Presentation (CTI)

OBJECTIVES: To assess the financial implications of increased emergency service utilization in a large Colombian Health Promoting Entity (EPS) operating in the Caribbean region. Despite efforts to expand risk management cohorts, the rising consumption of urgent care services has generated growing pressure on the insurer’s cost structure and threatens financial sustainability.
METHODS: A descriptive financial analysis was conducted using internal EPS data (2020-2024), including indicators on urgent care notifications, contributable services, and total cost-to-income ratios. The evolution of affiliated population, emergency events, and financial performance was tracked. The study also compared the trajectory of urgent care use with the growth of risk cohort enrollment to assess whether preventive strategies reduced high-cost service utilization.
RESULTS: Between 2020 and 2024, the EPS experienced a 122% increase in emergency service notifications (from 400,009 to 885,263 cases), outpacing the growth in enrollment and cohort coverage. While over 507,000 patients were enrolled in risk management cohorts by 2024, the cost-to-income ratio of the EPS escalated from 93.5% (2020) to 105.1% (2024). This indicates a tipping point where healthcare costs exceed revenues. Chronic cohort programs, such as cardiovascular and oncology, failed to offset urgent care needs, revealing a gap between prevention goals and actual health outcomes. The EPS absorbed higher per capita costs, driven by emergency consultations, diagnostics, hospitalizations, and ICU admissions—leading to negative operating margins.
CONCLUSIONS: Uncontrolled growth in emergency care utilization can erode the financial performance of health insurers, especially when risk management interventions are ineffective or poorly integrated. Colombian EPSs must implement stronger predictive models, enhance cohort effectiveness, and realign incentives toward reducing unnecessary emergency visits. Failure to do so jeopardizes not only financial stability but also the quality and continuity of patient care.