Health plans want to propose changes to the autism list – 01/07/2024 – Market

Health plan companies intend to submit to the ANS (National Supplementary Health Agency) a proposal to change the list of coverage for the treatment of patients with ASD (autism spectrum disorder) and other TGDs (pervasive developmental disorders), according to Abramge , an association that brings together more than one hundred companies in the sector.

The suggestion, according to Cassio Ide Alves, medical superintendent at Abramge, is that a line of care be created with more detailed guidelines than those applied today for treatments.

The sector complains about the regulatory changes adopted in recent years by the ANS, such as the resolution that made it mandatory to cover any technique or method indicated by the attending physician and the authorization of unlimited consultations in therapies such as speech therapy and psychology.

For FenaSaúde, the measures did not stipulate conditions for the proper use of the system and opened gaps for the occurrence of fraud and abuse, in addition to creating a lack of trained professionals to meet demand and increased costs.

The ANS says that it has been meeting with representatives of companies and society to discuss issues linked to access and sustainability of the sector in light of the demands of beneficiaries with TGD.

In a public hearing held in October last year with hundreds of participants, FenaSaúde presented cases of patients with overtime, such as a prescription for more than 80 hours per week of care for an 8-year-old beneficiary undergoing multiple treatments with the same therapeutic purpose, in addition to requests for coverage for techniques without scientific evidence.

“On the occasion, representatives of the regulator and professional councils highlighted the increase in the number of services provided to consumers with TGD and the importance of comprehensive and quality monitoring for them, which reduces the worsening of problems, and, consequently, the increase in costs with higher value treatments and procedures”, states the ANS, in a note.

According to Cassio Alves, before submitting its proposals, Abramge will wait for a statement from the agency regarding the hearing. In his opinion, the country is going through a moment of regulatory vacuum.

“There are countless therapies with too many hours, which are not good for the child. We see many distortions that, regardless of the waste, end up harming patient safety. We need to qualify access to treatment with scientific evidence, with a line of care, a protocol. If we have a qualified rational use guideline, as is used all over the world, this waste will be cut”, says Alves.

The initiative concerns patient representatives and occurs at a time when complaints about the assistance provided by the plans are also growing.

“We do not consider the so-called line of care to be adequate. Autism is a spectrum, therefore, it is not possible to establish a single parameter of care when we consider that there are varying degrees of support and individualities. The operators themselves already adopt this understanding of individualization by denying or granting hours of therapeutic care, for example, in the context of legal actions. Standardization, in this context, is an irresponsible way of cutting costs”, states in a note the advisor to state deputy Andrea Werner (PSB), who also chairs the Commission on Defense of the Rights of People with Disabilities in the Legislative Assembly of São Paulo.

The deputy has been one of the main spokespeople for patients undergoing treatment who had their plans unilaterally canceled by operators last year. Between April and May, her office received about 200 reports of unilateral termination, most involving children with autism, cancer and epilepsy.

“It is important to highlight that lines of treatment must be defined in discussion with society and advice from health professionals, such as Cremesp, the Federal Psychology Council or even by Anvisa, when there is a need to use medications, and not unilaterally, by companies and an agency that regulates the provision of services”, he says, in a note.