The judgment of the Superior Court of Justice (STJ) on the list of procedures of the National Supplementary Health Agency (ANS) is anxiously awaited by the sector, as it will define whether the list should be exhaustive (to be followed to the letter, without additions) or exemplary (in which new therapies can be included based on advances and discoveries). THE Fenasaúdewhich represents 16 private health groups that hold 40% of the sector, says that the plans will be more expensive if the magistrates choose the second option.
According to the director-president of the entity, Vera Valente, the increase in monthly fees may lead to the departure of clients from private health plans. “Innovation is important, but health systems can’t stop all drugs for all people, this doesn’t happen in any country,” she says.
For the executive, the discussion, which began last year, will define whether the list of more than 3,000 ANS procedures will require payment for drugs that are still in the final stages of testing or for therapies that cost thousands of dollars for each procedure. If that happens, she says, it will be almost impossible to calculate the value of health plans in the country.
According to Vera Valente, this is a decision that is “fundamental for the survival of the sector”. Read the main excerpts from the interview below.
How is the list of ANS procedures composed?
Medical innovation is important, but health systems cannot afford all drugs for all people. This does not happen in any country. In countries with an organized health system, there is an analysis of what the system will pay and what it will not pay. When it comes to something niche, which does not go to phase 3 (testing), it brings more insecurity about drug use. It is necessary to define the effectiveness of the drug, its real benefit and cost of this product. We fully understand that anyone who has a specific problem (requiring alternative or very recent treatment) go to court to try treatment, but whoever judges cannot just look at individual interest.
And what can be defined with the decision of the STJ?
The list of procedures covered encompasses 3,300 items, but a $300,000 gene therapy is not trivial. If we are to consider this, it will be impossible to calculate the value of the plan. The taxing role protects the consumer, brings predictability and guarantees the sustainability of the system. Today, Brazil has 700 health operators and most of them are in the countryside and they will not be able to absorb this. The worst way is judicialization and not everyone can access justice. If the STJ defines that the list of procedures is exhaustive, the jurisprudence will guide the first instance so that it has a better understanding of how the system works.
But it is natural for the beneficiary to seek the plan to pay for treatment for diseases…
It is understandable, but the judge cannot pursue the isolated case. Today, the process of analyzing new products and procedures by the ANS has been streamlined. The analysis is done in a judicious way, to define what should be taken and what does not pay, as no benefit has been proven. That’s how it is here and all over the world. In the fight against cancer, for example, all types have treatment. The plan pays for surgery, radio, chemo… In infusion treatment, it automatically enters the coverage list. New oral drugs, on the other hand, undergo evaluation. Today there are 58 on the list. The system pays for most things.
How to increase access to health plans?
We were in the range of 46 million beneficiaries and today there are 49 million, because in the pandemic there was a greater concern with health. The readjustment of plans will come more expressive, but the sector wants to keep these users and increase the number. For this, we believe that a modernization of the law is necessary, to adapt to a new reality. One of the points is to have a real outpatient plan. Today this plan also “hanged” the emergency, which is something of a hospital nature. And today there is a contingent of people wanting access to private healthcare for consultations and exams. However, in an election year those agendas that need more debate are more difficult.
What about the regulation of telemedicine after the end of the pandemic?
There were millions of telemedicine consultations with a very high satisfaction rate, but the legal support for this is based on a decree, which established telemedicine during the pandemic. As this decree no longer exists, there is no security to continue, and this cannot go back. We need to turn this into law.