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Barriers of access to care in a managed competition model: lessons from Colombia.

Vargas I, Vázquez ML, Mogollón-Pérez AS, Unger JP - BMC Health Serv Res (2010)

Bottom Line: Access, particularly to secondary care, is perceived as complex due to four groups of obstacles with synergetic effects: segmented insurance design with insufficient services covered; insurers' managed care and purchasing mechanisms; providers' networks structural and organizational limitations; and, poor living conditions.The results show how in the Colombian healthcare system structural and organizational barriers to care access, that are common in developing countries, are widened by both the insurers' use of mechanisms that limit the utilization and the public healthcare providers' change of behavior in a competition environment.They provide evidence to question the promotion of the managed competition model in low and middle-income countries.

View Article: PubMed Central - HTML - PubMed

Affiliation: Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Av Tibidabo 21, Barcelona 08022, Spain. ivargas@consorci.org

ABSTRACT

Background: The health sector reform in Colombia, initiated by Law 100 (1993) that introduced a managed competition model, is generally presented as a successful experience of improving access to care through a health insurance regulated market. The study's objective is to improve our understanding of the factors influencing access to the continuum of care in the Colombian managed competition model, from the social actors' point of view.

Methods: An exploratory, descriptive-interpretative qualitative study was carried out, based on case studies of four healthcare networks in rural and urban areas. Individual semi-structured interviews were conducted to a three stage theoretical sample: I) cases, II) providers and III) informants: insured and uninsured users (35), health professionals (51), administrative personnel (20), and providers' (18) and insurers' (10) managers. Narrative content analysis was conducted; segmented by cases, informant's groups and themes.

Results: Access, particularly to secondary care, is perceived as complex due to four groups of obstacles with synergetic effects: segmented insurance design with insufficient services covered; insurers' managed care and purchasing mechanisms; providers' networks structural and organizational limitations; and, poor living conditions. Insurers' and providers' values based on economic profit permeate all factors. Variations became apparent between the two geographical areas and insurance schemes. In the urban areas barriers related to market functioning predominate, whereas in the rural areas structural deficiencies in health services are linked to insufficient public funding. While financial obstacles are dominant in the subsidized regime, in the contributory scheme supply shortage prevails, related to insufficient private investment.

Conclusions: The results show how in the Colombian healthcare system structural and organizational barriers to care access, that are common in developing countries, are widened by both the insurers' use of mechanisms that limit the utilization and the public healthcare providers' change of behavior in a competition environment. They provide evidence to question the promotion of the managed competition model in low and middle-income countries.

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The model of managed competition in the Colombian healthcare system. Figure legend text: FOSYGA: Fondo de Solidaridad y Garantía (Solidarity and Guarantee Fund); EPS: Empresa Promotora de Salud (Insurance Company for the Contributory Regime); EPS'S: (Insurance Company for the Subsidized Regime); IPS: Instituciones Prestadoras de Servicios de Salud (Healthcare Provider); ESE: Empresa Social del Estado (Public Health Provider). → Monetary flows. Source: authors.
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Figure 1: The model of managed competition in the Colombian healthcare system. Figure legend text: FOSYGA: Fondo de Solidaridad y Garantía (Solidarity and Guarantee Fund); EPS: Empresa Promotora de Salud (Insurance Company for the Contributory Regime); EPS'S: (Insurance Company for the Subsidized Regime); IPS: Instituciones Prestadoras de Servicios de Salud (Healthcare Provider); ESE: Empresa Social del Estado (Public Health Provider). → Monetary flows. Source: authors.

Mentions: Colombia radically reformed its healthcare system with Law 100 of 1993 [3], which created the General Social Security System in Health, with two insurance schemes: the Contributory Regime for formal sector employees and people able to pay, financed by mandatory contributions [3]; and the Subsidized Regime for people without the ability to pay, funded by resources from the Contributory Scheme and other sources of financing, such as taxes (Figure 1). Healthcare Insurers (Empresas Promotoras de Salud - EPS) were introduced for managing the Contributory Regime, as well as Subsidized Regimen (Empresas Promotoras de Salud Subsidiadas - EPS'S). They were to compete for the enrolment of population and received a capitation payment to cover different benefit packages in each regime (Plan Obligatorio de Salud - POS and Plan Obligatorio de Salud Subsidiado - POS-S) [4]. Currently, the contributory market is characterized by the predominance of private insurers - 86.1% of the affiliation - and the concentration in 5 private insurers that hold 50% of markets share [5]. The largest public insurer has been transformed into a mixed company with private capital and 5.8% of membership [5]. Competition for contracts with the insurers was also introduced among public and private healthcare providers (Instituciones Prestadoras de Salud - IPS). Healthcare for the uninsured (vinculados) and services excluded from the POS-S are provided by public hospitals funded by local and regional authorities [6], that represent 31.3% of total healthcare providers [7]. The uninsured have to pay for services and the insured make a co-payment according to their income [8].


Barriers of access to care in a managed competition model: lessons from Colombia.

Vargas I, Vázquez ML, Mogollón-Pérez AS, Unger JP - BMC Health Serv Res (2010)

The model of managed competition in the Colombian healthcare system. Figure legend text: FOSYGA: Fondo de Solidaridad y Garantía (Solidarity and Guarantee Fund); EPS: Empresa Promotora de Salud (Insurance Company for the Contributory Regime); EPS'S: (Insurance Company for the Subsidized Regime); IPS: Instituciones Prestadoras de Servicios de Salud (Healthcare Provider); ESE: Empresa Social del Estado (Public Health Provider). → Monetary flows. Source: authors.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2984497&req=5

Figure 1: The model of managed competition in the Colombian healthcare system. Figure legend text: FOSYGA: Fondo de Solidaridad y Garantía (Solidarity and Guarantee Fund); EPS: Empresa Promotora de Salud (Insurance Company for the Contributory Regime); EPS'S: (Insurance Company for the Subsidized Regime); IPS: Instituciones Prestadoras de Servicios de Salud (Healthcare Provider); ESE: Empresa Social del Estado (Public Health Provider). → Monetary flows. Source: authors.
Mentions: Colombia radically reformed its healthcare system with Law 100 of 1993 [3], which created the General Social Security System in Health, with two insurance schemes: the Contributory Regime for formal sector employees and people able to pay, financed by mandatory contributions [3]; and the Subsidized Regime for people without the ability to pay, funded by resources from the Contributory Scheme and other sources of financing, such as taxes (Figure 1). Healthcare Insurers (Empresas Promotoras de Salud - EPS) were introduced for managing the Contributory Regime, as well as Subsidized Regimen (Empresas Promotoras de Salud Subsidiadas - EPS'S). They were to compete for the enrolment of population and received a capitation payment to cover different benefit packages in each regime (Plan Obligatorio de Salud - POS and Plan Obligatorio de Salud Subsidiado - POS-S) [4]. Currently, the contributory market is characterized by the predominance of private insurers - 86.1% of the affiliation - and the concentration in 5 private insurers that hold 50% of markets share [5]. The largest public insurer has been transformed into a mixed company with private capital and 5.8% of membership [5]. Competition for contracts with the insurers was also introduced among public and private healthcare providers (Instituciones Prestadoras de Salud - IPS). Healthcare for the uninsured (vinculados) and services excluded from the POS-S are provided by public hospitals funded by local and regional authorities [6], that represent 31.3% of total healthcare providers [7]. The uninsured have to pay for services and the insured make a co-payment according to their income [8].

Bottom Line: Access, particularly to secondary care, is perceived as complex due to four groups of obstacles with synergetic effects: segmented insurance design with insufficient services covered; insurers' managed care and purchasing mechanisms; providers' networks structural and organizational limitations; and, poor living conditions.The results show how in the Colombian healthcare system structural and organizational barriers to care access, that are common in developing countries, are widened by both the insurers' use of mechanisms that limit the utilization and the public healthcare providers' change of behavior in a competition environment.They provide evidence to question the promotion of the managed competition model in low and middle-income countries.

View Article: PubMed Central - HTML - PubMed

Affiliation: Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Av Tibidabo 21, Barcelona 08022, Spain. ivargas@consorci.org

ABSTRACT

Background: The health sector reform in Colombia, initiated by Law 100 (1993) that introduced a managed competition model, is generally presented as a successful experience of improving access to care through a health insurance regulated market. The study's objective is to improve our understanding of the factors influencing access to the continuum of care in the Colombian managed competition model, from the social actors' point of view.

Methods: An exploratory, descriptive-interpretative qualitative study was carried out, based on case studies of four healthcare networks in rural and urban areas. Individual semi-structured interviews were conducted to a three stage theoretical sample: I) cases, II) providers and III) informants: insured and uninsured users (35), health professionals (51), administrative personnel (20), and providers' (18) and insurers' (10) managers. Narrative content analysis was conducted; segmented by cases, informant's groups and themes.

Results: Access, particularly to secondary care, is perceived as complex due to four groups of obstacles with synergetic effects: segmented insurance design with insufficient services covered; insurers' managed care and purchasing mechanisms; providers' networks structural and organizational limitations; and, poor living conditions. Insurers' and providers' values based on economic profit permeate all factors. Variations became apparent between the two geographical areas and insurance schemes. In the urban areas barriers related to market functioning predominate, whereas in the rural areas structural deficiencies in health services are linked to insufficient public funding. While financial obstacles are dominant in the subsidized regime, in the contributory scheme supply shortage prevails, related to insufficient private investment.

Conclusions: The results show how in the Colombian healthcare system structural and organizational barriers to care access, that are common in developing countries, are widened by both the insurers' use of mechanisms that limit the utilization and the public healthcare providers' change of behavior in a competition environment. They provide evidence to question the promotion of the managed competition model in low and middle-income countries.

Show MeSH
Related in: MedlinePlus