Last week, the Superior Court of Justice (STJ) finally decided whether the list of procedures described in health plans would be exemplary or exhaustive. In general, what was perceived was an attempt by the Court to reconcile the need to preserve people’s lives with the financial health of health plan operators. But it seems to us that this discussion is just the basis of the problem.
It is a fact that the constant advances in medicine have brought undeniable benefits to the health of all of us. There are interventions, such as vaccines, with very low cost per inhabitant and that generate huge benefits. But there are also cancer and rare disease treatments that save thousands of lives, but are much more expensive.
Knowing which treatments offer the desired benefit and within an acceptable value is a discussion present throughout the world. A good example of a public health system is the National Health Service (NHS) or British National Health Service. This system has an Institute called NICE (The National Institute for Health and Care Excellence), in a free translation, National Agency for Health and Care Excellence.
NICE makes assessments recommending what should or should not be incorporated into the health system, considering variables such as cost, severity and frequency of the disease, as well as possible alternative treatments. These assessments directly impact the assistance provided by the NHS. Such is the credibility of NICE that many pharmaceutical companies celebrate the approval of their products by this Institute.
In Brazil, the National Health Agency (ANS) was created with the institutional purpose of promoting the defense of the public interest in supplementary health care. It regulates sector operators, including in their relationship with consumers, contributing to the development of health actions in the country.
Thus, it makes perfect sense for the ANS to establish a list of procedures that must be offered to users of health plans. Ensuring that these procedures are cost-effective, leading to the best possible assistance to users and guaranteeing the solvency of operators, is in the public interest.
Inadequate treatments harm consumers and operators themselves, as they can be too expensive, have poor clinical outcomes, or both. Unfortunately, what can be seen is that the list of ANS procedures (a commendable and necessary initiative) has presented several problems since its creation.
The first of them is the slowness in the inclusion of new procedures because, by arbitrary rules, this list can only be changed with time intervals that reached two years. There are also strange rules, which involve the automatic incorporation of intravenous drugs, but which require the separate incorporation of drugs by mouth.
Given the speed of advances, a better and even cheaper treatment is often refused by the operator, as it is not included in the current Role; and this causes delays, lawsuits, inevitable cost increases, and worsening patient outcomes.
The ANS and the operators defend themselves by saying that the Rol will be improved, however, this is a conversation that has been heard for years, without any noticeable improvement. Unfortunately, medical specialty societies are only called upon to give their opinion after the reports that give rise to the new defined Role are ready.
Unlike NICE, ANS opinions are often not written by experts in the field and reversing their content in a public hearing becomes an arduous task, subsequently generating all kinds of problems. Diagnostic tests, for example, are problematic, particularly when it comes to those that are rarely requested, but that are not expensive.
This is also the case with serum levels of busulfan and voriconazole, used in transplant patients, which end up not being paid. The operators and the ANS claim that it is enough to ask for the incorporation, however, the process is arduous, consumes time and funds.
Deep down, the discussion about Rol being categorical or not is something outdated. We should have been discussing for a long time how to improve it, through the improvement of analysis processes, incorporations and exclusions of procedures.
By simply assuming that the current Role will regulate what can or cannot be provided to users of health plans, without considering that it should be understood as a dynamic process to be improved, we will be maintaining a greater overload of judicialization, with inadequate treatments and of increased costs.
The discussion needs to go much deeper. On the one hand, revoking each and every Rol, forcing operators to cover everything, will imply an insane increase in costs, making supplementary health care unfeasible. On the other hand, leaving people completely unattended is also not acceptable.
It is necessary to have a correct look, building a technical, coherent, ethical and cost-effective Role, very far from what we have today. If the discussion continues in its current form, everyone will be harmed; operators, users and the SUS itself, which will have to encompass more millions of people excluded from supplementary health.