“There is a problem of financing all the proposals, it can also be fertile ground for corruption.”
The power given to the Addresses and the New EPS with the health reform proposal, could lead to thinking about a new restructuring of what in the past was the Social Security Institute (ISS).
This is the opinion of Gustavo Quintero, dean of the School of Medicine and Health Sciences of the Universidad del Rosario, who pointed out that “after reading the 152 articles and their annexes there are several concerns.”
In his opinion, there is a problem of financing all the proposals. “It seems to be an ambitious and structural initiative that requires financing that must be subject to budget availability, the Medium Term Expenditure Framework and the Medium Term Fiscal Framework, and which, furthermore, can be fertile ground for corruption.”
Ordinary law or statutory law?
“It is not clear the transition time of the norm, nor the process that it will take, whether as an ordinary law or as a statutory law, which implies different times, said Gustavo Quintero.
For Daniel Figueredo De Pérez, professor at the Faculty of Jurisprudence of the Universidad del Rosario, although this health reform may require statutory law, this argument must be considered with caution. Not because a bill touches aspects of a fundamental right, it has to be processed as statutory law.
“In my opinion, this depends on something crucial: whether the reform of the system’s structure has an impact on the elements that make up the human right to health (availability, accessibility, acceptability, and quality). The question is if this project affects the availability of health products, access to them, is it done in an unacceptable way or if the quality of health is diminished”, explained Figueredo De Pérez.
“However, if the argument prevails that because it is a health issue it must be processed as a statutory law in Congress, with that same argument the unconstitutionality of laws 100, 1122 and 1438 that were processed as ordinary laws could be demanded” , I note. For this reason, it is essential that the analysis be qualified and that the extent to which the reform fits into any of the requirements for the processing of statutory laws indicated by the Constitutional Court be answered.
Reform forgets the logic of competition of the system
Paul Rodríguez, professor at the Faculty of Economics at the Universidad del Rosario, regretted that the bill did not take into account the arguments that were presented in different academic and trade union spaces around the health reform.
“The initiative does not take into account the current capacities of the Colombian Health System, which is essential to implement such a profound reform,” said Dean Quintero.
“The competition logic of the system, which has been operating for 30 years, where there are companies and entities in charge of recruiting people and they compete for those affiliates, is being forgotten. We are moving to a model of territorial silos where attention is concentrated. Although it makes sense to do it in regions where there is little supply of insurers and health providers, in urban areas it will affect user care,” said the health expert.
In urban areas people can currently choose the company that will take care of their health and change if they deem it convenient. “In this new system this is not going to happen, because they are going to be affiliated with a primary care center (APIRS),” he noted.
“This can generate problems and disagreements among users when one of the centers fails, added to the fact that they are going to be small. According to the project, maximum 25,000 people and for a large city these are small numbers. That is going to be quite difficult to operate and implement,” Rodríguez said.
purchase of supplies
There are many actors at the territorial level and it is not clear exactly who is responsible when something goes wrong. “Someone orders the spending, which are the attention centers, and someone pays, which has been like the diluted version of the territorial ADRES. But it is not clear who takes responsibility when there is excessive spending, which leaves many doubts as to how it could function efficiently, which is one of the great achievements that the current system has had, ”he commented.
The purchase of services is another fundamental point. At this time, the EPS are in charge of negotiating and purchasing health and technology services. These have great bargaining power due to the millions of members who support them. Apparently, with the reform, primary care centers would be the ones that are going to decide spending and, since they are small, they will have much less bargaining power.
“Although it is argued that it is going to be restructured around a tariff, that does not respond to the logic of local markets, since the prices of how much it costs to do a particular procedure or how much an input costs vary notably in the different regions of the country. . Having a tariff is not a good idea because it prevents you from taking advantage of the bargaining power of large entities,” Rodríguez argued.
“In addition, there is not enough money for the expansion of health in the primary regions and in the scattered areas. The rule is fixed to the fiscal framework. It could be decades before we can see primary centers in scattered areas,” he stated.
Recruitment
The reform proposes a change to public hospitals in their administration, strengthening the role of managers and giving them an option to hire employees without having to outsource them. “With the complexity of becoming public employees, flexibility is taken away from hospitals in labor matters. The norm that appears in the articles is quite ethereal and opens the door to ‘distribute jam’ creating public squares”, noted Rodríguez.
For the expert, there is also a supply subsidy in these public hospitals, that is, in addition to being financed through the purchase of services as is the case today and there are many complaints about EPS payments and the like, now part of the money would go as the government budget.”
Information system and Superhealth
There is an important point in the text, which is the implementation of a robust information system. “The problem of the information system is very delicate, it really is required, but the investment is very high and the construction time for it is very long,” said Gustavo Quintero, dean of the School of Medicine and Health Sciences of the Rosario University.
“It is literally written as a wish list that does not appropriate the reality or the complexity of building a system of this nature. We have spent years discussing how to make the systems of the different entities that exist (hospitals, insurers, State) interoperable,” said Rodríguez.
Something key to the reform is the strengthening of the Superintendence of Health. This is a central point to be able to decongest the justice system, like the burden of guardianships today, although it is impossible to know the impact that it could have, since the system would change radically and it would not be known exactly what kind of problems would be dealt with. would have and where the Superintendency could act quickly.
For Quintero, “an additional concern is the extraordinary powers that are requested of the President of the Republic in terms of labor provisions for human talent in health, both private and public, to modify and complement public health regulations, a fairly extensive topic, to establish the transition process and to capitalize the New EPS”.