus, transitioning away from them may worsen existing vulnerabilities within healthcare funding structures.

Financial Sustainability Questions

Funding Sources and Usage

• Key questions arise regarding how funds will be sourced and allocated efficiently while preventing theft or misappropriation within the healthcare system.

Consequences of Budget Exhaustion