Increasing health plans sparks debate over recalculation Economy

Sofia Bernardes

Increasing individual and family health plans is leading to controversy over the recalculation calculation

In May, the National Agency for Complementary Health (ANS) announced another setback for the budget for middle-class families. In 2021, after a negative adjustment of 8.19%, the regulator approved a 15.5% increase for individual and family plans, the largest increase in the historical series. The decision created mixed opinions for customers and the impact on the healthcare industry. Specialists and operator representatives advocate different calculation methods for defining price lists.

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

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

According to Marcos Novais, executive superintendent of the Brazilian Association of Health Plans, a smaller number of individual plans is normal. “The health insurance market is closely linked to the behavior of the Brazilian economy, especially the labor market. The vast majority of the population has health insurance for employment. Novais explained.

“I think this decision by the ANS is very bad for the consumer relations of the health plan users, as there has been no increase in the salary of all public and private careers in the last two years. there is an increase of this size, ”says Buzanello.

Although the 15.5% readjustment has only been approved for individual and family plans, Lígia Bahia, a doctor and professor at the Federal University of Rio de Janeiro (UFRJ), has warned that the increase could also affect other modalities. “This becomes a parameter for other plans. Collective business plans can go up by more than 15.5%,” says Lygia. If this happens, the measures will only apply to individuals who created the CNPJ to hire business plans.

According to Lygia, the sale of this type of plan is becoming more and more common. “It simply came to our notice then. [pessoa jurídica]. A person joins a company to have a plan. So they are individual, but they are a way to avoid the law, ”says the doctor, who explained that this modality is more interesting for operators because it allows them to break contracts unilaterally.

One of the plan clients who received this offer was Parliamentary Adviser Manuel Evangelista, who has benefited from the individual plan for 40 years. Unemployed due to the pandemic, he found it difficult to pay for the service and decided to go to the operator’s unit in person to negotiate. Before entering the building, however, he was approached by plan brokers who tried to persuade him to register as an individual micro-enterprise (MEI) to hire a business plan.

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

At Manuel’s home, two other friends use the individual plan, his wife and 83-year-old mother. He believes the readjustment will weigh heavily on family spending, which is already under pressure from inflation. “It’s not just the plan. Gasoline is R $ 8.1, a kilo of carrots is R $ 19, secondary beef is R $ 36,” Manuel points out angrily.

Inflation in April, the month before the readjustment, was 1.06%, with a significant impact on the health sector. According to the April Consumer Price Index (IPCA), pharmaceutical products grew by 6.13%, which had an even greater impact on the household budget.

For Manuel, who suffers from chronic migraine, the price of medication is considered a burden. In treatment for more than 10 years, he should take an imported injection worth R $ 2,850 per dose. Unable to withstand treatment and the health plan refuses to pay for the product, he takes another less effective medicine, which costs R $ 120 a week.

Your mother also needs medication for diabetes, cholesterol, and osteoporosis. All this generates an expenditure of R $ 3,000 per month, which is not compatible with the income of the retiree. To deal with the situation, “he continues to try to sign these lab deals to pay cheaper, he keeps trying to get an insurance plan because he can’t get free medicine,” Manuel says.

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

Even though revenue is under pressure, he tries to maintain the plan for fear of losing SUS treatment. “SUS can’t handle the number of people who need to be cared for at the moment. You go to a public health center and there is a doctor who cares for 150 people; now there will be a doctor who cares for 300 people. And there is no specialist. he works out for a month. Then he arrives on the day of the consultation and there are no specialists yet, ”he says.

According to Vera Valente, executive director of the National Federation of Complementary Health (FenaSaúde), the readjustment of the plan is not as effective as the rise in other sectors of the economy. “From the user’s point of view, the last two years have seen a negative adjustment in 2021, reflecting the 2020 scenario. If the 2021 adjustment is average with the 2022 adjustment, we have seen a 6% increase, which is well below inflation,” says Vera.

In addition to inflation, families trying to keep up with their plans have yet to face another economic downturn: declining incomes. According to the National Household Sample Survey (PNAD) conducted by the Brazilian Institute of Geography and Statistics (IBGE) in the quarter ended April, the regular real income was R $ 2,569, which indicates stability and stability compared to the previous quarter. A decrease of 7.9% compared to the same quarter of the previous year.

In the face of the pandemic-hit economic scenario, some have already abandoned plans with broader coverage for basic contracts. That’s the case with show producer Elísio Paiva. “I had a very complete plan. Then came the pandemic, which dried up the market [de trabalho]. I was forced to cancel my entire plan and I was subject to my wife’s retired teacher plan, which is very basic, ”says Elísio. With the change, he started paying R $ 150 for the plan, which he used for exams. you need more complex care, you use the Integrated Health System (SUS).

“I have seen a lot of results in public service and there is no longer much difference between public and private conditions. In fact, my income has improved because it was a burden. It was almost my plan and that of my wife. R $ 2.5 thousand.” says the producer.

For Ligi, cases like Elísio’s should be more common. “It simply came to our notice then [operadoras] they have reduced customers, forcing them to opt for a less-covered plan. So they always get a very positive result, but at the expense of a very negative result for the customers. ”

As for Vera, that move shouldn’t be the rule. He recalled the increase in the number of registered customers during the pandemic and said that the additional healthcare sector was working to prevent the loss of users. “We want to increase individual access, we don’t want to lose a beneficiary. We don’t think this adjustment will lead to a loss of customers. People want to keep their health plans going,” says the executive director. He explained that the individual plan covers less than 20% of the contracts, due to the low cost offered by the few operators.

“On the one hand, we have vertical operators, which means the operator has the whole chain under it. The hospital is its own, hired by the doctor itself. On the other hand, there are those who do not work with a verticalized system, that is, operators who do not own the hospital, those who do not have a laboratory and a contract doctor. readjustments do not offset costs. Today, operators who sell individual plans are generally verticalized, but we all wanted to commercialize that type of plan, ”says Vera.

During 2021, the costs of healthcare facilities increased due to the resumption of elective procedures, which were suspended in 2020. In addition, hospitalizations of covid-19 patients in 2021 were more costly for the system, such as a lack of supply of hospital equipment. as an element of personal protective equipment and intubation. To compensate for these costs, the ANS defines readjustment based on the costs and the data provided by all operators, whether vertical or not. This represents an increase in the average value, which was 15.5% this year.

“We have a huge or huge equation for the consumer. There was no increase in wages, there was an increase in inflation and plans. We are also talking about the impact on the household budget of 25% of the household. “This is resolved with a 15.5% time distribution; it increases by 5% every six months. With this, people gain time to plan their economic life. The costs would be recovered in 18 months, ”says the teacher.

For Lygia, the income of the operators should also be included in the equation. “As they say, medical inflation is rising, but medical inflation is a game of spending. What about revenue? These companies have revenue and what do they do with it? They pay for advertising, high salaries for their manager. Partners, etc. “So we have to strike a balance between income and expenditure,” he said.

FenaSaúd, on the other hand, argues that the ANS implements different readjustments for each operator. To do this, the plans would present their costs individually, the profile of their portfolios and the readjustment required to recover costs. “This will lead to more competition, as operators will have to make smaller adjustments and fight for more customers. That way you can sell them all. This is an agenda we have started discussing with ANS. Verak.

The entity also discusses with the ANS the outpatient segmentation to offer lower coverage contracts, only with consultations and examinations, for lower values. Currently, outpatient segmentation includes emergency and urgent care for the first 12 hours and includes therapies.

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