Presentation (CTI)

OBJECTIVES: To develop business optimization strategies for cost management in health insurance, integrating strategic management principles, organizational efficiency, activity-based costing (ABC), and public value creation. The study analyzes contractual and operational modalities between Health Promotion Entities (EPS) and Health Service Providers (IPS) in the Colombian Caribbean to propose a governance framework that enhances financial and social sustainability.
METHODS: A mixed-methods approach was applied. Quantitative data from 27 IPS and 5 EPS were collected, including cost structures, efficiency indicators, and contract types. ABC models identified inefficiencies in care delivery, while technical efficiency was measured using Data Envelopment Analysis (DEA). Qualitative methods included semi-structured interviews with 18 health managers and experts, coded through grounded theory. Value-Based Health Care (VBHC) frameworks and institutional theory supported the evaluation of alignment mechanisms. Scenarios simulated the financial and operational impact of adaptive governance models.
RESULTS: The study identified a critical misalignment between EPS and IPS contractual arrangements, driven by asymmetrical information, conflicting incentives, and fragmented cost control mechanisms. Only 42% of IPS analyzed achieved optimal technical efficiency, with administrative costs averaging 17.8% above recommended benchmarks. ABC models revealed recurrent inefficiencies in clinical-administrative workflows, particularly in chronic disease care and pharmaceutical management. In parallel, VBHC indicators exposed low alignment between service delivery and patient-perceived outcomes, especially in rural and dispersed populations. Simulation scenarios showed that implementing adaptive contracting models and coordinated cost control mechanisms could reduce overall costs by 12-18%, while increasing patient satisfaction and improving financial sustainability across the EPS-IPS network.
CONCLUSIONS: Optimizing cost management in health insurance requires a shift toward adaptive, value-driven governance structures. The proposed model combines strategic alignment, cost accountability, and outcome-based performance to improve sustainability in complex health systems. In territories like Colombia’s Caribbean region, where fragmentation and inequality persist, these findings offer a roadmap for transformation based on public value and strategic efficiency.