Increase in health plans provokes discussion on the calculation of the readjustment | Economy

Increase in individual and family health plans provokes discussion about the calculation of the readjustment
Sophia Bernardes

Increase in individual and family health plans provokes discussion about the calculation of the readjustment

In May, the National Supplementary Health Agency (ANS) announced yet another setback for the budget of middle-class families. After a negative adjustment of -8.19% in 2021, the regulator approved an increase of 15.5% for individual and family plans, the highest increase in the historical series. The decision generated opposing opinions about the impacts for customers and the healthcare industry. Specialists and representatives of operators defend different methods of calculation to define the price lists.

For José Buzanello, a professor at Unirio and coordinator of the Infrastructure Regulation Research Group (Proreg), the measure can help more customers cancel their plans. “People are migrating from the private to the public because they don’t have the capacity to support it. It’s not the plan; they don’t have raises and they suspend the plans”, says the expert.

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According to recent data from the ANS, the Metropolitan Region of Rio ended March with 670,000 beneficiaries of individual and family plans, a number below the 700,000 beneficiaries of this modality in the same period last year. On the other hand, the number of business plan customers increased from 2,730,746 in March 2021 to 2,792,264 in March this year.

According to the executive superintendent of the Brazilian Association of Health Plans, Marcos Novais, the lower number of individual plans is normal. “The health insurance market is closely linked to the performance of the Brazilian economy, mainly to the job market. The vast majority of the population has health insurance due to employment. Here it is, in the United States it is like this, in Australia it is like this . Every country with a more developed health plan market works this way”, explains Novais.

“I think this decision by the ANS is very bad for the consumer relations of health plan users, due to the lack of a salary increase for all public and private careers in the last two years. In addition, there is a substantial loss due to inflation , turning around 12% per year. Thus, there is a brutal loss for the user with an increase of this magnitude”, says Buzanello.

Although the 15.5% readjustment has been approved only for individual and family plans, the doctor and professor at the Federal University of Rio (UFRJ) Lígia Bahia warns that the increase may also impact other modalities. “This becomes a parameter for other plans. The collective-business plans can increase more than 15.5%”, says Lígia. If this happens, individuals who created CNPJ just to hire business plans will be affected by the measure.

According to Lígia, the sale of this type of plans is increasingly common. “They (operators) found a way to sell individual plans pretending to be collective. They are PJ plans [pessoa jurídica]. The person joins a company to have the plan. So they are individual, but they are a way to circumvent the law”, says the doctor, who explains that this modality is more interesting to operators because it allows them to break contracts unilaterally.

One of the plan customers who received this offer was parliamentary advisor Manuel Evangelista, beneficiary of the individual plan for 40 years. Unemployed due to the pandemic, he found it difficult to pay for the service and decided to go in person to the operator’s unit to negotiate. Before entering the building, however, he was approached by plan brokers who tried to convince him to register as an individual microentrepreneur (MEI) to hire the business plan.

“Health plans are no longer interested in having individual contracts. They just want contracts with companies, because they earn much more. You pay less per person, but you get a company and make a thousand contracts. Millionaires, if they want, pay, but the middle class will leave the health plan”, evaluates Manuel.

At Manuel’s house, two other people use the individual plan, his wife and his 83-year-old mother. For him, the readjustment will weigh on family expenses, already pressured by inflation. “It’s not just the plan. Gasoline is R$8.1, a kilo of carrots is R$19, second-class beef is R$36”, emphasizes Manuel, indignantly.

Inflation in April, the month prior to the approval of the readjustment, was 1.06%, strongly impacting the health sector. According to the Broad Consumer Price Index (IPCA) of April, pharmaceutical products increased by 6.13%, which further affected the household budget.

For Manuel, who suffers from chronic migraine, considered disabling, the price of medication is a burden. In treatment for more than 10 years, he needs to take an imported injection that costs R$ 2,850 a dose. Unable to maintain the treatment and with the health plan refusing to pay for the product, he takes another less effective drug, which makes him spend R$120 a week.

Your mother also needs medication for diabetes, cholesterol and osteoporosis. All this generates an expense of R$ 3 thousand per month, which is not compatible with the retiree’s income. To get around the situation, she “keeps trying to sign up for those lab deals to pay cheaper, she keeps trying to get an insurance plan, because you can’t get any medicine for free”, says Manuel.

Putting even more pressure on the family’s income, the wife’s contract provides that the operator, in addition to applying annual adjustments, increases the monthly fee by 30% every five years until she turns 60. She is in her 40s. “With 30% of the five-year contract plus the 15% annual adjustment, the monthly fee will increase by 45%. Her plan goes from R$1,500 to almost R$3,000”, says Manuel.

Even with his income pressured, he tries to keep the plan for fear of not getting treatment in the SUS. “SUS can no longer handle the number of people it has to care for today. You go to a public health center and there is a doctor to care for 150 people; now there will be a doctor to care for 300. And there is no specialist. he goes to a doctor to see a urologist and schedules for six months from now. 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 Supplementary Health (FenaSaúde), Vera Valente, the readjustment of the plan is not as impactful as the increases in other sectors of the economy. “From the user’s point of view, in the last two years, we had a negative adjustment in 2021, reflecting the 2020 scenario. If you average the 2021 adjustment with the 2022 adjustment, we had an increase of 6%, it is very below inflation”, says Vera.

Added to inflation, families that try to keep the plans still have to deal with another economic aggravating factor: the decrease in income. According to the National Household Sample Survey (PNAD), for the quarter ended in April, carried out by the Brazilian Institute of Geography and Statistics (IBGE), the usual real income was R$ 2,569, indicating stability compared to the previous quarter and a decrease of 7.9% compared to the same quarter of the previous year.

Faced with the economic scenario heavily impacted by the pandemic, some have already left plans with broader coverage to adopt basic contracts. This is the case of show producer Elísio Paiva. “I had a very complete plan. Then came the pandemic, dried up the market [de trabalho]. I was forced to withdraw my full plan and I became dependent on my wife’s retired teacher plan, a very basic thing”, says Elísio. With the change, he started to pay R$ 150 for the plan, which he uses to take exams When you need more complex care, you use the Unified Health System (SUS).

“I have seen a lot of results in the public service and there is not much difference between the conditions of the public and the private anymore. In fact, my income has improved, because it was a burden. My plan and my wife’s was almost R$2, 5 thousand”, says the producer.

For Lígia, cases like Elísio’s should become more common. “I think, in a way, they [operadoras] have pushed customers down, forcing them to opt for a plan with less coverage. So they always have a very positive result, but at the expense of a very negative result for customers”.

As for Vera, this movement should not be the rule. She recalls the increase in the number of customers registered during the pandemic and says that the supplementary health sector works not to lose users. “We want to increase access to the individual, we do not want to lose a beneficiary. We do not believe that this adjustment will bring about a loss of customers. People want to keep their health plans”, says the executive director. She explains that individual plans correspond to less than 20% of contracts because, due to costs, few operators offer them.

“On the one hand, we have vertical operators, that is, the operator has the entire chain under her. The hospital is hers, the doctors are hired by her. The company has absolute control of costs, manages to organize the patient’s journey and avoid waste So, probably, the readjustment for the verticalized operator is greater than it needs to recover its costs. On the other hand, there are those that do not work with a verticalized system, which are those operators that do not own the hospital, the laboratory and that do not have a doctor working under contract. Non-verticalized companies do not have cost control. So the expenses are higher and the readjustments do not compensate for the expenses. Today, the operators that sell individual plans, in general, are the verticalized ones, but we wanted all of them commercialize this type of plan”, says Vera.

During 2021, costs with health facilities increased due to the resumption of elective procedures, which were suspended in 2020. In addition, hospitalizations with patients with covid-19 in 2021 were more costly to the system, due to the lack of supplies hospital equipment, such as personal protective equipment and intubation items. To offset these expenses, ANS defines the readjustment based on expenses and data provided by all operators, whether vertical or not. This leads to an average increase in value, which this year stood at 15.5%.

“In this way, we have a terrible or horrible equation for the consumer. There was no salary increase, there was inflation and an increase in plans. We are talking about an impact on family budgets in the house of 25%, in addition to the reduction of revenues”, says Buzanello. He defends another way of applying the readjustments. “This is solved with the temporal distribution of 15.5% in time; every six months it increases by 5%. With that, people gain time to plan their economic lives. In 18 months, the costs would be recovered”, says the teacher.

For Lígia, operators’ revenues should also enter the equation. “As much as it is said, it is increasing according to medical inflation, but medical inflation is an item of expenses. What about revenues? These companies have revenues and what do they do with it? They pay advertising, high salaries for their director members, etc. So we need to make this balance between income and expenses”, concludes the doctor.

FenaSaúde defends that the ANS establish different readjustments for each operator. For this, the plans would individually present their costs, the profile of their portfolios and the readjustment necessary to recover the costs. “This will lead to greater competition, because operators will fight to have smaller readjustments, to have more customers. That way you have a possibility for everyone to sell. This is an agenda that we have already started to discuss with the ANS. It’s not a simple change, but we consider it an important change to increase the number of individual plans”, explains Vera.

The entity also discusses with ANS the outpatient segmentation to provide contracts with smaller coverage, only with consultations and exams, for lower values. Today, outpatient segmentation includes emergency and urgent care in the first 12 hours and therapies.

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