The suffering of Brazilians with health plans

“Poor health and a lot of sauva are the ills of Brazil”. One of the most famous phrases in Brazilian literature contained in the book Macunaíma, by Mário de Andrade, serves as a point of reflection on one of the country’s problematic issues, the health of its citizens. This time, what calls attention and is a matter of concern for more than eight million people is the decision of the Superior Court of Justice (STJ), changing the list of mandatory coverage of health operators. The Court decided that, from now on, the list that financially covers surgical procedures, therapies, medications, among other activities for the sick insured is exhaustive. In other words, health plans, which were previously required by the courts to pay the bill in case there was a need for the consumer to undergo new procedures, are supported by denying treatments and medicines. According to the decision, companies no longer need to bear the costs of any treatments outside the official role of the National Supplementary Health Agency (ANS), even if there are sentences to that effect.

“The insurance company denied me medication, examination and immunotherapy. I had to file a lawsuit against the plan several times.” Ana Maria Teixeira Eland, 66, patient undergoing cancer treatment

In fact, what the STJ did was to throw a cold shower on consumers, since the Judiciary itself had recognized, through several decisions, that the list was an example, which, depending on the situation, should include other procedures. In short, the 3,300 procedures, which are already on the list as mandatory expenses for health insurance companies, become a straitjacket for anyone who needs some new therapy quickly. People who are undergoing treatment may have their therapies summarily discontinued. As dynamic as the field of medicine is, innovations are constantly emerging. “The decision is bad. Now, people will have to pay out of pocket for innovative treatments”, says Renata Abalém, a specialist in consumer law and a member of the OAB-SP Consumer Law Commission. She is right. “Nowadays, there are adults diagnosed with autism, and with that comes different needs,” she says.

REACTION For Senator Mara Gabrilli, many people will now be helpless (Credit: Kleyton Amorim)

Recognition of innovations actually happens. The novelties do enter the list of coverage of health operators. However, this update does not happen overnight. A very long one hundred and eighty days is required for this, and only after that period are medicines, technologies or therapies accepted. “This is the time required for a new drug, for example, to be analyzed with due scientific rigor”, points out Vera Valente, executive director of the National Federation of Supplementary Health (FenaSaúde), an organization that represents fifteen groups of operators and 40% of beneficiaries of health care plans. According to Vera, the decision of the STJ was balanced because it brings predictability to the sector. “The previous situation could compromise the functioning of medium and small companies”, she says. But his reasoning receives criticism from all sides.

“I had to resort for Manuela to do an exam, had access to cannabidiol and underwent surgery” Jessica Brandão, mother of Manuela, 5 years old, who suffers from cortical dysplasia

HIGH COST Each package of the medication consumed by Manuela costs R$5,000 per month (Credit:Marco Ankosqui)

“The number of incursions in Justice will increase to guarantee what should be a right”, says Renata. “Only in the courts can we ensure the continuation of many treatments and, consequently, avoid deaths”, says Columbano Feijó, lawyer, specialist in supplementary health law, and partner at Falcon, Gail, Feijó & Sluiuzas Advocacia. That is to say, if before the deliberation it was difficult for operators to accept to pay, now it will get worse, as lower courts will certainly be impacted by what the STJ defined, and, thus, what was previously judged in a favorable way to the consumer, will now be able to be analyzed in the opposite way. “A person who is undergoing cancer treatment, for example, and needs surgery or a new drug quickly may not have time to wait and die”, explains Columbano Feijó. He says that the patient is now obliged to prove that the treatment requested by the doctor outside the list is really something that will be beneficial to him. “Health plans are supported to deny everything that is out of the list”, he says.

Customers of health plans are frightened by the situation of insecurity created from now on. This is the case of Jéssica Brandão, mother of Manuela, 5 years old. Since the age of two, the child has had epilepsy, and has had thirty episodes of instability a day. “My daughter hugged me and said that the crisis was coming”, says Jessica. To help Manuela, Jessica had to go to court three times against the agreement. First to do an important exam, which she defined the diagnosis, but which has a cost of R$ 14 thousand. Afterwards, she went to the courts to ensure that Manuela had access to cannabidiol, a drug that reduced crises to ten cases a day. The girl has to take two vials a month, but due to the price, the treatment would be discontinued, since each unit costs R$ 2,500. The third moment she needed to process the health plan was when she received the diagnosis: cortical dysplasia. “With an injunction we managed to have her operated on,” she says. Today, the epilepsy has disappeared, but the child still needs some medications, including cannabidiol. “It’s a weaning phase, I’m afraid the plan will stop providing,” she says.

“When you looked at me in the mirror I felt disgust. This situation affects me socially.”
Patricia Grunheidt, 48, has had bariatric surgery and is awaiting some repairs

The dread of not being able to maintain treatment is a feeling shared by many people. Marketing director Patricia Grunheidt, 48, is also in this fight. She underwent bariatric surgery in 2013 when she weighed 130 kilograms. She has reduced her weight to 64 kilograms and, like all people with this condition, she had to undergo surgical maneuvers to repair the leftover skin. She has been in the operating room on three occasions as her entire body needed repairs. But she only managed to get the plan to pay for the procedures with an injunction in her hands. “When I looked at myself in the mirror, I felt disgusted. This situation affects me socially,” she says. The medical insurance was willing to pay for part of the procedures, but not for the total. She says she is afraid of not being able to continue the treatment. “Just now that I just need to take care of my arms”, she says.

WEAR Patrícia has been in the operating room on three occasions to remove excess skin: injunction on hands (Credit: João Castellano)

Another example of how the list of tax coverage is harmful to consumers, even in situations where people are bedridden, there is a need to resort to justice. That’s what Ana Maria Teixeira Eland, 66, says. She struggles with ovarian cancer that has gone metastatic and also with her medical care. The agreement denied him medication, examination and immunotherapy. “I had to file a lawsuit against the plan several times,” she says. One of the drugs that keeps him alive, taking two pills a day, costs R$25,000. “The taxing role represents one more uncertainty,” she said.

The STJ’s deliberation took place on Wednesday, 8, and had six votes in favor of the exhaustive list, including that of the rapporteur, Minister Luis Felipe Salomão. It happens, however, that a decision taken with such tranquility by the magistrates represents, now, a huge concern for people who are in complex health treatment. More: confirms that Mário de Andrade was right, the natural condition of growth of the anthill and poor health of Brazilians will remain. In the political world, especially in the Senate, there was a reaction against the STJ’s decision. Senator Mara Gabrilli, (PSDB), for example, says that this is an old discussion in Congress and asserts forcefully that the definition is bad for the entire population, especially for people with disabilities, autistics and people who have diseases. rare. “These people will be left helpless, the taxing role kills”, says Mara. She says that she is articulating a reaction with fellow senator Randolfe Rodrigues (Rede Sustentabilidade), who has a bill that, if approved, changes the scenario and makes the list exemplary. Anyway, in this political game that is developed, the consumer is always threatened and loses.


Hope for bowel cancer

A new drug in clinical trials was able to eliminate a rare type of colon cancer in 100% of patients undergoing tests. The drug called dostarlimab was administered to twelve people every three weeks for six months and the follow-up was effective for two years. The incredible and surprising result prevented the volunteers from undergoing conventional treatments: surgery, chemotherapy and radiotherapy. Furthermore, there was no return of the disease in any patient. The research has just been published in the renowned medical journal The New England Journal of Medicine. The remedy is an immunotherapy, a type of medication that restores the ability of the sick person’s own immune system to recognize, control and even destroy diseased cells. In addition to being a tumor with a rare mutation, it was the first time that a test of this type was performed in metastatic cases, when the disease spreads throughout the body. Participants did not have the tumor return. The National Health Surveillance Agency (Anvisa) approved in March, the marketing of dorstarlimab in Brazil. But, for now, there is no permission to use in cases of bowel cancer, only endometrium. The pharmaceutical GlaxoSmithKline, maker of the product has not yet set its price.

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