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This is the update for 2019. If you want to see the update for the 2020 please log in HERE 


PBS 2019 what was it that changed?

Foto-Laura-Van-ConvertImage

Laura van der Werf Paintings
MSc
MBE Researcher
NeuroEconomix

The media and social networks have been filled with news reporting about a new POS. This is due to the publication of resolution 5857 of 2018 that updates the drugs, procedures and services that will be financed with resources from the Capitation Payment Unit. But what is this benefit plan? Why is it no longer called POS? What exactly changed?

Benefit plans. What do we need them for?

Health systems in all countries face growing health needs and limited resources to meet them. Taking into account that it is not possible for health systems to finance all the medicines and services that exist, it is necessary to establish which are the most important to meet the needs of the population, thus ensuring that there are resources to finance them. Many health systems define a detailed and specific list of drugs and services that will be covered by the health system. This type of list is known as a benefit plan, benefit package or basket of services (1). In Colombia the benefit plan used to be the POS. Now the POS has been replaced by the Health Benefits Plan Charged to the Capitation Payment Unit (PBSUPC).

 

But where does the name of this new benefit plan come from? Why is it no longer called POS?

 

From the Mandatory Health Plan to the Health Benefits Plan charged to the UPC Did you just change the name?

Law 100 of 1993 in its article 156 created the Obligatory Health Plan, known as POS. At that time, the POS was defined as "a comprehensive health protection plan, with preventive, medical-surgical care and essential drugs", which had to be provided by the Health Promoting Entities (EPS). In order to provide POS services, it was defined that the EPS would receive a value for each affiliate called the Capitation Payment Unit (UPC), which would be established according to the characteristics of the affiliated population, the covered services and the average costs of providing services.

 

In 1994, agreements 008 and 009 defined for the first time the POS for the contributory regime (POS-C) and the POS for the subsidized regime (POS-S). In the initial POS-S only a fraction of the benefits of the POS-C were included, hoping to equal the benefit packages of both regimes for 2001. Furthermore, at that time it was defined that the UPC recognized to the EPS of the subsidized regime would be equivalent only to the 50% of the UPC recognized to the EPS of the contributory regime. This difference between the benefits received by the affiliates of the subsidized regime and the contributory regime was considered a cause of inequity in health (2,3). In addition, many benefits that were considered necessary by health professionals were not included in the POS. To access them, it was necessary to fill out the so-called No-POS form and then go to a Technical-Scientific Committee to approve the financing with public resources. This cumbersome process made it very difficult to access those benefits not covered by the POS. Furthermore, it was necessary to evaluate each case separately to determine whether or not public resources should be used to finance a drug, service or procedure.

 

Between 1994 and 2008 the benefits included in POS-C and POS-S increased. However, the benefit plan of the subsidized regime had not been equal to that of the contributory regime. For this reason, the Constitutional Court, through ruling T-760 of 2008, ordered the adoption of measures to unify the benefit plans of both regimes.

 

After several agreements that unified the benefit plans - first for children and then progressively for adults - in 2012, the benefit plans of the subsidized and contributory regime were finalized. However, the value recognized to the EPS by each affiliate continued to be lower for the subsidized scheme than for the contributory scheme.

 

In 2015, the Statutory Health Law determined that the health system would guarantee the fundamental right to health through the provision of services and technologies, structured on a comprehensive concept of health, including promotion, prevention, palliation, care of the disease and rehabilitation of its consequences. Due to this new way of conceiving health, there was a change in the way of understanding which benefits should be covered by the health system. Everything was considered to be included, unless explicitly excluded. As of 2016, the Mandatory Health Plan ceased to exist, being replaced by the Health Benefits Plan charged to the UPC (Resolution 5592 of 2015).

 

The difference between the POS and the PBSUPC is that the latter list does not determine the benefits that will be covered by the health system, but only which of the covered services should be financed with the resources delivered to the EPS, that is, with the CPU. Many other benefits, which are not included in this list, are covered with other resource schemes of the health system. These benefits are prescribed through the MIPRES system and are explicitly limited by a list in which those drugs and services that cannot be financed with public resources are determined -List of exclusions: Resolution 687 of 2018: https://www.minsalud.gov.co/Normatividad_Nuevo/Resolucion%20No.%205267%20de%202017.pdf

 

There is a lot of confusion in the media on this issue, because there is a lack of clarity about what the Health Benefits Plan charged to the UPC is, what are the exclusions and what are the benefits that are covered with public resources.

Watch:

 

 

PBS figura 1
Figure 1 Configuration of the current benefit plan

 

What changed with the last update?

In accordance with current legislation, the PBSUPC must be updated every year. These updates are necessary because the diseases that affect the Colombian population are changing and because new medicines and other health technologies are emerging all the time, while others are becoming obsolete. The PBSUPC was updated in 2017 by resolution 5269 of 2017 and more recently by resolution 5857 of 2018.

 

Resolution 5857 of 2018 largely maintained the content of resolution 5269 of 2017, however, in its three annexes there were significant changes. In the first annex, which includes the drugs to be financed with UPC resources, 18 new drugs were included, most of them for the management of anxiety disorders and osteoporosis (Table 1). In addition, 15 new therapeutic groups were included, which include 75 drugs. These groups include drugs for the treatment of very common chronic diseases such as high blood pressure and diabetes. (table2). Of these 75 drugs, 22 were already included in the PBS charged to the UPC in its last update. In the second annex, which contains the health procedures, 13 procedures were added (table3). The biggest change was in the last annex, which contains the clinical laboratory procedures, to which 40 procedures were added (table4).

 

Some final thoughts

The changes that have occurred since statutory law regarding the benefits covered by the health system have several implications. The financial sustainability of the health system depends on the careful selection of those benefits that should not be financed with public resources, without this hindering the right to health.

 

At the same time, the fact that benefits are covered by the health system, unless they are explicitly excluded, allows health professionals a great deal of autonomy in what they formulate. This greater autonomy also implies that a large part of the responsibility for using resources properly falls on them, because only if they formulate the most cost-effective drugs and procedures, is it possible for the health system to be sustainable.

 

Finally, the inclusion of new drugs and procedures in the PBSUPC makes their financing the responsibility of the EPS and can reduce administrative barriers to access them. However, it must be taken into account that the increase in benefits included in this list must be in accordance with the resources allocated to cover them (the UPC), otherwise the incentive for the EPS to deny or delay the provision of services included in the PBSUPC it will increase.

 

Boards

Table 1 Medications added to the PBSUPC in 2019

PBS tabla 11

 

Table 2 Therapeutic subgroups added to PBSUPC in 2019

PBS tabla 2

Table 3 Procedures added to the PBSUPC in 2019

PBS TABLA 3

 

Table 4 Clinical laboratory procedures added to PBSUPC in 2019

PBS tabla 4

 

If you want to download the PDF of resolution 5857 click HERE

If you want to download the PDF of the tables with the new PBS technologies, click  HERE

References

1. Rovira J, Rodríguez-Monguió R, Antoñanzas F. Health benefit packages: objectives, design and application [Internet]. Washington, DC: World Health Organization; 2003 [cited 2019 Jan 24]. Available from: https://www.paho.org/hq/documents/conjuntosdeprestacionesdesaludobjetivosdisenoyaplicacion-ES.pdf

2. Daniels N, Bryant J, Castano RA, Dantes OG, Khan KS, Pannarunothai S. Benchmarks of fairness for health care reform: a policy tool for developing countries. Bull World Health Organ. 2000; 78 (6): 740–50.

3. Vargas Jaramillo J, Molina Marín G. Access to health services in six cities of Colombia: limitations and consequences. National School of Public Health: The scene for public health from science; 2009. 121-130 p.

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