Introduction:

The subsidized regime (SR) of the Colombian health system has structural problems that have not yet been resolved and there is a lack of studies that allow the understanding of most of them. The aim of this study was to explore with stakeholders of the subsidized regime the experience about strategic, financial, and health risk management and the differences perceived with the contributory regime.

Methods:

A qualitative study was performed; the analytic technique used was the discourse analysis under socio-hermeneutic perspective. 10 participants were interviewed, among them directors of insurance companies of SR and health care system managers. The interviews were recorded, prior informed consent, and analyzed according to the discourse analysis.

Finding:

Three discursive patterns emerged that explain risk management in SR and its differentiation from contributory regime. These patterns are connected through the role of the social determinants of health as the main axis that explain the health-disease and care processes in this regimen. At the same time, these living conditions are what determine the epidemiological profile, access, cost of care and, in general, the way in which health services are consumed by the affiliated population.

Discussion:

The health insurance literature reports that risk management is a central function, and it is a strategic exercise for the proper management of claims to optimize the use of resources, however, the findings show that the social determinants of health are not being taken into account as a key element for healthcare organization, therefore, risk management focuses on care for pathologies in advanced stages.

Conclusions:

The actors perceive that the health situation in this regime is more severe, more complicated and with a greater burden disease, which generates a tension in terms of sufficiency of the Per Capita Unit. There is a discursive absence on the role of the care model and its correlation with the needs of this population.