Effect of mass transfers of enrollees from liquidated health insurance companies on the financial sustainability of health insurance: an ecological study in the Colombian health system

Background The liquidation of health promoting entities
(Entidades Promotoras de Salud (EPS)) in Colombia and the
forced transfer of millions of enrollees to solvent insurers have
raised concerns about the financial sustainability of the health
insurance system. This study examines the impact of these
uncompensated mass transfers on key financial indicators of
receiving EPS.
Methods A multitemporal ecological study and a difference-in-
differences
(DiD) model were conducted using national
administrative data. Nine continuously operating EPS that
received enrollees from liquidated entities were included.
Key financial indicators analysed included operating margin,
capitation payment unit (Unidad de Pago por Capitación (UPC))
sufficiency, medical loss ratio, per capita medical cost and
enrolment volume. Linear mixed-effects
and fixed-effects
DiD
models were applied.
Findings Average operating margins decreased from 3.2%
(2017) to –0.59% (2024). In mixed-effects
models, UPC
sufficiency was the strongest positive correlate of margin
(β=0.28, 95% CI 0.14 to 0.41), while per capita medical cost
(β=−0.43, 95% CI −0.66 to −0.21) and enrollee transfers
(β=−0.014, 95% CI −0.027 to −0.002) were negatively
associated. DiD estimates show that mass transfers reduced
operating margins by 1.2 percentage points (95% CI −1.5
to −0.9), with the strongest effects in the first 2 years and
consistent results across sensitivity analyses.
Interpretation Uncompensated mass enrollee transfers
from liquidated EPS have a significant negative impact on the
financial sustainability of receiving insurers. Regulatory reforms,
including risk-adjusted
premium adjustments and interinsurer
compensation mechanisms, are urgently needed.