Cut-off therapy plans for autism without STJ decision – 2022/06/07 – Equilíbrio e Saúde

Even before the STJ’s decision on whether the STJ (High Court of Justice) could be forced to pay for proceedings on the ANS (National Supplementary National Health Agency) list, the health plans have been suspended. they were already offered to children with ASD (Autism Spectrum Disorder) because they were not on the regulatory agency’s list.

The trial is set to begin this Wednesday (8) due to a request for a hearing (which began in September 2021 and was canceled in February 2021). The decision has been long overdue, as it could serve as a basis for future rulings. To date, although many decisions are in favor of users, there is judicial uncertainty, with different interpretations of the process, depending on where it is judged.

The fight for STJ involves the beneficiaries of the plans and health care operators.

Users, patient associations, and consumer protection want an exemplary role to play, which is to ensure that the ANS list functions as a minimum reference and that other requirements can be met at the request of physicians.

Health plans, on the other hand, advocate for a specific model without the possibility of introducing therapies or tests that are not listed by regulatory agencies, a model that works in other countries, such as the United Kingdom and Canada.

So far, STJ’s score is level 1-1. Narrator Luiz Felipe Salomão voted for the exact list and Nancy Andrighi for the model list.

Presenting his vote last September, Minister Salomão said the tax model was necessary to protect the beneficiaries of the plans from excessive increases and to ensure the evaluation of new health technologies. But it does support exceptions, such as CFM (Federal Council of Medicine) -approved therapies.

Despite the stalemate, health plans in at least four states in recent months (São Paulo, Rio de Janeiro, Bahia and Rio Grande do Norte) have suspended therapies for children with autism, some of which have been mandated.

Therapies include ABA (Applied Behavior Analysis), which focuses on behavioral analysis and interventions to reduce language, everyday independence, and risky behaviors, such as aggression.

Last month, a group of 80 mothers of children with autism in El Salvador (BA) protested after plans to cancel such treatment. The justification for the operator, according to the mother, is that the role of the ANS does not provide support coverage for this type of therapy.

In April, 300 parents of children and adolescents with autism also protested in Natal (RN) after plans were suspended by TA (therapeutic assistants) who worked in the home and school environment to help organize a child with autism. daily activities, for example. The reason for the suspension of the operators was also the lack of foresight in the ANS list.

Secretary Luzia, who has a six-year-old son with autism, says without therapy and without a professional to help the child in the classroom, the boy stopped going to school. “It’s more aggressive.” Generally, these therapies take between 30 and 40 hours a week and can cost around R $ 18,000 a month, depending on the number of court cases.

According to autistic rights activist Andrea Werner, 13-year-old Theo’s mother, diagnosed with ASD, has declared a vote in favor of a role model by Minister Salomão in September 2021, with several plans suspending the treatment of children with disabilities.

“The argument is always the same: since it is not on the ANS list, we will not answer any more. It created a huge ripple effect, even without a final decision.

According to lawyer Vanessa Ziotti, the legal director of Instituto Lagarta Vira Pupa and the mother of the autistic trio, health plan lawyers have “copied and pasted” Salomão’s vote to demand the cancellation of orders guaranteeing full assistance to people with disabilities, including at home. care services.

Even in cases where the patient’s order has been maintained, Ziotti says there are repeated violations by health care providers. “We see a lack of restrictions on operators to break the order. They are not afraid, even if they impose fines of R $ 300,500.”

According to the lawyer, another practice of the operators has been to exclude therapists and clinics that only treat autistic people and, at the same time, create their own care centers that concentrate children with various disabilities, such as Down syndrome.

THE Tab verticalization of services with two medical auditors has found that operators have found a way to control the costs and outcomes of these therapies. According to those requesting anonymity, they are investigating the cases of doctors who prescribed autism-only therapies that were only available in certain clinics, at very high prices and without evidence of efficacy.

But despite these discussions, Vera Valente, executive director of FenaSaúde (National Federation of Complementary Health), understands that in the case of autism, the situation has calmed down since July 2021, when the ANS allowed the right to an unlimited number. sessions with speech therapists, psychologists, physiotherapists and occupational therapists.

“But that also needs to be a little more specific, because there are situations where kids do things 80 hours a week. Hell! These kids are sleeping together. [por terapeutas], eat together? There are aspects that are far more instructive than treatment. Health insurance is a treatment, ”he says.

In his view, the questions related to autism therapies are those that go beyond what is established by the ANS. “These are very alternative things that need the seal of medical societies. You can’t do things without scientific evidence with other people’s money. [que têm planos de saúde]. “

The resumption of the trial in STJ this Wednesday should go hand in hand with new protests in Brazil.

According to Vera, the list has always been detailed, covering all the diseases listed in the ICD (International Classification of Diseases) and its updating is based on scientific evidence, made by a collegial and broad participation of society. “It’s evaluated quickly and quickly. If there’s enough evidence to show that the product is different from what it already is, it’s accepted.”

According to him, 50% of what is submitted for inclusion is already rejected by the ANS because it does not meet the minimum criteria required for evaluation.

Valent recalled that there is no country in the world that has unlimited coverage for all treatments or procedures and that everyone does assessments.

He says there is tremendous pressure to incorporate highly expensive drugs, such as rare diseases, which are sometimes registered with incomplete clinical trials and need to be validated in the real world.

“We understand their mother’s situation, they look at their case, their pain, but society’s decisions must all be taken into account.”

In a statement, Abramg (Brazilian Association of Health Plans) said that formulating the price of an unlimited coverage product, which includes all existing procedures, medications and treatments, could make access to a health plan unfeasible and put continuity. Brazilian health supplement under control.

“The concept of having an exemplary list is completely contradictory. The current list of procedures has more than 3,000 items that have passed the Health Technology Assessment (HTA), which is highly recommended by the WHO. [Organização Mundial de Saúde] and recognized by the international community. This process is essential in health care systems. ”

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