Appendix #03 — Tariff Regime under ARTERIA

Front: operationally critical

The smart contract pays on confirmed event. But at what tariff? This is the hard operational question — and this appendix answers it.

Executive summary

ARTERIA operates direct payment from ADRES to the IPS (health provider) upon event confirmed in the national immutable registry, modulated by a multidimensional quality factor (§6.5 technical document). The pending operational question is: at what base tariff does each event get paid?

The current system coexists with multiple fragmented tariff regimes — SOAT Manual, historical ISS Manual, FOSYGA tariffs, bilaterally negotiated EPS-IPS tariffs, MIPRES tariffs — with no coherence or transparency. The same medical consultation can have five different prices depending on who pays, with no clinical justification. This tariff opacity is one of the structural vectors that sustains the fragmentation of the system.

ARTERIA establishes a unified national tariff regime with five properties:

1. Single catalog of clinical acts standardized (compatible with ICD-11 + national nomenclature of procedures)
2. Base tariff per act defined by the National Health Tariff Commission — a multipartisan technical body
3. Multidimensional quality factor applied to effective payment (§6.5)
4. Tariff published in real time via a public national API
5. Smart contract of payment executes the effective tariff over the confirmed event, with no administrative discretion

The tariff regime is NOT decided unilaterally by the Ministry. The National Tariff Commission operates with multipartisan technical composition (medical guilds, hospitals, rural providers, patient associations, academia, international auditor), with a public calculation methodology based on audited real cost structure + international benchmarks + annual adjustment for inflation and technological updating.

§1. Current tariff framework — inherited fragmentation

The Colombian health system today operates with multiple coexisting and non-coherent tariff regimes:

Framework norms:

• Law 100 of 1993 (arts. 154, 155) — State functions in regulation + General System of Social Security in Health
• Decree 1011 of 2006 + SOGCS — mandatory quality assurance system
• Resolution 5269 of 2017 — pricing reference

§2. Structural problems of the current tariff model

2.1. Lack of inter-regime coherence

The same general medicine consultation can have a different tariff depending on who pays: SOAT, contributory EPS (health insurer), subsidized EPS, military regime, private. Result: there is no national price for the standard medical service. The price depends on who pays, not on the clinical value delivered.

2.2. Opaque bilateral negotiation as a capture vector

EPS-IPS tariffs are negotiated bilaterally with no public traceability. Powerful providers (large urban clinics) obtain higher tariffs; weaker providers (rural IPS, small ones) receive marginal tariffs. The negotiation is structurally asymmetric.

2.3. Invented disallowances over tariffs

On top of agreed tariffs, EPS apply glosas (billing objections) that reduce effective payment. The current system has no automatic mechanism to distinguish legitimate disallowances from instrumental disallowances (a pressure mechanism via delay). Result documented by ACHC: 58% of receivables overdue beyond 90 days + effective discounts over what was billed.

2.4. Zero economic incentive to quality

Current tariffs are flat per service. The physician who adheres to clinical guidelines, who has a low complication rate, receives the same payment as the mediocre physician. There is no structural economic incentive to clinical excellence.

2.5. Zero differentiation by real complexity

Tariffs distinguish by administrative category (medium vs high complexity) but not by real clinical complexity of the case. A simple oncological case is paid the same as an oncological case of difficult management.

2.6. Obsolete SOAT Manual

The SOAT Manual, which serves as a historical technical reference for the system, was last structurally updated in prior periods. New diagnostic and therapeutic technologies have no reference tariff.

§3. ARTERIA tariff model — seven unified tariff types

3.1. Tariff per simple event

For discrete clinical events of low-medium complexity: general medicine consultation, nursing consultation, basic diagnostic exam, dispensation of standard medication.

Base tariff defined by the CNTS + Quality factor applied to effective payment (§6.5 technical document).

3.2. Tariff per procedure

For defined clinical procedures (surgery, specific intervention, sedation, biopsy, endoscopy) with a standardized national taxonomy compatible with international classifications.

Base tariff per procedure + verified supplies (medications, devices, prostheses with lot traceability) + quality factor.

3.3. Tariff per complete episode (bundled payment)

For conditions requiring multiple coordinated clinical acts: care of acute cardiopathy, care of cancer in remission, high-risk pregnancy.

Base tariff per episode covers the whole chain. Structural incentive: the provider receives the complete bundle if the episode is well resolved; downward adjustment if there are avoidable complications. Analogous to DRG (Diagnosis Related Groups) used in US Medicare and OECD systems.

3.4. Tariff per patient-month in chronic pathologies

For chronic conditions of continuous management: diabetes, hypertension, COPD, heart failure, HIV under treatment, chronic mental health.

Monthly tariff per patient under effective management + bonus by clinical outcomes (controlled HbA1c, controlled blood pressure, undetectable viral load, etc.).

This is capitated payment per event + outcome, NOT the UPC (per-capita payment unit) capitated to an insurer of the legacy model. The key difference: payment goes to the IPS that actually manages the patient, modulated by the verifiable clinical outcome.

3.5. Emergency tariff

For urgencies and critical care of limited time.

Elevated base tariff + response-time factor (penalty for delay, bonus for immediate response). For critical emergencies (cardiac arrest, severe trauma, stroke) response within the therapeutic window receives maximum bonus.

3.6. Resolutive Primary Care tariff

For Resolutive Primary Care visits that fulfill the resolutive commitment (§3.7.5 technical doc): a visit that resolves on-site + first dose administered + referral with assigned appointment.

Superior base tariff to a pass-through Primary Care visit. Structural justification: Resolutive Primary Care delivers greater clinical value and reduces the burden on higher levels of the system.

Operational tariff difference:

3.7. Effective prevention tariff (P4P — Pay for Prevention)

Innovative component. Payment to the IPS for clinical events that DO NOT occur because prevention was effective.

Mechanism: the IPS that effectively manages prevention (adherence control, intervention in social determinants of health, timely vaccination, screening) receives a bonus when patients under its management DO NOT develop expected clinical events (hospitalization due to decompensation, expected complication of a chronic pathology).

Bonus calculation: comparison between the expected rate of clinical events for the cohort (adjusted for baseline risk) vs the actual observed rate. If the actual rate is significantly lower than expected, the bonus is released proportional to the difference.

Origin: OECD Pay for Performance (P4P) models adjusted to the Colombian context + materialization of the preventive component of Decree 858/2025.

§4. National Health Tariff Commission (governance)

ARTERIA creates or consolidates a National Health Tariff Commission (CNTS), a multipartisan technical body with a specific function.

4.1. Composition

4.2. Operational function

1. Define and publish the national catalog of clinical acts (taxonomy compatible with ICD-11 + procedures)
2. Calculate the base tariffs with a public methodology based on:
   • Audited real cost structure (supplies, salaries, infrastructure, technical administration)
   • International benchmarks adjusted to the Colombian context
   • Elasticity and financial sustainability analysis
3. Update tariffs annually for inflation + technological updating + methodological review
4. Audit tariff compliance of the system
5. Resolve tariff disputes between actors
6. Publish tariffs in real time via a public national API

4.3. Relation to other bodies

• National Medicines Pricing Commission (CNPM): complementary, not overlapping
• Supersalud: oversees tariff compliance + operates the sanctioning regime
• Solicitor's office delegated to the health sector: disciplinary
• Citizen and academic audits: public dashboard + access to methodology

§5. Automatic payment mechanics to the provider

Each clinical event attended and confirmed in the system's immutable registry automatically triggers payment to the provider. Payment operates under verifiable regulated logic (no opaque discretion) and combines three main components:

Execution: the logic verifies the components against the event confirmed in the system, calculates the effective payment and triggers the transfer from ADRES to the providing IPS within the defined deadline (≤ 30 days, instrumented via Law 1438 art. 13). No intermediate procedure, no discretionary disallowance, no opaque negotiation.

Audit: each payment is logged in the immutable registry. Any independent auditor can verify the coherence between the confirmed event, the applied tariff and the effective payment, without permission from the Ministry.

The exact mathematical formula for calculating effective payment, the category weighting factors and the metric-to-payment-factor mapping function are documented in the technical repository under the control of the Foundation of the Standard (technical proposal §10), auditable by qualified technical teams.

§6. Transitional regime of the tariff model

Transition guarantee: during months 6-18, providers have a no-loss guarantee. The ARTERIA tariff in this period cannot be lower than the effective average tariff that the provider received in the legacy regime adjusted for inflation. This protects providers who migrate early.

§7. Applicable legal framework

Legal vehicle of the tariff reform:

• Regulatory decree recognizing the CNTS and the national catalog as a technical standard
• MinSalud Resolution on the national catalog and provisional base tariffs
• Specific Bill of Law for modification of aspects of Law 100 that require legal rank

§8. International comparisons

8.1. DRG (Diagnosis Related Groups) — US Medicare

Bundled episode payment model used in US Medicare and many OECD systems. It groups clinical cases into homogeneous groups by expected cost and pays a fixed tariff per group independent of actual effective cost.

Applicability to ARTERIA: the Tariff per complete episode (§3.3) component is DRG-style. It reduces the incentive to over-provision, rewards clinical efficiency.

8.2. APR-DRG (All Patient Refined DRGs)

Refinement of DRG adjusted by patient severity. Useful for heterogeneous clinical cases.

Applicability: the Modifier by real complexity of the smart contract operates as an APR-style adjustment.

8.3. Pay for Performance (P4P)

OECD models that link payment to verifiable clinical outcomes. United Kingdom (Quality and Outcomes Framework), US (Medicare ACO), Germany (Disease Management Programmes).

Applicability: both the Quality factor of payment and the Effective prevention tariff (§3.7) are P4P-style.

8.4. Risk-adjusted capitation

Models where capitation to the provider (not to insurer) is adjusted by the real clinical risk of the managed population. The Netherlands, Israel (HMOs), parts of the NHS UK.

Applicability: the Tariff per patient-month in chronic pathologies (§3.4) is risk-adjusted capitation applied to the provider, not to an intermediary insurer.

8.5. International reference tariff

Comparison with OECD country tariffs adjusted to purchasing power parity. The CNTS uses international benchmarks as one of the components of the public methodology.

§9. Adversarial defenses

9.1. «Does this make care more expensive?»

For some providers yes. For others no. The criterion is real quality delivered. The provider that delivers superior quality charges more; the one that delivers inferior quality charges less. The aggregate effect: total system spending does not increase because quality modulation operates within the range defined by the CNTS. Spending is redistributed from inefficient providers toward efficient providers — incentivizing clinical excellence.

9.2. «What if the base tariff is unfair?»

The CNTS operates with multipartisan composition (18 seats with representation of physicians, hospitals, rural providers, patients, academia, ADRES, MinSalud, international auditor). The calculation methodology is public and auditable. Decisions are made by qualified 2/3 majority. There is a technical appeal mechanism for specific cases. Mandatory comparison against international benchmarks. Capture of the CNTS by specific interests would require simultaneously capturing multiple structurally independent blocs — operationally difficult.

9.3. «How are emergencies and catastrophic illnesses handled?»

Emergency tariff (§3.5) with response-time factor covers emergencies. Catastrophic illnesses operate in coordination with the High Cost Account (CAC) — specific regime that ARTERIA preserves and reinforces (see pending Appendix #05).

9.4. «Doesn't this contradict medical professional autonomy?»

No. Medical professional autonomy (Statutory Law 1751 art. 17) is fully preserved. The physician decides what to prescribe, what procedure to perform, what referral to make. Tariffs regulate what the system pays for each act — not what acts are performed. Adherence to clinical guidelines as a quality metric operates on pertinence (Res. 2696/2024), not on the physician's individual clinical criterion.

9.5. «Isn't this State paternalism over the market?»

No. It is technical regulation of a market with insurmountable structural asymmetry (the patient does not negotiate the price of an urgent surgery). Throughout the developed world, health tariffs are regulated: US Medicare operates DRG; Germany operates Kassenärztliche Vereinigung tariffs; France operates CCAM; the United Kingdom operates the NHS Tariff. Colombia is atypical in the sense of bilaterally negotiated EPS-IPS tariffs with no unified framework — that atypicality is a vector of capture, not of market efficiency.

9.6. «How is it prevented that the State captures tariff-setting to reduce spending at the cost of quality?»

Triple structural safeguard:

1. Multipartisan CNTS — the Ministry has 1 voting seat out of 18; it does not unilaterally control
2. Mandatory international benchmark — tariffs cannot arbitrarily fall below adjusted international standards
3. Annual external audit — independent international auditor verifies methodology and results

9.7. «And the special regimes (military, teachers, Ecopetrol)?»

They keep their regimes with operational coordination. They may adopt the national catalog of clinical acts and the ARTERIA tariff as a reference, retaining administrative autonomy. If they opt to keep their own differentiated manuals, they retain autonomy but assume the cost of the lack of harmonization (see pending Appendix #04 special groups).

§10. Tariff implementation plan

§11. Executive summary of defenses

Unified national tariff + modulation by real quality + multipartisan technical governance + public transparency in real time + self-executable smart contract + annual update mechanism + mandatory international benchmark. This is what ARTERIA delivers operationally on top of a system that today pays the excellent physician and the mediocre one alike, pays the suffocated rural hospital and the powerful urban clinic alike, with no transparency and with systematic capture via opaque bilateral negotiation + instrumental disallowances + 30-40% discounts at closing.

The tariff regime is not accessory — it is the economic mechanism by which ARTERIA simultaneously materializes direct ADRES → IPS payment, the closing of intermediary capture, the incentive to clinical quality, the recognition of differential value, the operationalization of Resolutive Primary Care, the reward for effective prevention, and compliance with legal payment deadlines.

State of the appendix

• v1.0: 2026-06-11
• Front: operationally critical
• Audience: MinSalud technical team, ADRES, ACHC, medical guilds, High Cost Account, MinHacienda, multilaterals (IDB, WB for international benchmark)
• Next iteration: when the methodology for calculating base tariffs is articulated in detail by the technical subteam