On the eve of carnival, the run-up to Lent, the Supreme Court resumed and had already set aside a decision on whether the role of the ANS was exhaustive or exemplary. And it stirred up social media, whatsapp groups, discussion forums about health and law, politics, in short, Brazilian society.
The role of the ANS was a tool created to prevent barbarism. Let me explain: health care is a sector in which there is information asymmetry. This means that the actors that make up this system have very different levels of information about each other, that is: one knows a lot about what the other knows nothing about. To this, which creates a distortion in the balance of power and benefits one actor at the expense of another, the founding paper of the 1970s by the founder of the science of regulation, called the lemons dilemma.
To ensure that healthcare operators do not offer an asymmetrical and under-provisioned range of procedures and technologies to their beneficiaries, the legislation has rightly set a common minimum for all products offered in the complementary healthcare market to set a floor below which no plan can fall in terms of coverage. And so far everyone has agreed…
However, technology in the healthcare world is advancing at Bolt’s pace, with new and promising technologies being introduced to the global healthcare market every month. Naturally, what is reasonable today, from the point of view of the minimum role, tomorrow is already below the acceptable level. But the fact is that health, although priceless, has a price. And this cost in a mutual system like our extra health is proportional to the monthly fee that everyone pays. And besides, in order to calculate the amount payable based on the opinion of the actuary (who is the guy who calculates the risk of this portfolio), health insurance companies need to have a very realistic idea of what they will have to do. offer for those who buy their products.
In other words, in the culinary analogy, to make a cake, you need to know what ingredients the recipe contains so you can calculate how much of each ingredient you will buy. And based on that, if you figure out some price to resell it. The problem arises when you don’t know how many pieces of cake you need to bake and whether you need to add chocolate icing, confetti, or some special topping. In case of uncertainty about this, the confectioner tends to assume that there will always be additional, unpredictable costs that will arise in the middle of the process. And to try to ensure its economic viability, it will tend to raise its resale price.
Proponents of the exhaustive role argue that it provides security and predictability to the contracting party, in this case the patient, and the contracting party, represented here by the operator. And that by not doing this, both are in danger, because if you don’t know what the rules of the game are, you can’t judge; and in the face of this, in an attempt to price with some confidence, either you will charge more than is actually necessary, or you will not be able to guarantee contractual services, because medical companies will eventually go bankrupt.
Those who favor an indicative list argue that this is just a starting point, a minimum threshold, just a general reference and that if the beneficiary needs a treatment not covered by the original contract, the operator is obliged to include this, immediately, to what is provided by the contract plan .
Both are right in essence, but wrong, in my opinion, in the premise of the discussion. After all, it is important for the patient to see how his health problem, once identified, is best dealt with in a plan that is best suited to his pocket.
It is important for a health care operator that its provider offers the beneficiary the best possible outcome at a lower unit cost. Service providers have a vested interest in providing the best possible care, creating value for their patients, and being paid proportionately and fairly for their work. Society, in fact, is interested in the sustainability of the complementary health ecosystem. When we advocate exhaustive or exemplary, what we really want is for us to have a role, above all a decisive one.