Amid profound changes in supplemental health, consumers are losing rights

Cris Braga is a cancer patient. After several surgeries and treatments over more than a decade, he has to undergo periodic health checks due to the risk of recurrence. In September, with medical requests for several tests in hand, the broadcaster called the usual lab and received information that its health plan had banned that service. Frightened, he called the hospital where he is treated for guidance. To his surprise, he discovered that the institute’s diagnostic service had also been excluded from his plan.

He says he hasn’t received any notification from the plan that the accredited network would change. “I had gone to the doctor days before and was treated normally,” she says. With a number of invasive procedures performed over the years, she requires specialist care to be able to pass the exams. “Not just any lab can do the procedures. My arms are empty and that makes the exam very difficult. That’s why I always do it in the same places,” he explains.

Changing the coverage network is required by law. The plan has the prerogative to change its suppliers, but there are rules for this to happen. As Emerson Nepomuceno, health care attorney at Vilhena Silva Advogados explains, the firm must notify the client 30 days in advance. Also, simple discrediting of the network is not allowed. There must be a replacement. “If these conditions are not met, change cannot happen,” he explains.

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In addition to the legal issue, the change of accredited network has a more harmful consequence for those in treatment. “This type of interruption is something terrible for the user, also for the impact along his care path. The issue of assistance, the breaking of the link with the trusted professional, all affect the right to health. In the field of integrative healthcare, also due to deregulation, there are fewer safeguards”, says Matheus Falcão, analyst of the Health Program of the Institute for Consumer Defense (IDEC).

The cases pile up

Situations like this are becoming public frequently. In December 2021, for example, the operator Amil surprised consumers who had an individual plan by selling its entire portfolio of customers in the states of São Paulo, Rio de Janeiro and Paraná of ​​this type to the company APS (Personalized Health Care). belonging to the same economic group. About 340,000 projects were implemented. Before the transfer, APS had only 11,000 customers.

The change was not a simple CNPJ change. Customers immediately began to report important changes in the accredited network, with a reduction in coverage. The complaints piled up. Idec was one of the entities that officiated at ANS on the issues. The pressure from the company paid off and, in April 2022, ANS intervened in the negotiation and suspended the deal “due to lack of information to the regulator on the alleged acquisition of control of APS”.

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“It was the duty of the Agency to analyze the request beyond the formal and bureaucratic aspects and to interpret the market signals which, in this case, have been worrying from the outset and have been denounced by Idec more than once, from 2021. Situations like this cannot happen again,” said Ana Carolina Navarrete, an attorney and Idec Health program coordinator at the time.

Entrepreneur Alana Buaride had a similar problem to Cris Braga. Also a customer of the SulAmérica family plan, on 16 September he received an email from the company informing him that from the 19th – just three days later – he would have access to only one laboratory for carrying out tests. She underwent treatment for thyroid cancer and was followed up for over seven years. “Because of the differences between the labs, I always need to get tested in the same lab,” she says.

Difficulty for individual plans

All the cases mentioned have in common that they involve individual plans. They exemplify a problem that has been referred to by specialists as a problem. Large companies in the sector, increasingly concentrated in the hands of a few entrepreneurs, are trying to get rid of individual or family health plans.

This is because this type of contract is heavily regulated by the ANS. Readjustments, for example, are calculated by the agency, not by the market. Conversely, collective or company plans can be freely adapted, it being understood that there is room for negotiation between contractors and operators.

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In 2022, for example, ANS allowed a 15.5% increase for individual plans, which account for 16% of contracts in the country. The adjustments of collective plans are more difficult to measure, precisely because of the lack of regulation. According to ANS, business plans with up to 29 participants had an average readjustment of 8.7% in 2022. There are records of operators, however, increasing their monthly rates by more than 100%.

Matheus Falcão, from Idec, says that there is indeed a movement on the part of operators to give preference to collective plans. “There is a tendency in the market to always look for unregulated solutions, that is, to try to offer the consumer the type of health plan that has less protection from the state,” he explains. “There’s also this trend of creating quasi-artificial legal entities, small CNPJs, for example MEI, so that a plan can only be contracted into this business plan scheme.”

Falcão explains that the consumer of this plan can suffer very high adjustments. “Some adjustments reach double digits and there is very little transparency in the sector,” he says. “The sector has very good economic results, it is even one of the few that has proved profitable during the pandemic”. Idec therefore defends the regulation of adjustments also for collective plans.

large conglomerates

Alana Buaride, who intends to file a lawsuit against her doctor, says she sees this kind of shift as a trend in health plans: limiting access as much as possible to services that aren’t part of the same economic conglomerate.

This is a reality of the integrative health sector. With less and less competition, consumers end up running out of options. SulAmérica itself is involved in a gigantic acquisition: Rede D’Or obtained, on December 12, the green light from the Board of Directors for Economic Defense (Cade), for the purchase of SulAmérica. Rede D’Or already owned 29.8% of the shares of SulAmérica. The rest of the shares were sold for R$6.1 billion. The deal was closed in June.

In a website interview Other healththe health professional José Sestelo, author of the book Health plans and financial domain, said that this type of acquisition is unprecedented in Brazil. “It is worth noting the unprecedented nature of seeing a traditional insurance company, a financial sector company with a strong presence in health insurance, be controlled by a group in the health services sector. The new controllers reveal that their interest for the purchase is based on the complementarity of action of the two groups,” he says.

“I think it may also be evidence of the spread of modus operandi of financialisation in the corporate strategies of companies, whose declared social objective does not formally fall within the financial sector, but which, in practice, are managed as if they were financial companies. It is a hospital/insurance combination that will occupy a prominent place in our health system, especially in the control of hospital beds”, says Sestelo.

Model of care and regulation

This trend in the healthcare sector poses a major regulatory challenge in the country. In a highly oligopolistic area, competition decreases and there is little for consumers to do. “All this brings out a very relevant picture of the need for a change in the regulation and an improvement in the inspection mechanisms. Who is responsible for it is above all the National Agency for Integrative Health, but above all the collegial college of the ANS, which is the highest political example of this agency, which takes or not these decisions to regulate and protect more or less those who consume the health plan,” explains Matheus Falcão.

Idec, as a body that represents consumer rights, has built suggestions that can counterbalance the appetite of companies to maximize their profits. “Our proposals start from the regulation of readjustments for collective plans. Today health professionals have a lot of freedom to define and establish very high readjustments”, says the lawyer.

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But that’s just the beginning. For him it is necessary to carry out a very in-depth discussion on the relationship between public and private, that is, on the financial flow between the state and supplementary health care. “It is a sector that benefits a lot from the existence of the Unified Health System, it also has financial incentives and, also for this reason, it should also have a much greater socio-economic responsibility towards society. more regulation by the ANS,” Falcão argues.

Other side

When asked to comment on the changes in the coverage of the Cris Braga and Alana Buaride plans and on the tendency to direct customers towards the collective plans, SulAmérica limited itself to replying that “there have been adjustments only in the network of referenced laboratories” and that all changes followed the ANS rules.

Read the note in full:

– SulAmérica has not disqualified the laboratories of its network. What happened recently were some adjustments in the network of laboratory services (clinical analyzes and imaging tests) in the city of São Paulo, only for some Exato and individual plans.

– The examinations carried out in the hospital, during hospitalization and treatment in the emergency room, were not adequate.

– In the case of the aforementioned beneficiaries there have been adjustments only in the network of reference laboratories. The adjustments were communicated in advance, and informed where they could carry out their laboratory tests within qualified suppliers of their accredited network, at various addresses in SP.

– SulAmérica complies with all the standards established by the National Integrative Health Agency (ANS) and has acted strongly so that its providers adequately guide the beneficiaries, so that no one is left unattended.

– Customer service channels are ready to answer any question from our beneficiaries via app, website, whatsapp or phone.

Edition: Glauco Faria

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