Why Are Costs Rising? Cohort Expansion Without Impact in a Colombian Health Insurer Region
Author(s)
JUAN C. FERNANDEZ MERCADO, MBA, MSc, PhD, MD1, Nelson Alvis-Guzman, MPH, PhD, MD2.
1UNIVERSIDAD DE CARTAGENA, Cartagena, Colombia, 2Universidad de Cartagena - ALZAK Foundation, Cartagena, Colombia.
1UNIVERSIDAD DE CARTAGENA, Cartagena, Colombia, 2Universidad de Cartagena - ALZAK Foundation, Cartagena, Colombia.
OBJECTIVES: To analyze the relationship between health expenditures and the expansion of risk management cohorts in a Colombian Health Promoting Entity (EPS) with over 2.6 million enrollees in the Caribbean region. The study evaluates whether the increased enrollment in risk-based cohorts leads to expected reductions in emergency visits and hospital-related costs, and examines potential causes of persistent cost escalation.
METHODS: A retrospective observational analysis was performed using internal cohort management data (2021-2024), cost indicators, and service utilization metrics. Key variables included: number of patients per cohort, urgent care service use, hospitalization rates, and cost-income ratio by year. Cohort effectiveness was assessed based on their ability to reduce secondary complications. Trend analysis and deviation mapping were applied to compare spending versus cohort coverage.
RESULTS: Between 2021 and 2024, the number of patients enrolled in risk cohorts grew by over 60%, reaching more than 500,000. However, instead of stabilizing expenditures, total healthcare costs rose sharply: from a cost-to-income ratio of 93.5% in 2020 to 105.1% in 2024. Urgency service consumption increased by 121% in the same period, revealing a paradoxical trend. Cohorts such as cardiovascular, oncology, and renal risk showed high enrollment growth but failed to demonstrate reductions in emergency events or intensive care usage. This disconnect points to inefficiencies in cohort design, follow-up continuity, and clinical impact, threatening financial sustainability.
CONCLUSIONS: The current risk cohort strategies implemented by EPSs in Colombia may fall short of their preventive purpose if not aligned with robust outcome metrics and predictive analytics. The case of this Caribbean-region EPS demonstrates that expanding risk coverage without effectiveness monitoring may result in increased financial exposure. Strategic redesign of cohort models, with a focus on impact evaluation and care integration, is urgently required to contain costs and improve care value.
METHODS: A retrospective observational analysis was performed using internal cohort management data (2021-2024), cost indicators, and service utilization metrics. Key variables included: number of patients per cohort, urgent care service use, hospitalization rates, and cost-income ratio by year. Cohort effectiveness was assessed based on their ability to reduce secondary complications. Trend analysis and deviation mapping were applied to compare spending versus cohort coverage.
RESULTS: Between 2021 and 2024, the number of patients enrolled in risk cohorts grew by over 60%, reaching more than 500,000. However, instead of stabilizing expenditures, total healthcare costs rose sharply: from a cost-to-income ratio of 93.5% in 2020 to 105.1% in 2024. Urgency service consumption increased by 121% in the same period, revealing a paradoxical trend. Cohorts such as cardiovascular, oncology, and renal risk showed high enrollment growth but failed to demonstrate reductions in emergency events or intensive care usage. This disconnect points to inefficiencies in cohort design, follow-up continuity, and clinical impact, threatening financial sustainability.
CONCLUSIONS: The current risk cohort strategies implemented by EPSs in Colombia may fall short of their preventive purpose if not aligned with robust outcome metrics and predictive analytics. The case of this Caribbean-region EPS demonstrates that expanding risk coverage without effectiveness monitoring may result in increased financial exposure. Strategic redesign of cohort models, with a focus on impact evaluation and care integration, is urgently required to contain costs and improve care value.
Conference/Value in Health Info
2025-11, ISPOR Europe 2025, Glasgow, Scotland
Value in Health, Volume 28, Issue S2
Code
EE756
Topic
Economic Evaluation, Health Service Delivery & Process of Care, Organizational Practices
Topic Subcategory
Budget Impact Analysis, Cost/Cost of Illness/Resource Use Studies
Disease
Cardiovascular Disorders (including MI, Stroke, Circulatory), Diabetes/Endocrine/Metabolic Disorders (including obesity), Oncology, Respiratory-Related Disorders (Allergy, Asthma, Smoking, Other Respiratory), Urinary/Kidney Disorders