Appendix #06 — Master Accounts of the subsidized regime and territorial anti-corruption

Front: departmental anti-corruption — defense against the challenge to the mechanism by which resources of the subsidized regime have historically been diverted in governorates, mayoralties, and territorial health secretariats

The artery does not negotiate with the intermediate muscle about how much blood should reach the final organ. The muscle contracts or relaxes, yes, but by reflex, not by whim. The organ receives the blood it requires. When an intermediate vessel decides to keep part of the flow, that vessel no longer serves the body — it serves itself, and the organ becomes necrotic. ARTERIA eliminates the parasitic vessel without eliminating the territorial circulatory system.

Executive summary

Master Accounts (CM — Cuentas Maestras) are bank accounts in which territorial entities (departments and municipalities certified in health) receive resources of the subsidized regime and transfer them to subsidized EPSs (EPSS — health insurers), which in turn pay IPSs (health providers). This territorial intermediation is the most documented point of political capture in the Colombian health system: recurring fiscal findings by the Comptroller's Office, paradigmatic embezzlement cases (Caprecom, liquidated subsidized EPSs with unrecovered departmental receivables), inflated tariffs, contracts with EPSSs of questionable solvency tied to local interests, mass invoice objections (glosas) against hospital IPSs, structural delay in transfers that suffocates public and private hospitals serving the poorest population.

Structural thesis: ARTERIA generalizes the mechanism of direct transfer from ADRES to IPSs based on verifiable clinical events (which already exists partially since Resolution 5193/2021, but operates incompletely and with a regulatory cap of 80% of UPC resources). The payment flow for clinical services ceases to pass through the Master Account and through the Subsidized EPS as financial intermediaries. EPSSs evolve into health risk managers (see §6.4 of the main technical document and Appendix #03 §6.3) — they no longer manage provider receivables. The territorial entity retains its constitutional role as planner and steward of public health (Law 715/2001 + Law 1438/2011), but ceases to be the payer of individual clinical services. The Master Account is reduced to non-clinical resources (Collective Interventions Plan, epidemiological surveillance, equipment, territorial infrastructure), with absolute public traceability in real time via the ARTERIA transparency layer.

Explicit commitment: ARTERIA does NOT suppress constitutional territorial autonomy. It suppresses the concrete mechanism that has allowed the capture of resources from the most vulnerable sector of the system — the population of the subsidized regime.

§1. Diagnosis — the Master Account as a point of systematic capture

1.1. Regulatory framework of the current flow

1.2. The current flow step by step

1. National collection: contributions (Contributory Regime), general taxes earmarked for health, transferred revenues (lotteries, liquors, cigarettes), royalties earmarked for health, own resources of territorial entities.
2. SGP settlement: the Nation settles the health component of the SGP and distributes it to departments, districts, and certified municipalities according to formulas established in Law 715/2001.
3. Master Account: resources are deposited in a registered and supervised bank account — the "Master Account" — managed by the territorial entity.
4. Contracting with EPSSs: the territorial entity contracts with subsidized EPSs operating in its territory for the enrollment and care of its population.
5. UPC-S transfer to EPSSs: monthly, the territorial entity transfers the subsidized UPC per capita per enrollee to the EPSS.
6. Payment from EPSS to IPS: the EPSS contracts with the provider network (IPS) and pays it according to the contract (capitation, event, mixed). This is where the most severe past-due receivables in the system accumulate.
7. Partial Direct Transfer (Resolution 5193/2021): the Direct Transfer mechanism allows up to 80% of UPC resources to be transferred from the territorial entity directly to the provider network without passing through the EPSS — but with the territorial entity still acting as a pass-through node and with a regulatory cap of 80%.

1.3. The four structural vulnerabilities

Vulnerability 1: Territorial political capture

The governor or mayor controls the Master Account through the health secretary they appoint. The secretary decides (a) which EPSSs to contract with, (b) when to transfer resources, (c) which EPSSs receive advances, (d) which contracts are signed for complementary services. Historically documented: partisan ties with owners or representatives of EPSSs, political payback (votes, campaign financing) for contracts awarded, deliberate delay of transfers to non-affiliated hospital IPSs, cost overruns in accessory contracts. The Office of the Comptroller General of the Republic reports ~COP 11 trillion in fiscal findings and disciplinary proceedings related to the health sector between 2022 and 2025, with significant concentration in territorial operations of the subsidized regime.

Vulnerability 2: Past-due receivables of IPSs operating in the subsidized regime

According to ACHC (Colombian Association of Hospitals and Clinics), total IPS debt with the system amounts to ~COP 25.7 trillion, with 58% over 90 days past due. A significant proportion of this corresponds to subsidized regime operations where the EPSS did not pay the IPS, or the territorial entity did not transfer in a timely manner to the EPSS, or the chain broke at some segment. The hospitals serving the poorest population — frequently low- and medium-complexity public hospitals — are the ones most suffocated by these receivables.

Vulnerability 3: Invoice objections (glosas) as a delay mechanism

When the EPSS does have resources, the glosa mechanism (objection to the provider's invoice) allows legitimate payments to be delayed without real sanction. The IPS bills → the EPSS objects on administrative grounds (incomplete documentation, miscoded service, late authorization, insufficient clinical support, appropriateness criteria, etc.) → the IPS must respond to the objection through reconciliation → cycles of months or years. The glosa is NOT a clinical audit — it is a financial power mechanism of the EPSS over the IPS.

Vulnerability 4: Operational mixing with non-clinical resources

The Master Account also contains resources for the Collective Interventions Plan (PIC), epidemiological surveillance, territorial equipment, infrastructure, and territorial public health. Operationally mixing these resources with the EPSS payment flow facilitates opacity: "public health" transfers can be assigned to contracts of questionable real health benefit. Subsequent auditing is slow and frequently ineffective.

1.4. Direct Transfer — a partial and insufficient advance

Resolution 5193/2021 established the Direct Transfer mechanism: the territorial entity may transfer up to 80% of UPC resources directly to the provider network, without passing through the EPSS. This has marginally reduced past-due IPS receivables and vulnerabilities 1 + 3. But the mechanism (a) still leaves 20% as a capture margin, (b) keeps the territorial entity as a pass-through node with operational discretion, (c) does not resolve mixing with non-clinical resources, (d) does not resolve political capture in contracting with EPSSs (which ones exist, their contracts, their tariffs, their complementary services).

ARTERIA builds on the logic of Direct Transfer and extends it to 100%, eliminating the territorial entity as a financial node in the clinical flow.

§2. How ARTERIA operates with the subsidized regime

2.1. ADRES pays IPSs directly based on verifiable clinical events — 100% of the clinical flow

Under ARTERIA:

1. National collection → ADRES (not territorial Master Account).
2. The IPS treats the subsidized regime citizen according to their HCEU (unified electronic clinical record) and national protocols.
3. The IPS reports the clinical event to the system. A smart contract verifies (a) effective enrollment of the patient in the subsidized regime, (b) appropriateness of the service per protocol, (c) national reference price (Appendix #03).
4. ADRES pays the IPS directly within 7–15 days, without intermediation by EPSSs or the territorial Master Account.

The Master Account ceases to be the payment vehicle for individual clinical services.

2.2. EPSSs under ARTERIA — health risk managers, not receivables payers

Subsidized EPSs that demonstrate technical capacity + quality indicators transition to the role of population health risk managers (model described in §6.4 of the main technical document and Appendix #03 §6.3):

• They receive a risk-adjusted per capita premium (UPE — unit per expected event) for each enrollee under their management, calculated based on demographic profile, epidemiology, comorbidities, geographic risk
• Their responsibility is clinical management, risk management, user navigation, network planning, epidemiological surveillance of their population
• They do NOT manage provider receivables: IPSs bill directly to ADRES, not to the EPSS
• Quality indicators (Appendix #03 §6.5) determine the payment factor of the UPE — direct incentive for the quality of the service managed
• EPSSs that do not demonstrate technical capacity + quality indicators → orderly shutdown of operations; enrollees redistributed to competent EPSSs or to a subsidiary territorial operator; no enrollee loses coverage

2.3. Residual function of the Master Account — non-clinical resources

The Master Account is NOT eliminated. It is reduced to its legitimate function: receiving and managing non-clinical resources of the territorial entity, mainly:

• Collective Interventions Plan (PIC) — Resolution 1597/2025 articulated with Appendix #00
• Territorial epidemiological surveillance — constitutional competence of the territorial entity
• Public health in its territory — promotion, non-individual prevention, control of sanitary events
• Equipment + territorial sanitary infrastructure (when applicable per delegated competencies)
• Specific territorial programs (community mental health, victim care, ethnic programs)

These resources are NOT mixed with the clinical flow resources (which no longer pass through the Master Account). Management of the residual Master Account is under absolute public traceability — each transaction is visible in real time in the ARTERIA transparency layer.

2.4. The territorial entity as planner and steward — not as payer

The department, district, or certified municipality retains its constitutional role:

• Planning of the service network in its territory (opening, closure, location of IPSs, adjustment for local epidemiological needs)
• Coordination with local health authorities and with MinSalud
• Stewardship of territorial public health
• Epidemiological surveillance + response to outbreaks and sanitary emergencies
• Articulation with education, housing, drinking water, and other social determinants
• Integral territorial management per Resolution 1597/2025

The change is not a suppression of competencies — it is the elimination of the payer-intermediary function in the individual clinical flow, which is where historically capture has concentrated.

§3. Structural anti-corruption — blocked by architecture

3.1. Political capture blocked by technical impossibility

Under ARTERIA, what can a departmental health secretary discretionarily contract with a politically linked operator? The list is drastically reduced:

3.2. Algorithmic auditing + citizenship as auditor

The ARTERIA transparency layer publicly exposes:

• Each clinical event, anonymized, with its associated payment (without patient identification; with identification of IPS, date, type of service, amount)
• Each transaction of the residual Master Account with full identification (provider, contract object, amount, date, evidence of compliance)
• Quality indicators by IPS, by EPSS, by territorial entity, in real time
• Detectable aggregate patterns (concentration of contracts in a single provider, cost overruns vs. reference price, suspicious temporal sequences)

Any citizen, journalist, CSO, comptroller, inspector general, or ombudsperson may consult these data without procedure, without authorization, without legal action. Auditing is not the exclusive competence of a state body — it is a citizen's right to public information.

3.3. Supersalud + Comptroller's Office — auto-initiation of proceedings

When the pattern-detection algorithms identify a transaction or series of transactions that deviates from the expected statistical behavior, ARTERIA auto-generates an operational alert and forwards it simultaneously to Supersalud, the Comptroller General, and the Inspector General. The disciplinary / fiscal / criminal process begins with evidence consolidated in the ARTERIA layer itself — it does not depend on a citizen's complaint, does not depend on legal action, does not depend on investigative press. This does NOT eliminate or reduce the discretionary sanctioning power of these bodies — it equips them with structural information they do not have systematically today.

3.4. Cryptographic temporal traceability

Each system transaction is cryptographically signed and chained in an immutable verifiable registry, which makes retrospective falsification impossible. A decision made today is fixed in the registry and cannot be altered tomorrow without the alteration itself being registered and publicly detectable. This is the most profound structural change relative to the current Master Account model: today, departmental accounting books can be adjusted; under ARTERIA, they cannot.

The specific cryptographic primitives underlying this traceability are documented in the technical repository under the control of the Foundation of the Standard, auditable by qualified technical teams.

§4. Territorial public health — strengthening, not weakening

4.1. Collective Interventions Plan (PIC) under ARTERIA

The PIC is the set of public health interventions aimed at collectives in each territory (vaccination campaigns, educational campaigns, active epidemiological surveillance, environmental health, prevention of communicable diseases, community mental health, attention to social determinants). It is the competence of the territorial entity and is financed with specific resources in the Master Account.

Under ARTERIA:

• The PIC maintains its financing and its territorial competence — it is not transferred to the national level.
• PIC interventions are reported in the national registry with PIC code + territorial entity + type of intervention + effective coverage + impact indicators.
• Public traceability of the PIC is absolute: any citizen may consult how much was spent on which intervention in which municipality with what coverage.
• ARTERIA provides territorially detailed epidemiological inputs to the territorial entity for PIC targeting (where information was previously fragmented and delayed).
• Effective coverage indicators of the PIC (not contractual execution of the PIC) are criteria for evaluating territorial performance.

4.2. Strengthened epidemiological surveillance

Epidemiological surveillance is a territorial competence coordinated with INS. Under ARTERIA:

• The HCEU + the national clinical events registry are the primary source of real-time epidemiological surveillance.
• Territorial entities have access to epidemiological data on their population disaggregated by municipality, neighborhood, age, sex, ethnicity, social conditions (with privacy through aggregation).
• Outbreaks and sanitary emergencies are detected automatically by statistical patterns (more cases of the same diagnosis within a temporal and geographic window).
• INS receives the same data consolidated nationally — effective coordination.

4.3. Social determinants and intersectoral articulation

ARTERIA does NOT aim to substitute intersectoral work (education, water, housing, environment) — but it offers the territorial entity solid data to argue for and operationalize articulation: where health problems are concentrated, which epidemiological patterns correlate with which territorial conditions, which intersectoral interventions have the greatest measurable impact.

§5. Territorial workers in transition

5.1. Departmental and municipal health secretariats

Officials in territorial health secretariats retain a relevant role under ARTERIA — the territorial entity remains planner + steward + executor of the PIC + epidemiological monitor. The function reduced is administrative management of the EPSS payment flow (which no longer exists under ARTERIA) and negotiation of contracts with EPSSs (because manager EPSSs operate under a national license, not under individual territorial contracting).

Appendix #01 §5 on labor transition covers the retraining of these officials toward (a) PIC operation with the information ARTERIA provides, (b) active epidemiological surveillance, (c) territorial network planning based on data, (d) intersectoral articulation.

5.2. Subsidized EPSs — their workers

EPSSs that demonstrate technical capacity + quality indicators retain operations under the new role of risk managers. Their workers in areas of clinical management, user navigation, patient support, technology, planning, epidemiological surveillance of their population retain employment and/or transition to equivalent roles. Workers in areas of glosa, returns, internal EPSS↔IPS billing, restricted network contracting are those who lose structural function — Appendix #01 §1.3 documented the magnitude and §5 the retraining paths.

5.3. Contractor personnel in the Master Account

Historically, around territorial Master Accounts there has been a concentration of a significant proportion of fictitious employment in the sector: service-provision contractors without verifiable objectives, political quotas, clientelist networks. Appendix #01 §1.3 documented this category as "Category C" — fictitious jobs without productive function. Under ARTERIA, these positions are structurally closed. The real technical human resources (medical auditors, epidemiologists, public health professionals, real territorial managers) are retained and reoriented.

§6. Adversarial defenses

6.1. "This centralizes the system and eliminates territorial autonomy" — false

ARTERIA does NOT centralize stewardship or territorial planning — that autonomy is fully retained per art. 287 of the Constitution and Law 715/2001. What it centralizes is the payment flow for individual clinical services — eliminating a concrete mechanism of documented territorial political capture with COP 11 trillion in 2022–2025 Comptroller findings. Territorial autonomy is not exercised by managing a clinical payment portfolio — it is exercised by planning the territory, executing public health, monitoring, and articulating intersectorally. These functions are strengthened under ARTERIA, not weakened.

6.2. "Subsidized EPSs are the ones who know their territories — eliminating them is losing that knowledge" — distinction

ARTERIA does NOT eliminate EPSSs. Those that demonstrate technical capacity + quality indicators transition to health risk managers, where their territorial knowledge becomes even more valuable (clinical management of populations with specific profiles, user navigation, network planning). What they lose is the financial function of payer-intermediary, which does not require territorial knowledge but bank access. EPSSs without technical capacity + without quality indicators — historically the most questioned in terms of effective service — are wound down in an orderly manner; relevant territorial knowledge from their teams may be absorbed by competent managers or by territorial secretariats themselves.

6.3. "Public hospitals depend on EPSSs to sustain themselves — without EPSSs they go bankrupt" — inverse

Public hospitals today are on the verge of structural bankruptcy precisely because they depend on payment from EPSSs that do not pay on time or massively object — 58% over 90 days past due of IPS debt according to ACHC. Under ARTERIA, public hospitals bill ADRES directly, within 7–15 days, on verifiable events, without subsequent objections. This radically strengthens the sustainability of public hospitals, especially the low- and medium-complexity ones in municipalities that mostly serve the subsidized regime population.

6.4. "Eliminating the Master Account is unconstitutional — it violates territorial financial autonomy" — legal response

The Master Account is NOT eliminated. It is reduced to its legitimate function of managing non-clinical territorial resources (PIC, surveillance, public health, equipment). The individual clinical flow is concentrated in ADRES with direct payment to IPSs based on events — a mechanism the legislator itself partially authorized with Resolution 5193/2021 (Direct Transfer). ARTERIA extends the same mechanism to 100% of the clinical flow. Constitutional Court Rulings C-1040/2003 and C-313/2014 (among others) establish that territorial autonomy is compatible with national stewardship in health when the model is justified by system unity and fundamental rights. The elimination of a concrete payer-intermediary mechanism to combat structural corruption and guarantee the right to health (Statutory Law 1751/2015) is legally sustainable.

6.5. "Small municipalities lose sanitary response capacity" — response

Health-certified municipalities (small ones frequently are NOT certified, but are subsidiary to the department) retain or acquire real capacity, not formal capacity. Today a small certified municipality's mayor has little real response capacity because (a) the local provider network is weak, (b) resources arrive late with intermediate capture, (c) the epidemiological information they have is fragmented. Under ARTERIA, the municipality (a) retains its planning role with solid real-time data, (b) executes PIC with stable, traceable financing, (c) receives detailed epidemiological inputs about its population. Real capacity increases — nominal administrative capacity is redistributed.

6.6. "This is the Petrista unification model that was already rejected" — distinction

That characterization confuses two things. The Petrista health reform proposal (Law 339/2023 / 010/2024) put forward regional unification with state-run CAPS as a single gateway + operational elimination of EPSs + concentration in a centralized state operator. ARTERIA has points of overlap (elimination of reimbursement claims, strengthening of APS, ADRES as single payer) but decisive structural differences:

• ARTERIA keeps competent EPSSs as risk managers (it does not eliminate them)
• ARTERIA does NOT replace APS with state-run CAPS — the first level retains its institutional plurality with Resolutive APS (§3.7.5 of the main technical document)
• ARTERIA does NOT concentrate operations in a centralized state operator — provision remains pluralistic (public, private, mixed, ethnic)
• ARTERIA does NOT suppress territorial autonomy — it reorients it toward the planner-steward role and the PIC, not toward clinical payment
• ARTERIA introduces cryptographic traceability + structural anti-corruption absent from the Petrista proposal
• ARTERIA is technical interoperability + smart contract, not operational centralization

The similarity lies in the diagnosis (departmental corruption + structural past-due receivables + fragmented access); the divergence lies in the architecture of the solution.

6.7. "Without the EPSS as payer, small/rural IPSs have no interlocutor for complex authorizations" — response

The interlocutor for complex authorizations does NOT disappear — but it ceases to be the individual EPSS with opaque discretion. Under ARTERIA:

• Authorizations for standard services per national protocol → automatic via smart contract (no calls, no paper, no waiting)
• Authorizations for non-PBS technologies / complex cases → treating physician prescribes in HCEU; prospective algorithmic audit (Appendix #05 §2.5); extraordinary human review only if there is misalignment, with a 72-hour regulatory deadline
• Complex clinical support (specialist interconsultation, second opinion) → immediate national specialized telemedicine network (Appendix #03 §3.7.5 — Resolutive APS component)

The small/rural IPS has MORE structural support under ARTERIA, not less.

6.8. "This is a technocracy replacing political control" — clarification

Political control is exercised over what is legitimate to control politically: sanitary policy, epidemiological priorities, territorial targeting, public health programs, network planning, territorial ordering. Individual payment to an IPS for a service provided to a registered patient is NOT a legitimate object of political control — it is a verifiable operation that must be executed per protocol, not per the discretion of the political actor in office. Removing that segment of the flow from political control is NOT "technocracy replacing democracy" — it is protecting a fundamental right (health) from capture by particular interests. Democracy is exercised better over stewardship and policy decisions, not over who receives how much in which administrative transfer.

6.9. "This will be subject to massive litigation by governorates and municipalities" — management

Possible. Mitigated by (a) gradual implementation where territorial entities that adopt the model first demonstrate benefits — reverse attraction, not imposition; (b) permanent dialogue tables with the Colombian Federation of Municipalities + the National Federation of Departments during the legislative design of support (organic law or specific reform to Law 715); (c) explicit protection of the territorial planner-steward role in the regulatory text; (d) PIC resources under public traceability but managed territorially; (e) negotiated transition period in which governorates collaborate with implementation in exchange for strengthening their technical capacity.

6.10. "Commercial banks that administer Master Accounts lose business" — response

Yes, partially. The residual Master Account (non-clinical resources) still requires bank administration. What is lost is the handling of clinical resources, which now flow through ADRES directly to IPSs. This is an acceptable collateral effect of the redesign — the financial cost (commissions, bank float, fees) that the system bears today for the additional step disappears as such. Banks can offer financial services to IPSs, to manager EPSSs, and to citizens, just as today — but they cannot charge for mediating a flow that the system can execute without mediation.

§7. Implementation schedule

§8. Institutional framework — who does what

§9. Conclusion

The Master Account of the subsidized regime has been the most documented point of capture in the Colombian health system — the Comptroller's Office reports COP 11 trillion in findings 2022–2025 with significant concentration there. The mechanism does not fail due to individual bad faith — it fails by architecture: when an intermediate node has opaque discretion over the payment flow to the most vulnerable sector, capture is structural, not anecdotal.

ARTERIA does NOT suppress territorial autonomy — it protects a fundamental right from partisan capture. The territorial entity is strengthened as planner-steward, executor of the PIC, epidemiological monitor, intersectoral articulator — all functions that require better information, better technical capacity, better coordination, all of which ARTERIA provides. What the territorial entity loses is the function of payer-intermediary of the individual clinical flow, which should never have been an object of local political control but a verifiable operation per protocol, on a verifiable clinical event, with direct payment from national collection to the effective provider.

This is NOT centralization — it is disintermediation of a capturable node while preserving territorial stewardship where it is legitimate. Public hospitals bill ADRES directly within 7–15 days, without subsequent invoice objections. The subsidized regime population ceases to be used as a vehicle for territorial political financing. Cryptographic traceability + algorithmic auditing + citizenship as auditor of public information substitute a slow and ineffective post-hoc control system with a structural one verifiable in real time.

The strongest argument in favor of ARTERIA is the diagnosis that the Comptroller's Office has repeated every year for two decades. When a mechanism has proven to fail systematically because of its architecture, the legitimate response is not more oversight over the same architecture — it is to change the architecture.

Version: v1 — 2026-06-12 Next review: after consultation with the Colombian Federation of Municipalities, the National Federation of Departments, the Comptroller General, the Inspector General, Supersalud, MinSalud, ACEMI, Gestarsalud, ACHC.