According to the dice According to the National Health Agency (ANS) in March 2023, Brazil had more than 50 million beneficiaries in health plans, equivalent to 25% of the population. Supplementary health faces widespread difficulties, a scenario in which operators experience losses, providers are slow to receive, and clients suffer from readjustments.
On the operators' side, according to ANS, an operating loss of R$ 10.7 billion was recorded in 2022. In addition, the National Federation for Supplementary Health (FenaHealth) indicated that, between 2021 and 2022, there was a positive variation of 5.6% in revenues, while operators' expenses increased by around 11.1%, evidencing this mismatch. In 2022, the entity indicated that the accident rate - the ratio between the amount paid by the beneficiary and the cost of the procedures - of medical and hospital health plans reached 89.21% in the last quarter of the year, being one of the central factors in this difficult context. Still, with a comparison with older data, according to Supplemental Health Information Book, in 2006, the accident rate was registered at 79.1%.
This crisis stems from many factors, the main of which is the increase in the use of services. It is worth mentioning that the country is going through a process of demographic transition and this Ageing of the population increases the demand for health services. In addition, FenaSaúde believes that this scenario is aggravated by the obligation to offer increasingly expensive treatments, fraud, an increase in the price of medical supplies, judicialization and an end to the limitation of outpatient consultations and therapy sessions with psychologists, speech therapists and other professionals.
This critical context within operators directly influences the readjustment of health plans, also impacting the beneficiaries. Many of them choose to leave the plans based on the readjustment rates, further burdening the public health system. On average, the adjustment was 11.4% between December 2022 and February 2023. The highest indices come from Bradesco, which increased prices by 22.3%, and from SulAmérica, by 16.6%.
Also, due to the lack of cash, health operators also face complaints from hospitals and service providers, as they started to renegotiate or delay payments, impacting this end of the chain. For example, operators have adopted some measures that increase the payment period for bills, such as extending the deadlines from 60 to 80 days to 120 days. In addition, some of them established a rule in which hospitals can only send the total monthly bill in one day, instead of three to four days, as was the case before. Finally, in numbers, according to the ANAHP Hospital Indicator System, accumulated from January to November 2021 and 2022, the disbursement rate - meaning the non-payment of an item that is part of the patient's hospital bill - went from 3.63% to 4.61%, which highlights this imbalance in the relationship between operators and hospitals.
Fee for service and alternative compensation models in health
This health crisis raises a question about current compensation models, which have been considered outdated and unsustainable. In Brazil, the most common is Fee for service, whose compensation is based on the service performed, which includes exams, appointments, medications, etc. In this sense, the model prioritizes the number of services, ignoring outcomes, which can encourage the use of unnecessary services and generate waste.
Other existing alternatives are pay-per-performance (or P4P), bundle, and capitation. The P4P attaches compensation to the outcome, so that the payment is calculated based on the costs for generating positive clinical results, prioritizing the quality of the service; payment per bundle is more suitable in the case of a specific treatment line, since it consists of a closed package that will meet all the needs of a given condition; finally, the payment by capitation transfers an amount to the health center, which will use the amount to carry out the necessary care and procedures.
As Healthtechs Force the movement of traditional operators
In response to the current health crisis, there are Healthtechs who try to solve the sector's pain with technology, also requiring the movement of Players traditional. These startups have been addressing these pains with proposals that promise more humanized care and greater efficiency, offering primary care with telehealth and a more in-depth analysis of health data, in addition to a more limited network, resulting in a lower value.
These movements of Healthtechs of health plans, added to the crisis, have led traditional operators to a search for adaptations. Some began to focus on the use of technology, for the coordination of care, primary care, and more limited networks. In addition, ANS has also been promoting incentive actions, accrediting Unimeds with Primary Health Care Certification, for example.
Another challenge is to make the population aware of the value of preventive care, a process that is hampered by a cultural barrier, which prioritizes reactive health (treatment of the disease). Still, another difficulty for operators is making the modifications themselves, since the contracts are old and prevent a very sudden change in the current model. This creates a need to create new products from the start.
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