Introduction
The Colombian Health System operates on a framework of managed competition,1 where health maintenance organisation (HMO) insurance firms receive a risk-adjusted premium to fund a government-defined health benefits package (HBP). This inclusive package spans health services from promotion to palliative care, with specific criteria set through a negative list that applies universally. Diverse payment mechanisms, including the capitation payment unit (UPC by its Spanish acronym), maximum budgets (MBs) and reimbursements, contribute to the financing structure. The UPC serves as the insurance premium that comprehensively covers various services and technologies for each health condition, including oral health conditions. This premium is calculated through actuarial methods, considering the frequency and severity of different types of care, with further considerations for age, sex and geographical area.2 Several factors influence the determination of the UPC, including consumer price inflation, the national government budget, demographic changes and the regular updating of services and new technologies. Annually, at the year’s end, the Ministry of Health (MOH) defines the UPC for the following year, drawing on historical information on care as a foundational basis. In contrast, the MBs serve as an additional budget, complementing the UPC. This budget is calculated annually and aims to cover services and technologies not financed by the UPC. Such exclusions may arise due to uncertain conditions, high price variability or if they are complementary social services mandated by a judge. The MBs play a crucial role in covering or financing various aspects, including some drugs for orphan diseases, complementary social services, most new drugs, certain supplements and nutritional supplements, and drugs used for indications other than those approved by the regulatory agency.
By the end of 2022, Colombia recorded a staggering 6.34 million cases of COVID-19.3 Among these cases, 181 447 required hospitalisations in general wards, 26 907 in intermediate care unit (IMCU) and 70 566 in intensive care units (ICUs).3 The global healthcare infrastructure faced unprecedented challenges in delivering swift and precise medical attention to the substantial influx of COVID-19 patients, all while addressing the ongoing health needs of the broader population. This challenge proved, especially daunting in developing countries such as Colombia, marked by disparities in healthcare access and a noticeable shortage of hospital beds, quantified at approximately 1.7 beds per 1000 inhabitants as of 2018.4 Colombia, in comparison to other nations, notably stands out for enduring one of the highest years of life lost due to the pandemic,5 indicating a profound impact on the population and the urgency of addressing the healthcare challenges posed by the virus.
In response to the WHO declaring COVID-19 a pandemic, the Colombian National Government, recognising the gravity of the situation, declared a state of economic, social and ecological emergency through Decree 417 of 2020. The UPC for the year 2020, determined in December 2019, did not foresee possible changes in the health expenditure that could be generated by the pandemic. In response to the financial challenge posed by the pandemic, the initial government strategy was to permit insurers to use funds allocated for the HBP. This decision was based on the rationale that, during the lockdown period, the demand for healthcare services had decreased. Within this emergency framework, the MOH devised a comprehensive action plan aimed at mitigating the spread of the pandemic. This plan, among its multifaceted objectives, included strengthening the health system to ensure optimal conditions for care and prevention across healthcare, public health and service delivery.
However, as restrictions were lifted, the government established a reimbursement rate for inpatient stays associated with COVID-19. Considering the financial mechanisms of the health system, especially the sustainability of the UPC, the MOH implemented a measure called the ‘basket of health services and technologies intended for the care of the COVID-19’. This initiative empowered the MOH to define two aspects: first, the creation of care baskets tailored for patients with COVID-19, and second, the determination of values at which the National Health Fund (ADRES in Spanish) should directly compensate institutions providing health services. This compensation was based on information reported by HMOs or subnational governments.
In the execution of this measure, the MOH, as outlined in Resolution 1161 of 2020, identified the health services and technologies constituting the baskets for the care of COVID-19. This determination arose from a rapid study evaluating potential applications of health technologies for the direct care of the disease. However, a notable limitation surfaced during this study while many treatments were documented, their effectiveness in comparison to alternative treatments was not well established. For instance, distinguishing the impact of treatments from the natural progression of the disease proved challenging.
Subsequently, based on the information reported by the HMOs to the MOH of the services provided during 2020, it was evident that the UPC was sufficient to finance the services and technologies derived from COVID-19 care, which got to be compensated enough by the lessening of other services that had to be cancelled or postponed because of the quarantine periods. Thus, that reimbursement rate was used rather as a reference, but no disbursement was made based on it. Taking into account, (1) the peak of cases presented in 2021 for the months of May, June and July where the number of cases was twice above the average and (2) the statistics on hospitalisations that revealed the high demand for care derived from COVID-19 and the risks of deviation in the sufficiency of the UPC, Resolution No. 1585 of 13 October 2021 and 2390 of 28 December 2021 were issued, which established the reimbursements of the baskets for these periods and thus prevent possible imbalances in the sufficiency of the UPC, and therefore, the emerging of debts with Health Provider Institutions.
HMOs and healthcare providers raised concerns about the reimbursement rate that it was not accurately determined. The HMO association estimated a deficit in this financing scheme and formally requested the government to address the resulting economic loss.6
In this study, we evaluate whether the reimbursement rate for COVID-19 inpatients stays was well defined. We accomplish this by conducting a cost of illness study of patients with moderate, severe and critical illness between June 2020 and June 2021 based on the institutional registry of patients with COVID-19 from a high complexity institution in Colombia,7 and comparing median cost to actual with the actual reimbursement rates.