Health Insurance Cost Management: Perspective from the Caribbean Region, Colombia

OBJECTIVES: Identify and evaluate the causes of health insurance cost management, such as the different modalities of interaction between insurers and providers, which allow adjusting management costs, assessing the results, from the perspective of the insurer or third-party payer. The research focuses on understanding the specific challenges associated with health insurance cost management, with particular emphasis on the various modes of interaction between insurers and providers.

METHODS: Qualitative research, understanding and analyzing the subjective and contextualized aspects of the subject of study. It uses interviews, focus groups, and content analysis to explore the perceptions, experiences, and opinions of the different actors involved in insurance cost management. Since the perspective you would use would be that of the third party payer, then it is about the economic management of health risk carried out by insurers

RESULTS: Healthcare costs in the Caribbean region are 30% higher than in other parts of the country. The highest costs are concentrated in high-complexity services, such as surgical interventions and oncological treatments. Outpatient care costs are 20% higher than in other regions of the country. Hospital care costs are 40% higher than in other regions. Specialized care costs are 50% higher than in other regions of the country. These challenges are manifested through the inherent complexity of contracts, tariff structuring, and negotiation processes. Moreover, critical factors contributing to suboptimal efficiency, such as increased operational expenses and disparities in resource allocation, can lead to inequities within the Caribbean Region's health system.

CONCLUSIONS: The healthcare sector is a crucial part of the economy, and managing health organizations is a complex and challenging task. Organizational theories can assist managers in understanding how organizations operate and in making decisions to enhance performance. Within the health sector, organizational theory and managerial strategy are employed to improve care quality, reduce costs, and increase efficiency.