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).
Fenasaúde, which 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.
STJ gives approval for readjustments of collective health plans by age group
According to the director-president of the entity, Vera Valente, the discussion, which began in 2021, will define whether the list of more than 3,000 ANS procedures will require payment for drugs that are in the final stages of testing or for therapies that are still very expensive. For her, this decision is “fundamental for the survival of the sector”.
Read the main excerpts from the interview below:
How is the list of ANS procedures composed?
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. 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, the real benefit and the cost of this product.
And what can be defined with the decision of the STJ?
The list of procedures covered includes 3,300 items, but a gene therapy of US$ 300,000. It’s 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 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 their treatments…
It is understandable, but the judge cannot pursue the isolated case. Today, the analysis of 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… The infusion treatment automatically enters the list of coverage. 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.
The information is from the newspaper. The State of São Paulo.
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