Effects of managed care mechanisms on access to healthcare: results from a qualitative study in Colombia

• Published in: The International journal of health planning and management Vol. 28; no. 1; pp. e13 - e33
• Main Authors: Vargas, Ingrid, Unger, Jean-Pierre, Mogollón-Pérez, Amparo Susana, Vázquez, M. Luisa
• Format: Journal Article
• Language: English
• Published: England Blackwell Publishing Ltd 01.01.2013; Wiley Subscription Services, Inc
• Subjects: access; and evaluation; Colombia; Colombia - epidemiology; Content analysis; Delivery of Health Care - organization & administration; Delivery of Health Care - statistics & numerical data; Health administration; Health care access; Health care policy; Health insurance; health policy; Health Services Accessibility - organization & administration; Health Services Accessibility - statistics & numerical data; healthcare quality; healthcare quality, access, and evaluation; Humans; Insurance, Health - organization & administration; Insurance, Health - statistics & numerical data; Managed care; managed care programmes; Managed Care Programs - organization & administration; Managed Care Programs - statistics & numerical data; Models, Organizational; Organizational Case Studies; Profitability; Qualitative Research; Colombia
• ISSN: 0749-6753; 1099-1751
• DOI: 10.1002/hpm.2129

SUMMARY Background Managed competition has underpinned most health sector reforms aimed at improving access and efficiency, in Latin America and other countries. The aim of the paper is to analyse barriers to healthcare that emerge from the introduction of managed care mechanisms in Colombia. Methods Qualitative, exploratory, and descriptive‐interpretative research was carried out on the basis of case studies of four healthcare networks, comprised of insurers and their providers. Individual semi‐structured interviews were conducted with a theoretical sample of informants (managers, professionals, and users), between 24 and 61 per network. The final sample size was reached by saturation of information. An inductive thematic content analysis was conducted. The study areas were two municipalities of Colombia, in which most of the population live in poverty. Results A number of managed care mechanisms that act as barriers to access were identified by all informants, regardless of area and type of insurance regime. These mechanisms act directly on the patient (authorizations, fragmented insurance) or on the providers (purchasing mechanisms or limits to medical practice). The predominant mechanism appears to be related to the type of agreement established between insurers and providers. The reason for these barriers, according to informants, is insurers' search for profitability. As a consequence, there is delay in or no access to adequate treatment. This is particularly evident in secondary care. Conclusion A variety of managed care strategies that effectively hinder access to healthcare have been introduced by insurers, casting doubt on the usefulness of their application in low‐income countries and profit‐making contexts. Copyright © 2012 John Wiley & Sons, Ltd.