Impacto en la gestión de las enfermedades de alto costo en Colombia
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Fecha
2021
Autores
Sanes Flórez, Amaline
Cabrera Caballero, Susana
Delgado Velásquez, Sara Hess
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Ediciones Universidad Simón Bolívar
Facultad de Administración y Negocios
Facultad de Administración y Negocios
Resumen
Las enfermedades catastróficas, son aquellas que deterioran la salud de las personas, se
caracterizan por su alto grado de complejidad, son agudas prolongadas amenazantes para la
vida pues en su gran mayoría son letales, muchas de estas patologías producen la incapacidad
del paciente y provocan el desmedro económico del que las padece, de su familia o de la
institución aseguradora, pudiendo el asegurador ser una institución pública o privada.
Podemos evidenciar que las enfermedades de alto costo (EAC) representan un gran riesgo
para el equilibrio financiero de las empresas de salud y pueden ser un factor determinante
para su supervivencia en el mercado. Conocerlas mejor es esencial para prever su impacto en
el sistema de prestación de servicios de salud.
En la ley 100 de 1993 y en su reforma parcial, la ley 1122 de 2007 el gobierno colombiano
definió una lista explicita de eventos de alto costo en la que se incluían patologías,
prestaciones o tratamientos específicos y ámbitos de prestación.
En Colombia el abordaje de las patologías de alto costo ha evolucionado y va más allá de la
protección financiera de los ciudadanos, la cual se ha buscado por medio de la cobertura
universal (mayor del 95%), logrando niveles de pagos de bolsillo por debajo del 5%.
La identificación de patologías de alto costo se orienta también a lograr la gestión del riesgo
por medio de guías de práctica clínica, modelos de atención, normas técnicas, entre otros;
Para neutralizar el efecto de la selección de riesgos entre aseguradoras y desincentivar la
selección o discriminación de los pacientes con patologías de alto costo se incorporó al
sistema un ajuste de riesgo el cual actualmente se hace ex post, con base en un mecanismo
de redistribución de recursos entre todas las aseguradoras de salud, las cuales hacen parte
manera obligatoria de un fondo de compensación denominado Cuenta de Alto Costo - CAC,
complementando el ajuste de riesgo ex ante, el cual no incluye los diagnósticos dentro de su
estimación.
De acuerdo al decreto 2699 de 2007 que creo la Cuenta de Alto Costo, le corresponde al
Ministerio de la Protección Social determinar las enfermedades ruinosas y catastróficas (alto
costo) y en la resolución 3974 de 2009 se considera conveniente atender criterios de selección
y priorización tales como: Su importancia relativa en la carga de enfermedad del país; El
carácter permanente o crónico de la enfermedad; La disponibilidad o el actual desarrollo de
guías de atención integral; Las posibilidades de prevención de la enfermedad; El costo de la
enfermedad para el Sistema General de Seguridad Social en Salud. La Resolución 2565 de
2007 y la resolución 3974 de 2009 establecen con fines de ajuste por la Cuenta de Alto
Costo, una lista de patologías consideradas de alto costo a saber: Enfermedad Renal Crónica;
Cáncer de cérvix; Cáncer de mama; Cáncer de estómago; Cáncer de colon y recto; Cáncer de
próstata; Leucemia linfoide aguda; Leucemia mieloide aguda; Linfoma Hodgkin; Linfoma
no Hodgkin; Epilepsia; Artritis reumatoide; VIH/SIDA.
Catastrophic diseases are those that deteriorate people's health, are characterised by their high degree of complexity, are acute, prolonged and life-threatening, as most of them are lethal. Many of these pathologies lead to the patient's incapacity and cause economic losses for the sufferer, his family or the insurance institution, and the insurer may be a public or private institution. It is clear that high-cost illnesses (HCA) represent a major risk for the financial equilibrium of health companies and can be a determining factor for their survival in the market. A better understanding of these diseases is essential to anticipate their impact on the health care delivery system. In Law 100 of 1993 and its partial reform, Law 1122 of 2007, the Colombian government defined an explicit list of high-cost events, including specific pathologies, benefits or treatments and areas of provision. 6 In Colombia, the approach to high-cost pathologies has evolved beyond the financial protection of citizens, which has been sought through universal coverage (greater than 95%), achieving levels of out-of-pocket payments below 5%. The identification of high-cost pathologies is also aimed at achieving risk management through clinical practice guidelines, care models, technical standards, among others; To neutralise the effect of risk selection among insurers and discourage the selection or discrimination of patients with high-cost pathologies, a risk adjustment was incorporated into the system, which is currently done ex post, based on a mechanism of redistribution of resources among all health insurers, which are obligatorily part of a compensation fund called the High Cost Account (CAC), complementing the ex ante risk adjustment, which does not include diagnoses in its estimate. According to Decree 2699 of 2007, which created the High Cost Account, it is up to the Ministry of Social Protection to determine the ruinous and catastrophic diseases (high cost) and Resolution 3974 of 2009 considers it convenient to consider selection and prioritisation criteria such as: their relative importance in the country's disease burden; the permanent or chronic nature of the disease; the availability or current development of comprehensive care guidelines; the possibilities of preventing the disease; the cost of the disease for the General System of Social Security in Health. Resolution 2565 of 2007 and resolution 3974 of 2009 establish for the purpose of adjustment by the High Cost Account, a list of pathologies that are not included in the High Cost Account. Cost Account, a list of pathologies considered high cost, namely: Chronic Kidney Disease; Cervical Cancer; Breast Cancer; Stomach Cancer; Colon and Rectum Cancer; Prostate Cancer; Acute Lymphoid Leukaemia; Acute Myeloid Leukaemia; Hodgkin's Lymphoma; Non-Hodgkin's Lymphoma; Epilepsy; Rheumatoid Arthritis; VIH/SIDA.
Catastrophic diseases are those that deteriorate people's health, are characterised by their high degree of complexity, are acute, prolonged and life-threatening, as most of them are lethal. Many of these pathologies lead to the patient's incapacity and cause economic losses for the sufferer, his family or the insurance institution, and the insurer may be a public or private institution. It is clear that high-cost illnesses (HCA) represent a major risk for the financial equilibrium of health companies and can be a determining factor for their survival in the market. A better understanding of these diseases is essential to anticipate their impact on the health care delivery system. In Law 100 of 1993 and its partial reform, Law 1122 of 2007, the Colombian government defined an explicit list of high-cost events, including specific pathologies, benefits or treatments and areas of provision. 6 In Colombia, the approach to high-cost pathologies has evolved beyond the financial protection of citizens, which has been sought through universal coverage (greater than 95%), achieving levels of out-of-pocket payments below 5%. The identification of high-cost pathologies is also aimed at achieving risk management through clinical practice guidelines, care models, technical standards, among others; To neutralise the effect of risk selection among insurers and discourage the selection or discrimination of patients with high-cost pathologies, a risk adjustment was incorporated into the system, which is currently done ex post, based on a mechanism of redistribution of resources among all health insurers, which are obligatorily part of a compensation fund called the High Cost Account (CAC), complementing the ex ante risk adjustment, which does not include diagnoses in its estimate. According to Decree 2699 of 2007, which created the High Cost Account, it is up to the Ministry of Social Protection to determine the ruinous and catastrophic diseases (high cost) and Resolution 3974 of 2009 considers it convenient to consider selection and prioritisation criteria such as: their relative importance in the country's disease burden; the permanent or chronic nature of the disease; the availability or current development of comprehensive care guidelines; the possibilities of preventing the disease; the cost of the disease for the General System of Social Security in Health. Resolution 2565 of 2007 and resolution 3974 of 2009 establish for the purpose of adjustment by the High Cost Account, a list of pathologies that are not included in the High Cost Account. Cost Account, a list of pathologies considered high cost, namely: Chronic Kidney Disease; Cervical Cancer; Breast Cancer; Stomach Cancer; Colon and Rectum Cancer; Prostate Cancer; Acute Lymphoid Leukaemia; Acute Myeloid Leukaemia; Hodgkin's Lymphoma; Non-Hodgkin's Lymphoma; Epilepsy; Rheumatoid Arthritis; VIH/SIDA.
Descripción
Palabras clave
Enfermedades de alto costo, Gestión, Cuentas de alto costo