The proliferation of health programs sparks debate over adjustment calculations | Economy

Sophia Bernardes

The proliferation of individual and family health programs stimulates discussion about adjustment counts

In May, the National Agency for Extraordinary Health (ANS) announced a reversal of the budget for middle class families. After a negative correction of -8.19% in 2021, the regulator approved a 15.5% increase for individual and family plans, the highest increase in the historical series. The decision provided conflicting opinions about the impact on consumers and the health sector. Experts and operators’ representatives advocate different calculation methods to define price lists.

For José Buzanello, a professor at Unirio and the coordinator of the Research Group on Infrastructure Management (Proreg), the move could help more clients cancel their plans. “People are moving from private to public because they are incapable of supporting it. It is not a plan; they do not have elevators and stop plans,” says the expert.

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According to the latest data from the ANS, the Rio Metropolitan Region of Rio ended in March with 670,000 beneficiaries of individual and family programs, a number less than 700,000 beneficiaries of this approach in the same period last year. On the other hand, the number of business plan clients increased from 2,730,746 March 2021 to 2,792,264 March this year.

According to Marcos Novais, executive director of the Brazilian Health Planning Association, a small number of individual programs are common. “The health insurance market has a very close relationship with the functioning of the Brazilian economy, especially the labor market. The vast majority of people have health insurance as a result of employment. Here is the United States, Australia. It is this. Every country with a market The most developed health plan works this way, “explains Novais.

“I think this decision of the ANS is very bad for consumer health consumers’ consumer relationships, given the lack of salary increases for all public and private employees over the past two years. In addition, there are significant losses due to inflation. prices, which change around 12% per year. Thus, there is a brutal loss to the user and an increase in this size, “says Buzanello.

Although the 15.5% adjustment has been approved for individual and family planning only, doctor and professor at the Rio Federal University (UFRJ) Lígia Bahia warns that the increase could also affect other approaches. “This becomes a criterion for other programs. Joint business plans can add more than 15.5%”, says Lígia. If this happens, the people who created the CNPJ just to hire business plans will be affected by the move.

According to Lígia, marketing of these types of programs is becoming increasingly common. “They (operators) found a way to sell individual programs by pretending to be collective. They are PJ plans. [pessoa jurídica]. That person joins the company to have a plan. So they are individuals, but it is a way to evade the law “, says the doctor, who explains that this procedure is more attractive to operators because it allows them to break contracts on one side.

One of the program clients who received the offer was a parliamentary consultant Manuel Evangelista, a 40-year-old private program beneficiary. . Before entering the building, however, he was followed by program brokers who tried to persuade him to register as a small entrepreneur (MEI) to rent a business plan.

“Health programs no longer intend to have individual contracts, they just want contracts with companies, because they get more. You pay less for everyone, but you get a company and make a thousand contracts. Millionaires want to pay. But the middle class will stop health plan “, evaluates Manuel.

In Manuel’s home, two other people are using a private plan, his wife and his 83-year-old mother. “It’s not just a plan. Petrol is R $ 8.1, a kilo of carrots is R $ 19, second grade beef is R $ 36”, insists Manuel angrily.

Inflation in April, one month before the amendment was approved, was 1.06 percent, severely affecting the health sector. According to the April Consumer Price Index (IPCA), pharmaceutical products had a 6.13% increase, which further affected the family budget.

For Manuel, who suffers from a chronic migraine, considered to be disabled, the price of medication is a burden. In treatment for more than 10 years, she needs to take an external injection that costs R $ 2,850 per dose. He could not maintain his treatment and with a health plan refused to pay for the product, he is taking another very ineffective drug, which makes him spend R $ 120 a week.

Your mother also needs medication for diabetes, cholesterol and osteoporosis. All of this provides a cost of R $ 3,000 per month, which is not commensurate with the retirement income. To deal with the situation, “he continues to try to sign up for such laboratory contracts to pay for relief, he keeps trying to get an insurance plan, because you can’t get any medicine for free”, says Manuel.

To put more pressure on family income, the wife’s contract provides that the operator, in addition to using the annual adjustment, increases the monthly fee by 30% every five years until she reaches the age of 60. She is in her 40s. ” With 30% of the five-year contract plus 15% annual adjustment, the monthly fee will increase by 45%. Its plan ranges from R $ 1,500 to around R $ 3,000 “, says Manuel.

Even with the pressure of his income, he tries to keep the plan out of fear of not getting treatment in SUS. “SUS is no longer able to serve the population it is supposed to serve today, if you go to a public health facility there is a doctor to serve 150 people, now there will be a doctor to treat 300. And no specialist goes to the doctor to see a urologist and arrange six months from now and then he arrives on the day of the consultation and there is still no specialist ”, he says.

According to the executive director of the National Federation of Extraordinary Health (FenaSaúde), Vera Valente, the revision of the program has no effect such as the growth of other sectors of the economy. “From a user’s point of view, in the last two years, we had a negative correction in 2021, reflecting the 2020 situation. If you have an average of 2021 revisions and a 2022 revision, we had a 6% increase, it is very low. Inflation, ”Says Vera.

In addition to inflation, families trying to make plans still have to deal with another economic factor: declining incomes. According to the National Household Samples Survey (PNAD), for the quarter ended April, conducted by the Brazilian Institute of Geography and Statistics (IBGE), the average net income was R $ 2,569, showing stability compared to the previous quarter and a. a decrease of 7.9 percent compared to the same quarter of the previous year.

Faced with the dire economic situation affected by this epidemic, some have already abandoned plans and comprehensive coverage to approve basic contracts. This is the story of the producer of the show Elísio Paiva. “I had a complete plan. Then a catastrophe came, drying up the market [de trabalho]. I had to cancel my full plan and become dependent on my wife’s retired teacher’s program, which is very basic, “says Elísio. you use the United States Health System (SUS) System.

“I have seen a lot of results in the public service and there is no big difference between public and private status anymore, in fact my income has gone up because it was a burden. My plan with my wife was close. R $ 2, 5 thousand”, says the producer.

For Lígia, cases like Elísio’s should be more common. “I think, somehow, they [operadoras] has pushed customers down, forcing them to opt for a less efficient program. So they have very good results, but at the expense of very bad results for customers “.

As for Vera, this movement should not be legal. He recalls the increase in the number of registered customers during the epidemic and says that the extra health sector is working to keep consumers from losing it. “We want to increase individual access, we do not want to lose a beneficiary. We do not believe that these reforms will cause the loss of customers. People want to set their own health plans,” says the executive director. He explains that individual plans equate to less than 20% of contracts because, due to cost, fewer operators offer them.

“On the one hand we have vertical operators ie the operator has a whole chain under it, the hospital is his, the doctors are hired by him, the company has full cost control, manages the patient’s journey and avoids losing than it needs to recoup its costs.On the other hand, there are those who do not work with the vertical system, which are those operators who do not have a hospital. laboratories and that there are no doctors working on contract. Vertical companies do not have cost controls. plan, “says Vera.

In 2021, the cost of health facilities increased due to the resumption of election procedures, which were suspended in 2020. In addition, hospitalization of Covid-19 patients in 2021 was more costly for the system, due to lack of facilities. of hospitals. such as personal protective equipment and intubation items. To address these costs, ANS defines adjustments based on costs and data provided by all operators, whether vertical or not. This results in an average increase in value, which this year stood at 15.5%.

“That way, we have a terrible or alarming equation for consumers. There was no increase in wages, there was inflation and an increase in plans. We are talking about the impact on the family budget in the house by 25%, as well as reducing income, “Says Buzanello. He advocates another way to apply the amendment. every six months it increases by 5%. Despite this, people find time to plan their economic life. In 18 months, the costs could be reimbursed “, says the teacher.

For Lígia, operators’ income must also be balanced. “As it is said, it increases according to medical inflation, but medical inflation is costly. And revenue? What do these companies have and what do they do? They pay advertising, high salaries to their directors. income and expenditure ”, concludes the doctor.

FenaSaúde, on the other hand, argues that the ANS introduces different modifications for each operator. For this, the plans would present their individual costs, their portfolio profiles and the necessary adjustments to recover costs. “This is going to be very competitive, because the operators will struggle to have small adjustments, have more customers. That way you have the potential for everyone to sell. This is an agenda we have already started discussing with the ANS. It is not an easy change, but we see it as increase the number of individual programs “, explains Vera.

Huluki also negotiates with the ANS on the outpatient component to offer subcontracting contracts, for consultation and examinations only, at lower rates. Today, the outpatient division includes emergency and urgent care in the first 12 hours and treatment.

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