Losses and gains of health plans – 02/16/2023 – Cláudia Collucci

If it’s already difficult to pay for a health plan, get ready: the situation could get worse. Although this year supplementary health should reach 51.5 million users, a historic record, monthly fees have not been enough to sustain expenses.

“Since April 2021, the health plan business has not been able to pay for itself,” wrote Vera Valente, executive director of Fenasaúde (National Supplementary Health Federation), in a recent article.

In 2022, until September, the deficit amounted to R$ 11 billion. The accident rate (ratio between the amount paid by users and the cost of procedures) reached 93%, the highest percentage since the regulation of the sector in the country, 24 years ago.

Several factors contribute to this, including an increase in elective surgeries dammed in the Covid pandemic, new treatments, high cost of medications, inputs and technologies (quoted in dollars) and fraud.

Under pressure, operators have postponed payments to service providers, extending deadlines and paying for these services below inflation. Users also feel the impact, reflected in reduced coverage, delay in reimbursement of expenses and abusive readjustments.

This month, a new element left the plans in turmoil: Zolgensma (Novartis), medication for spinal muscular atrophy (AME) type 1, entered the list of mandatory coverage of the National Supplementary Health Agency. Dubbed the “most expensive medicine in the world”, the product costs BRL 7.2 million per patient to plans.

According to Fenasaúde, 25% of small operators, with up to 20 thousand lives, do not earn this amount in the year, which would be a threat to their sustainability; not to mention that there will be an increase in monthly fees, as the system operates on a mutual basis.

The way out, of course, is not to veto or hinder access to new technologies that can save lives or improve those living with serious illnesses.

By incorporating Zolgensma into the SUS, in December, the Ministry of Health agreed with Novartis that it will only pay the full amount of the medicine (R$ 5.7 million) if the treatment has a positive effect.

The first installment, 20%, is paid at the time of application, which is in a single dose. Payment of the other four installments, also 20%, is linked to the effectiveness of the therapy.

Sharing risks with pharmaceutical companies has been adopted by several countries and is a way to guarantee access to innovative treatments and also provide greater budget predictability.

More than that: it is a way of evaluating the effectiveness of new technologies in the real life of patients. Are they really worth what they cost?

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