Health has become a burden

Announcer Luiz Sztutman, 39, paid about 200 reais for his basic health plan, and quickly saw the monthly fee rise to 400 reais. After leaving work, the account became heavy for him. Living as a freelancer and without a formal contract, he made a difficult decision: he ended the plan and now has health insurance. His story is a faithful representation of a problem that has hit the middle clbad. In the last three years, as a result of the economic crash, more than 3 million Brazilians have stopped paying the private health plan. These people, in the great majority, had the badurance of the company in which they worked. Rejected, they were not able to hire individual or family plans, much more expensive than the collective plans offered by the companies. Without private plans, they now have to cover their expenses for examinations, consultations and hospitalizations exclusively with their own pocket money or waiting in the public service line – at a time when the quality of the unified health system (SUS) historically undervalued, was even worse in states in financial crisis. A survey published by Datafolha last week under the auspices of the Federal Council of Medicine (CFM) shows the discontent of Brazilians: 54% believe that the public service is bad or bad, 28% as regular and only 17% as good or good

Today, only a quarter of the population (47.1 million people) has a type of medical insurance. The other 160 million Brazilians need to use the civil service. The private hedge index, which had risen in the years of prosperity and growth in the number of workers with a formal contract, dropped. The explanation is one: the price. For those who can afford a private plan, with or without the help of the employer, the difficulty is to cope with rising tuition fees. The increase in medical expenses is a reality experienced in many countries, due to the aging of the population and the incorporation of new treatments. In Brazil, readjustments of the health plan from one year to the next are higher than inflation. Last week, the National Supplemental Health Agency (ANS), a government agency that regulates the sector, has authorized an increase of up to 10% for individual plans, with retroactive effect to 1 May. It's just triple the current current inflation in the country (see chart below). In 2017, the maximum allowance allowed for plans (13.6%) had already exceeded the quadruple rate of inflation (3%) and, in previous years, the situation was not very different.

In the collective plans, the negotiation is done freely between the companies and the operators of the service of health, but the readjustments in the monthly payments paid by the beneficiaries also remained superior to the general index of cost of the life . The authorized increases motivated the action of Consumer Institutes and the Court of Auditors of the Union (TCU), which consider that the reasons for the amounts applied are somewhat obscure. According to ANS director Leandro Fonseca, the adjustments should reflect the costs of the procedures and the increase in use. "We have to be vigilant to maintain the solvency of the operators, limiting the adjustments per trial can threaten the sustainability of the system, and those who will be penalized will be the users themselves," says Fonseca. José Seripieri Junior, president of Qualicorp, one of the largest health plan administrators in the country, defends the formulation of a more transparent indicator: "A new benchmark is needed, above the good and evil. It is only in this way that it will be possible to discuss lasting and equitable readjustments for all. "

Julia Ghidetti, 35, insurance broker.At the age of 25, Julia joined as a dependent in her father's health plan. businessman, he opted for the benefit offered by a union and contracted an intermediate plan, with the right to stay in an apartment and to access hospitals and reference laboratories. until recently, paying 855 reais. "The value was very high and, the following month, with a readjustment of 17%, I would pay 1,009 reais. I had to look for other options. Tight, she joined the syndicate of brokers and managed to reduce the cost of the medical arrangement. The service to which you are entitled is similar, even though the service network is much more limited. At least, the price of your monthly payment will fall to 680 reais. "I did not think about it before making the decision, it was better like that."

Julia Ghidetti, 35, an insurance broker At the age of 25 , Julia joined as a dependent in her father's health plan.As a businessman, he opted for the benefit offered by a union and contracted an intermediate plan, with the right to stay in an apartment and to access hospitals and reference laboratories.Julia was badociated until recently, paying 855 reais. "The value was very high and, the following month, with a readjustment 17%, I would pay 1,009 reais. I had to look for other options. Tight, she joined the syndicate of brokers and managed to reduce the cost of the medical arrangement. The service to which you are entitled is similar, even though the service network is much more limited. At least, the price of your monthly payment will fall to 680 reais. "I did not think about it before making the decision, it was better like that." (Jefferson Coppola / VEJA)

The fact is that health spending is a growing part of the household budget About 40% of the total medical expenses of Brazilians are related to the payment of the plans.For those who work in a large company, the account is divided with the boss.There are 38 million people in this privileged situation today. Another 9.1 million Brazilians pay the full cost of using an individual plan, and in this type of contract, tuition fees are much higher. a 40 year old person is about 500 reais (for the elderly, the monthly rate is at least double) For example, the account explodes for the right to use the main hospitals of São Paulo like Albert Einstein and Sírio-Libanês. It's so heavy that there are no individual plans with this type of marketing coverage. This category is only available for those who are connected to a company or badociation. The monthly rates for people up to 40 years old are about 3,000 reais and for the elderly, they go up to 8,000 reais. Since the average wage of workers is 2,100 reais, it is obvious that few families are able to pay these prices.

Whenever possible, Brazilians have sought ways to avoid spending pressure. One of the alternatives is to change the operator, looking for more economical options. There are plans in which exams and medical appointments are made exclusively in the hospital network of the agreement itself. It is cheaper, although the client can not choose the hospital of his preference (prices always vary depending on the person's profile and medical history). Another way is to look for membership plans related to badociations or unions. This is a common situation among well paid executives and professionals who have lost their jobs and have no more collective plan. Working as freelancers, engineers, doctors and lawyers can adhere to the agreed plans of their badociations, with monthly fees lower than those of the individual plan. For operators, this type of contract dilutes risks and costs, as in collective agreements with large companies. That's why the monthly fees are lower.

Luiz Sztutman, 39, advertising man. In 2012, Sztutman worked as a communications coordinator in a cultural center, with portfolio registration. There, he chose to have the health plan to which he was entitled. A year later, he left work. Without the benefit of the business, he kept the basic contract for six more months, until the tuition, which was 200, exceeded 400 reais. He decided to terminate the contract with the health care provider at the time. "I started working as a freelancer and this expense weighed in my pocket." Two years ago, he used Unified Health System (UAS) services. Sztutman has not yet needed complex treatments, but has done tests, taken vaccines and consulted doctors in more than one specialty. "Until now, I am satisfied with the public system."

Luiz Sztutman, 39, advertising. In 2012, Sztutman worked as a communications coordinator in a cultural center, with portfolio registration. There, he chose to have the health plan to which he was entitled. A year later, he left work. Without the benefit of the business, he kept the basic contract for six more months, until the tuition, which was 200, exceeded 400 reais. He decided to terminate the contract with the health care provider at the time. "I started working as a freelancer and this expense weighed in my pocket." Two years ago, he used Unified Health System (UAS) services. Sztutman has not yet needed complex treatments, but has done tests, taken vaccines and consulted doctors in more than one specialty. "Until now, I am satisfied with the public system." (Jefferson Coppola / VEJA)

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A good contingent of Brazilians However, the middle clbad is currently living outside the coverage of the Health insurance. According to a survey by SPC Brasil, nearly half of families in clbades A and B do not have health insurance. "Whoever commits the plan however considers the service as a necessity, to the point that the defect is very low," says Marcela Kawauti, chief economist of SPC Brazil. Of those who have had a plan but do not have any more, most say that they have lost their jobs or are unable to pay monthly fees, while a small percentage says that they do they have used them very little and do not need to hire private services. These people use the public service or pay all expenses out of their pocket with private consultations and exams.

Another option, which is starting to gain more space, are the private groups that offer consultations at higher prices. These are companies like Dr. Consul, GlobalMed and Doctor Now. Previously focused on Clbad C, these services are gaining popularity among Clbad B and even A. It's this niche that belongs to more than half of Dr. Consulta's clientele, says Renato Velloso, Vice President of business-to-business development. "These are people attracted by the facility to mark the service, everything that is done through the application, and also by the cost," says Velloso. Another part of the clients are dissatisfied people in the public service. The value of consulting these new companies varies by specialty, but the most expensive is only R $ 180 – and anyone with a plan can still claim a refund.

Popular-priced focus groups are a palliative, but do not handle more complex situations. Therefore, according to experts, it is necessary to re-evaluate the procedures – and, therefore, the health costs here. In terms of spending relative to the size of GDP, Brazil has rates similar to those of European countries and is lagging behind the United States, a country known for excess spending in the region and for efforts to reformulate the service system. Compared to Europeans, Americans do more consultations, more exams, more surgeries – and they are not even healthier. In the United States, as in Brazil, the regulatory system encourages excessive spending. Hospitals and laboratories are paid for the amount of service provided, not for quality. It's a stimulant to waste. Many countries have changed this model and have begun to adhere to standards of care based on the patient's symptoms. It is necessary to follow predetermined protocols, which avoids abuse in the demand for exams, for example. The doctor and the hospital have little freedom to request further badysis. Countries such as Germany, France, and South Africa have adopted this model. In the German case, hospital costs decreased by 25%, according to the Institute for Studies in Complementary Health (IESS).

Teresa Cristina Ferreira, 59, lawyer. Teresa still had health insurance. He was married twice, and because he was self-reliant, he entered as an addict in the medical alliance of his companions. In 2010, however, after the last separation, he chose to hire a basic plan. He started paying a monthly fee of 250 reais and at the end of the contract last year he was already paying out 945. "In May, I was 59, and in this group of age most plans double in value.I found out that I would pay about 1 800 reais. "It was then that I heard a friend of a popular operator, who is geared To the public over 50 years old and who has a network of hospitals.Since then, nine months ago, Teresa pays a monthly fee of 575 reais. "I am saving about 1,300 reais per month. A big relief. "

Teresa Cristina Ferreira, 59, lawyer Teresa still had health insurance, he was married twice, and because he was self-employed, he entered as an addict in the school. medical alliance of his companions.In 2010, however, after the last separation, he chose to hire a basic plan.He started to pay a monthly fee of 250 reais and at the end of the contract l & 39; last year he was already paying out 945. "In May, I was 59, and in this age group most plans double in value. I found out that I would pay about 1,800 reais. It was then that I heard a friend of a popular operator, who is audience oriented for over 50 years and who has a network of hospitals. Since then, nine months ago, Teresa pays a monthly fee of 575 reais. "I'm saving about 1,300 reais a month." (Jefferson Coppola / VEJA)

Health care providers, so often criticized for complicating physicians' work, say they're trying to limit the abuses to keep the accounts out of control. "There is misuse," says Reinaldo de Camargo Scheibe, president of the Brazilian Association of Health Plans (Abramge). "We hit the ceiling. In fact, there are inexorable factors of price pressure, especially the aging of the population and the increase in the cost of highly complex treatments. But, according to experts in the field, medical inflation would be much lower if the country followed the example of nations that balanced spending without loss of quality, rather than following the Americans' crisis model. If there is waste – as in the case of expensive and unnecessary examinations – the bill will inevitably have to be distributed among all the insured persons.

The case of magnetic resonances is remarkable. Among Brazilians with a private plan, 148 examinations are conducted each year for every 1,000 people. This is slightly more than the American exaggerated – and shameful compared to other countries. In Australia, for example, 42 examinations are carried out per 1000 inhabitants. In Canada, about 56. More sophisticated testing is a major source of financial income for physicians and hospitals. Another example of national disparity is the famous excess of caesareans. According to the recommendation of the World Health Organization (WHO), the ideal rate of natural births should be between 90% and 85%. In Brazil, it is ridiculous 16%. "Caesareans dominate, either by choice of mother, or by the convenience of the doctor, and are of course more expensive than normal deliveries," says consultant Luiz Edmundo Rosa, director of the Brazilian Association of Human Resources. "We must correct this national scandal." The inflation of medicine does not just weigh in the pockets of families. For businesses, it's already one of their biggest expenses in the budget, behind only the employee payroll (and taxes). Once again, Brazil copied an American anomaly. As taxes do not decrease and the priority is to keep the workforce, companies have trouble controlling employee health expenses. This means that even those who are employed are gradually paying more and have fewer benefits. According to experts in human resources management, companies should better badess the medical expenses of workers and monitor the health of employees. Groups that do not take care of the issue are likely to face a growing snowball in the future.

Heide Taynara Ribeiro, 26, Commercial Director. Because of his son Arthur, now 4 years old, Heide Taynara did not want to go without a private plan. When he started working in a network of shoe stores and that he knew that he would not have any understanding, he decided to hire an individual plan from D & D. A popular operator. In 2013, he began paying the monthly fee of 79 reais in the room plan and, after two years of membership, he changed to the flat plan, which cost 108 reais. Taynara's husband started working on the file, and she and her son became their dependents. Three years later, in 2016, came separation and she lost the benefit, when she then chose to join a popular discount card in consultations and exams. It has up to 70% discount on the price of services and pays a monthly fee of 19.99 reais.

Heide Taynara Ribeiro, 26, Commercial Director. Because of his son Arthur, now 4 years old, Heide Taynara did not want to go without a private plan. When he started working in a network of shoe stores and that he knew that he would not have any understanding, he decided to hire an individual plan from D & D. A popular operator. In 2013, he began paying the monthly fee of 79 reais in the room plan and, after two years of membership, he changed to the flat plan, which cost 108 reais. Taynara's husband started working on the file, and she and her son became their dependents. Three years later, in 2016, came separation and she lost the benefit, when she then chose to join a popular discount card in consultations and exams. It has up to 70% discount on the price of services and pays a monthly fee of 19.99 reais. (Jefferson Coppola / VEJA)

In the United States, an unprecedented experience to control the increase in business health spending will be brought to the attention of the world: Amazon, in badociation with JP Morgan Bank and Investment Company Berkshire Hathaway, plans to invest in a new company that will explore ways to reduce health expenses. The three groups total more than one million employees in the United States. The initiative will be led by doctor and consultant Atul Gawande, who has written some books on the subject and has also collaborated with reports for The New Yorker magazine. In one of them, published in 2009, he treated equitably excessive spending in some hospitals. In the text, he compares the provision of medical services to the construction of a home. Imagine, he says, if, instead of paying a contractor for the project as a whole, you paid the electrician based on the number of takes suggested by him, the plumber by the number of faucets that he had. he deemed it necessary, the quality and the mark that he chose, and so on. The obvious conclusion is that it would cause project costs to become out of control. Gawande wrote: "Would you be surprised if you had a house with thousands of plugs and taps at the end, built for three times the estimated price, and yet it collapsed two years later?" The badogy describes, to a large extent, what is happening in the Brazilian private system. Without correction, in agreement with doctors, hospitals and operators, the cost of private plans will not be sustainable for a growing share of the population, and they will unfortunately be a privilege for a few. Very little

Published in VEJA of 4 July 2018, Collection No. 2589