Elección de planes de salud mediante técnicas de clasificación fuzzy (Health plans selection using fuzzy classification techniques)

In the present difficult economic situation in Argentina, most companies are making efforts in implementing cost reduction strategies. This has an impact in the way these companies choose the health coverage for their employees, specially seeking to minimize the cost and at the same time to provide the maximum satisfaction of the needs of the employees and their families. In the years preceding this crisis, since there was no pressure on the Human Resources Area to focus on minimizing costs, the selection of the health coverage was made according to the criteria that were determined by this Area and the sales executive of the health company. The price was then calculated by the health company, and presented to the customer, which could accept it or ask for another alternative. In this last case, a new plan was selected, and a new price had to be calculated. This process continued until an agreement was reached. Therefore, from the health company’s point of view, the objective of its models was to determine an adequate, fair and competitive price given the employee group and the chosen health coverage. The present paper introduces a decision model based on Fuzzy techniques, that allows to determine the better health plan according to the priorities of the customer company and the maximum cost it is prepared to assume. The company puts forward its coverage requirements with certain priorities. These requirements include the list of health services providers (hospitalization institutions, health professionals, medical exams institutions, etc), and the coinsurance percentages or amounts for each health service (amounts in charge of the employees). In the first place, the model assumptions are presented: the health services groupings such as Medical Visits, Pathology Exams and Surgical Hospitalization, the different coverage options such as a fixed coinsurance of $5 for Medical Visits and a 50% discount in prescribed medicines, the health services costs that will depend on the contracts with the providers, and other ...