Autism surpasses cancer in plan costs, says sector – 01/07/2024 – Market

The increase in demand for treatments for patients with autism spectrum disorder and other global developmental disorders has become a topic of concern in the health insurance market.

Companies of different sizes report an increase in spending on therapies of this type, which are already beginning to reach levels in oncology — an area that traditionally consumes the main share of bills, according to sector entities.

According to a survey carried out by Abramge (Brazilian Association of Health Plans) in a group of operators associated with the entity, in 2023, the cost of therapies for ASD (autism spectrum disorder) and TGD (pervasive developmental disorders) exceeded 9 % of medical costs, while oncological treatments accounted for 8.7%.

A few years ago, such treatments used to represent less than 2% of the sector’s bills, according to Abramge.

The costs began to bother companies after regulatory changes announced by the ANS (National Supplementary Health Agency) from 2021, when the body determined that people with ASD would be entitled to an unlimited number of sessions with psychologists, occupational therapists and speech therapists to the treatment of autism in the coverage of the plans.

In 2022, the measures were expanded to include coverage of any methods or techniques recommended by the doctor for the care of patients with TGD.

The standard considers the ICD-10 (International Classification of Diseases), which covers diagnoses of childhood autism, Rett and Asperger syndrome among examples of global developmental disorders.

Operators, however, cannot deny coverage if the prescriber uses the ICD-11 parameters, which is an updated version of the WHO (World Health Organization) document, not yet mandatory in Brazil.

Then, the ANS also determined new adjustments to the coverage list, releasing an unlimited number of sessions for all plan users, with any illness or health condition listed by the WHO.

According to the agency’s most recent data, the number of speech therapy sessions and consultations jumped from a level of 8 million in 2021 to more than 10 million the following year.

Psychology visits rose from 28 million to almost 35 million, while occupational therapy went from 3.3 million to 4.7 million sessions and consultations in the period.

The increases were driven by diagnoses of TGD and ASD, according to Abramge.

From 2021 to last year, the association says it saw a 74.4% increase in the cost of ASD and TGD therapies, while oncology increased by 37.3%.

At the same time, complaints from patients against health insurance companies are also growing, motivated by problems such as denial of coverage, disqualification of clinics and cancellation of contracts.

José Cechin, superintendent of IESS (Institute of Supplementary Health Studies), estimates that the number of patients with ASD who have access to private healthcare in Brazil is around 500 thousand people.

In addition to regulatory change, he sees other factors responsible for the increase in demand, such as the evolution of diagnoses over the years.

According to data from the United States Center for Disease Control and Prevention, the prevalence of 8-year-old children on the autism spectrum was 1 in 150 in 2000, a proportion that rose to 1 in 36 in 2020.

“Diagnosis has increased a lot around the world, for several reasons. The diagnostic technique has improved and families want to provide better conditions for their children”, says Cechin.

In the assessment of FenaSaúde (National Supplementary Health Federation), unlimited therapies opened gaps for the occurrence of waste and abuse.

The effect on accounts varies depending on the profile of the companies. Those working with reimbursement have been most impacted.

According to Vera Valente, director of FenaSaúde, the sector has faced cases of fraud committed by clinics that are paying for health plans in the name of patients to request reimbursement for treatments with overtime, among other distortions.

“What we question are the abuses. The majority of beneficiaries, who act correctly, are paying the bill for those who abuse them. There are blatantly fraudulent situations. There are cases of patients receiving 82 hours of therapy per week. It is unfeasible. An 11-year-old patient submitted 154 reimbursement requests in just over two years. In psychotherapy alone there were 1,800 sessions, a total of R$550 thousand”, says Valente.

For the consumer protection NGO Idec, cases of fraud are not the responsibility of the common beneficiary.

Ana Carolina Navarrete, coordinator of Idec, assesses that the growth in the number of consultations actually reflects a demand that was repressed, because the previous rules were very restrictive and were unable to meet the real needs of patients.

“We know that a large part of the denials of coverage for procedures such as psychotherapy sessions, physiotherapy, speech therapy and others were routinely denied by the plans, with the justification that the ANS list only determined coverage for up to 12 sessions per year, in most cases “, says Navarrete.

Cassio Alves, superintendent of Abramge, denies that the companies’ intention is to restrict beneficiaries’ access to the service.

“The problem is not granting access to what is necessary. The problem is not qualifying this access. When there is a regulatory void in which there is no guideline for using this access, in addition to overuse occurring, you allow opportunists to take advantage. The concern is safety and efficacy. We have to target these therapies to deliver what is scientifically proven and safe for children. [O acesso] is being done in an uncoordinated way. There must be a guideline, a line of care, a protocol, otherwise safety, effectiveness and, of course, cost-effectiveness will be sacrificed”, says Alves.

The ANS confirms that it has been observing an increase in healthcare costs in general, but points out that the agency does not have a specific study on the amount of resources allocated to caring for beneficiaries with TGD and states that it does not regulate the values ​​of services and inputs charged by the market.