Did that improve the health system?

One of the diagnoses in which the government of President Gustavo Petro has insisted has been that the Health crisis responds, to a large extent, that it is the EPS as private actors that manage the resources. That is why among the backbone of the reform project is that insurers would no longer be responsible for directing health funds in the country, which add up to average about $ 100 billion pesos on average. On the other hand, it would be the ADRES, a state entity, which would turn directly and pay hospitals, clinics and pharmaceutical managers for the services provided to users.

However, given the complex progress of the reform project in Congress, in April last year the Government published a decree that allowed to change the conditions to increase the resources that were turned directly. In that sense, the EPS that did not meet the requirements (which were the majority) would no longer handle health resources, but would be Adres, which would directly pay clinics and hospitals, under certain parameters.

“The law allows us to turn hospitals and public and private clinics directly and we will do it to give more effectivewhereby the ADRES would begin to turn the resources corresponding to the UPC and the maximum budgets.

Just a year later, the Decree of the Ministry of Health has given results. According to ADRES data, in 2024 $ 57 out of every $ 100 pesos issued by that entity to pay services covered by the UPC did not pass through the EPS; but they turned directly to clinics and hospitals. In total, last year $ 48.1 billion pesos of health resources were paid through direct turn. So far this year, with a cut to April, $ 20.5 billion have been rotated through that mechanism.

Although the EPS that postulate clinics and hospitals to make this payment, today the Government, through the Superintendence of Health, controls more than 60 % of the affiliates with the 9 EPS that are intervened and an EPS that is under special vigilance. That means that the Government not only makes the direct turn, but through the Supersalud postulates and approves the health providing institutions (IPS) to which they are going to be paid, which last year were 7,291 in total.

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In that sense, at present the Government has achieved, without the need for reform, one of the changes that it had most requested to transform the system: that the EPS did not handle the money, but that it was the State in charge of paying for what patients receive. Today, a new decree project seeks to increase the scope of that direct turn.

Currently, the direct turn has a stop, that is, only 80 % of what the EPS would receive directly, the other 20 % reaches the insurer so that it manages the resources. Now a new Decree published for Comments by the Ministry of Health seeks to increase that 90 %stop.

Has patient care improved directly?

These figures of increase in direct turn have reached, as the Government, President Petro and his Minister of Health, Guillermo Alfonso Jaramillo for months, has this been enough to improve the health service? According to the data, everything indicates that no.

So far what the figures show is that, instead of improving, the situation has worsened in the EPS, where today is being made direct, which are mostly those intervened by the Supersalud and that concentrate more than 60 % of those affiliated with the system. That, because the Government does the direct turn, users are still affiliated with an EPS, which is the one who in theory responds for their service, although they no longer receive much of the payment they previously had for serving.

For example, in the case of Sanitas, the indicators have gone in decline in this last year, showing the discontent of their affiliates. In 2023, Sanitas received a total of 185,634 claims and in 2024 he received 221,565, which means a 19 percent increase in complaints and claims of the users of this EPS.

The months before the intervention, that is, January, February and March 2024, Sanitas accumulated 15,071, 15,721 and 14,367 complaints, respectively. A year later, during the intervention of the Supersalud, the insurer registered 23,495 complaints in January and 20,931 in February 2025. A source close to the intervention told El Time that PQRD, precisely, have been the headache during the process. “It came to have complaints of 22,000 and 23,000 averages monthly. However, in November (2024) it was reduced to 21,000,” said the source.

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The same has happened with new EPS. According to the figures of the Supersalud, in February 2024 the PQRD rate in Nueva EPS was 21.26 per 10,000 affiliates, and for February of this year it increased to 34.88, the highest figure of the last three years.

But that of Sanitas and Nueva EPS is not an isolated reality. According to the Supersalud data, the complaint rate per 10,000 affiliates has increased by 8 of the 9 EPS intervened, with the greatest increases in Western Health Services (SOS), Famisanar, Nueva EPS, Sanitas and Savia Salud.

On the other hand, and although the direct turn has accelerated the payments, during this year a growing number of health providing institutions (IPS) and pharmaceutical managers have decided to stop attending to the affiliates of Nueva EPS, due to the millionaire debts that the insurer has not paid, which prevents continuing to offer services such as hospitalizations and delivery of medications.

According to the spokesman for Patients Colombia, Denis Silva, although from the organization they have always been in favor of the direct turn, have not seen that this has been reflected in an improvement in obtaining the right to health for Colombians. Even in its concept, there has been a regression in attention for users and there are doubts about where the money is being turned.

“When one talks to public and private providers and pharmaceutical managers, everyone says that the money is not arriving. Then we ask ourselves: is the ADRES turning to paper companies or where the money goes? The second is that the EPS decides where the money goes, that is, this IPS is paid anymore no longer pays. A specific case is the subm For the Supersalud it seems that they were having a business where the EPS authorizes and the comptroller refuses to authorize the payment.

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And, despite the increase in direct turn, which according to the government would improve the management of resources, in eight of the ten EPS controlled by Supersalud, debts with clinics and hospitals grew in just 6 months according to the report of the Colombian Association of Hospitals and Clinics (ACHC).

According to the data, as of December 2024, the debt with its affiliates amounted to 20.3 billion pesos, which represents an increase of 6.9 % (around 1.3 billion pesos) with respect to the previous study, with a cut to June of the same year. The report also shows an increase in the value of the portfolio in default and its concentration. While in June 2024, Mora represented 55 %, as of December 2024 reached 55.3 %, with an increase of more than 770,000 million pesos between the two cuts.

As explained by the executive director of the Plural Citizen Participation Group, Cristina Isaza, although it is true that the increase in direct turn has centralized money management, this has not solved the structural problems of the system, as the government predicted. This, according to her, has led the patient to remain the same or worse, in a scenario where it is difficult to access medical appointments, medications or responses.

“The operational capacity of the EPS was weakened without having a clear or functional alternative model, resulting in more resources in the hands of the State, but less control and more uncertainty for those who must provide and receive the service. There is no evidence of real improvements: neither in opportunity, nor in quality, nor in coverage. Remove the silver from the private ones to give it directly to clinics and hospitals sound good in the speech, but in practice it has generated disorder, lack of audit and administrative chaos. There are no clear rules, or prioritization criteria, and with procedures that still depend on EPS that are in intensive care”Isaza said.

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For his part, the health and researcher doctor at the University of Los Andes, Luis Jorge Hernández, emphasizes that although the direct turn is an administrative advance, since the liquidity of some IPS that had financial difficulties that did not replace a structural reform that can strengthen the quality, opportunity and equity of the Colombian health system has improved.

“This measure has improved the liquidity of many providers and has reduced financial intermediation, one of the historical problems of the system. However, this change has not necessarily translated into better care for patients. Although hospitals receive the money faster, delays persist, fragmentation in care and lack of comprehensive coverage in several regions of the country,” Hernández stresses.

Former health minister Augusto Galán is more emphatic in stating that so far there is no evidence that the direct turn has helped improve the care of patients, and even questions if it is actually helping IPS, since many continue to point out that resources are owed and there are less and less funds available from the State to pay for health, since the increase in the UPC for this year was less than expected. “There is no evidence that shows that there is improvement. On the contrary, the deterioration in access continues and not necessarily the direct turn is improving the financial situation of clinics, hospitals, logistics operators and other entities that operate the health system,” Galán added.

Edwin Caicedo

Environment and Health Journalist

@Caicedoucros