Health plan model has sold out, but there are new options for consumers

The life of Brazilians with health insurance is a soap opera with repeated chapters. In the last two weeks, they returned there, causing fatigue in those who are tired of following a story that seems to have no happy ending. The 8 million people who have individual and family plans, regulated by the National Supplementary Health Agency (ANS), were shocked by the announcement of the 15.5% increase in monthly fees. The astonishment was added to the anxiety of the other 41 million customers of corporate plans who followed, once again, the judicial discussion about the pertinence of forcing operators to cover any procedure. As usual, the companies invoked in their defense the need to ensure the financial sustainability of the sector. About the increase, it would refer to the last two years, since in 2021 the monthly fees were 8% cheaper. It didn’t convince many people, as expected.

In the National Congress, ten projects ask for the suspension of the adjustment and the Federal Supreme Court accepted a request from the Rede Sustentabilidade party for ANS to explain the reasons for the price increase. “The values ​​should be calculated transparently”, defends the professor at the Federal University of Rio de Janeiro (UFRJ) Ligia Bahia, a researcher on the subject in Brazil. Regarding the request for the free incorporation of medical procedures, the allegation for the refusal was that without a prior technical evaluation it would be impossible to predict the costs. And then, on Wednesday 8, the Superior Court of Justice ruled in favor of operators, maintaining the rules. It remains as it is: the plans do not pay for services outside the ANS list. What is not described does not need to be covered. “The decision guarantees patient safety, legal security and the sustainability of the plans”, says Vera Valente, executive director of the National Federation of Supplementary Health.

None of these debates are new. What draws attention is how much each of them reveals, today, the exhaustion of a model. The supplementary health institute was born in Brazil in the 60’s and the relationship between customers and companies was never peaceful. At the root of the conflicts are the denials of coverage and the price. A survey recently completed by the University of São Paulo (USP) clearly demonstrates this. The report informs that 48.2% of the 11,600 judgments published between 2018 and 2019 by the São Paulo Court in lawsuits filed by clients were about coverage. Another 26% related to allegations of abusive raises. This is a very high rate, considering that 73% of users spend up to 33% of their income on health expenses and therefore expect satisfactory service. “There is inflation in the sector, but the operators want to automatically pass it on to the beneficiary or the contracting party of the plan”, says Mário Scheffer, from USP. “The sector is at a crossroads”, he summarizes. In fact, several bottlenecks in the chain that supports supplementary health make it difficult to balance the imbalance between satisfaction and the price paid by users. One of the most relevant nodes is the payment system, based on the services provided, an open door for exaggerations of exams and procedures. Another is the culture that plans are used to treat disease and not promote prevention. And treating, as we know, is more expensive than preventing.

However, a new understanding of how health care should be, considering the urgency of preventing chronic diseases, and the rise of digital access to health services make a change in direction inevitable. It is ongoing, supported by the healthy strength of the free enterprise of healthtechs that have understood the scenario and offer services at a lower cost. Among other behaviors, they focus on prevention, personalization, the use of data intelligence and telemedicine. Ample care avoids 40% of examinations and 18% of visits to emergency rooms, according to the ANS.

Launched in 2020, QSaúde was born under these new precepts. Today, it has 12,000 clients (45% of them did not have a plan when they hired it). The first contact is with family doctors at Hospital Israelita Albert Einstein, in São Paulo, or at Cia da Consulta, depending on the plan. They are the ones who will guide the beneficiaries in the necessary care, assisted by a multidisciplinary team that closely monitors the client’s health. “We are showing the effectiveness of a new model that really focuses on primary care”, says José Seripieri Junior, founder of QSaúde. The health manager Alice has a similar service, assuring the client a team formed by a doctor, nurse, nutritionist and physical trainer. The two offer also have remote service, an efficient way to solve most cases. “People want personalized service. A proactive call to find out how they are doing or access to a doctor contribute to better outcomes”, says Bruno Porto, partner at PwC Brasil, a company that has just completed a survey on the healthtech scenario in Brazil.

For companies, models like this come at a good time. There is an urgent need to lower the costs of the plans offered to employees and, therefore, one way out is to hire consultants to strengthen primary care among employees. Einstein is one of the institutions that provide advisory services of this kind, developing a culture of caring for physical and mental health among the employees of the contracting companies. “The more knowledge about health, the less costs”, says Eliézer Silva, director of Einstein.

There are dozens of healthtechs working in the same direction, but directly serving customers. For those who cannot afford a plan and do not want to depend on the SUS, there are options that include cards with credits to be used for consultations and exams, cheaper consultation and exam packages, and financing for procedures and medicines. Finally, the range expands. It’s great news.

Published in VEJA of June 15, 2022, issue no. 2793