Health Plan Operators Research Articles

Como a judicialização da cirurgia de implante coclear impacta o Sistema Único de Saúde

ABSTRACT Purpose To describe the impact of Judicialization on the performance of Cochlear Implant (CI) surgery in the Brazilian Unified Health System (SUS), including the public service and supplementary health. Methods A documentary survey of judgments of all National Courts and the Dominant Jurisprudence focused on CI surgery in the SUS from 2007 to 2019 was carried out through the Jusbrasil Platform using the term “cochlear implant” to carry out the search. A survey was also carried out on the DATASUS platform on how many uni and bilateral CI procedures were performed in the same period. Results According to DATASUS, from 2008 to 2019, 8,857 CI surgery procedures were performed by Public Entities or Health Plan Operators in the country. With regard to Judicialization, for requesting unilateral or bilateral CI surgery, a total of 216 processes were found, representing a total of 2.43% of Judicialization of Cochlear Implant (CI) surgery. Conclusion In view of the data, it is possible to perceive that the Judicialization of Health when we consider the CI surgery has represented a small portion of the cases, which does not demonstrate a large impact on the public budget and does not have an impact on the organization of the SUS.

Women’s voice on changes in childbirth care practices: a qualitative approach to women’s experiences in Brazilian private hospitals participating in the Adequate Childbirth Project

BackgroundIn Brazil, childbirth practices are strongly marked by surgical events and particularly in the private sector cesarean sections reach rates above 80%. The National Supplementary Health Agency proposed the Adequate Childbirth Project (PPA), a quality improvement project developed at Brazilian hospitals with the aim of changing the current model of childbirth care and reducing unnecessary cesarean sections. The objective of this study is to assess how the participation of women in the process of improving quality childbirth care occurred in two hospitals participating in the PPA.MethodQualitative study, based on interviews with 102 women attended at two hospitals that took part in the first and second stages of the “Healthy Birth”, an evaluative hospital-based research, conducted in 2017–2018, that assessed the degree of implementation and the effects of PPA. After thematic content analysis, supported by MaxQda software, three categories emerged: (1) how women gathered knowledge about the PPA, (2) how women perceived it, and (3) which are their suggestions for the PPA improvement.ResultsThe PPA was unknown to most women before delivery. A polysemy of terms, including adequate childbirth, promotes recognition of the “new” model of care. Visits to the maternity hospital and antenatal care groups for pregnant women are opportunities for contacts that change the perception of what childbirth can be. Women have expectations of a relationship with maternity that is not limited to the moment of delivery. The listening channels established between hospitals and women are fragile and not systematized. By increasing the supply of listening spaces, one can also increase the request to leave their suggestions and contributions, and thus gain more allies in improving the project. Women are not yet included as PPA agents and their voices are silenced.ConclusionsWomen’s participation to improve childbirth care is relevant and necessary. The women’s voice in the PPA is still incipient, and maternity hospitals and health plan operators should create strategies to insert and engage them. Women’s voices should be listened to not only during but also before and after childbirth.

Performance of health plan operators: before and during the pandemic

Objective: To analyze the economic-financial and operational performance of Health Plan Operators (HPO), before (3Q2018-4Q2019) and during the pandemic (1Q2020-2Q2021) under the theory of institutional isomorphism.
 Method: This is descriptive documentary research that uses statistical techniques to compare medians (Wilcoxon and Kruskal-Wallis) and correlation (Spearman) between performance and socioeconomic indicators, considering the five Health Plan Operators (HPO) with the largest number of beneficiaries.
 Results: A statistically significant reduction was observed, after the beginning of the pandemic, for the indicators of profitability, expenses, cost variation, and financial result. On the other hand, there was a growth in current liquidity and an increase in the mean receipt timeframe of payments (CRPM) and event payment (APTE). The performance comparison shows that in the pandemic, profitability and APTE were no longer significantly different. As for the association between the variables, the unemployment rate shows the highest number of relationships with the performance levels.
 Theoretical/methodological contributions: Highlights the performance of the five largest OPS, considering the Sars-Cov-2 pandemic period, considering that these companies can be directly affected by the potential increase in demand for health care by their beneficiaries. By the theoretical prism of institutional isomorphism, these companies are references for the sector.

NECESSIDADES DE SAÚDE DOS IDOSOS FRENTE À COVID LONGA E O ACESSO AOS SERVIÇOS DE SAÚDE

ABSTRACT Objective: to understand the health needs of aged people who had long Covid-19 and details about access to the health system to meet these demands. Method: an exploratory and qualitative study carried out with 41 aged individuals who had Covid-19 in 2020 and presented residual symptoms 18 months after the infection. Data collection took place between February and July 2022 through semi-structured interviews via telephone calls. In the analysis, initial and focused coding analytical techniques were used and the conceptual basis was grounded on the Primary Health Care “Accessibility” attribute. Results: four categories emerged when analyzing the results, namely: Understanding the need for professional care; Recognizing the demands that led aged people to seek health services; Understanding availability of the services; and Analyzing payment capacity. Conclusion: the aged population has developed specific health demands related to long Covid-19, and public and private health services are heterogeneous in their approach to this new condition, as care based on guidelines proposed by official bodies is not unanimous in public and private services and Health Plan Operators.

An appraisal of Brazilian private health plan operators’ economic-financial conditions: a note on finance and regulation

Objective: This study aims to evaluate the economic-financial performance of Brazilian private health plan operators and investigate possible sources of relative variations in the studied indicators. The article also discusses the question of regulation based on an economic-financial analysis of the regulated entities.
 Methodology: this is an empirical, analytical study with analysis and inference based on secondary data. The methodological base of the article is comprised of standardized economic-financial indicators, indicators adapted to the operational specificities of private healthcare plan operators and multiple range tests. The database in panel form was elaborated using information published by the National Private Healthcare Regulatory Agency and refers to a sample containing the fourteen largest health plan operators in activity in Brazil.
 Results: It is concluded that the health plan operators are well-situated in economic-financial terms and that the form of corporate organization, the relative size of the market and the operators’ regional markets have a significant influence on their performance. It is considered opportune to discuss whether the current regulatory model for private health provision in Brazil is adequately fulfilling its declared objective of ensuring the continuity of service while charging reasonably modest rates.
 Study contributions: the study contributes by showing how a relatively simple technique can benefit not only the regulatory process but also the evaluation of the regulation itself. It further contributes by revealing that the healthcare plan operators in Brazil are in a good situation in economic-financial terms thereby raising the question as to whether the current regulatory model for private health provision in Brazil is adequately fulfilling its declared objective of ensuring the continuity of service while charging reasonably modest rates.

Economies of Scale in Brazilian Supplementary Health

Low profitability has been responsible for the insolvency of a large number of health plan operators (HPO) in recent years, which increasingly requires these entities to assess which services can be optimized without compromising their final activities. An answer to this problem may lie in the adequate dimensioning of support activities. Therefore, the aim of this study is to investigate the economies of scale in the support activities of Brazilian HPO. In the presence of such economies, it can be considered that operators have room to dilute their administrative expenses, suggesting that profitability can be increased without the need for large price increases, which can guarantee the survival of companies in the sector without penalizing their customers. For this purpose, panel data regressions with Random Effects (RE), Fixed Effects (FE) and pooled were estimated, considering 5,185 observations for the period 2011 – 2018. The results found by estimating the total cost function were favorable to the hypothesis of economies of scale in the supplementary health sector. Finally, it was also possible to verify that the type of operator and the geographic location of the administrative headquarters of these entities contribute to the scale effect to a greater or lesser extent. These results show that the economies of scale existing in the sector can significantly contribute to the operational and financial maintenance of various HPO, providing an alternative to mitigate the low profitability of these companies.

Determinants and the Impact of COVID-19 Pandemic Crisis in the Continuity of Cooperative Health Plan Operators Through Liquidity

This research investigates Brazil's cooperative health plan operators (CHPOs) from the perspective of continuity in terms of liquidity ratios. The principle of continuity presupposes the going concern basis of the entity where liquidity is a critical issue. A detailed study of CHPO's financial accounting statements was made from a quarterly database from 2018 to 2020 to investigate this phenomenon. Two broad research questions were investigated. The first focuses on identifying the impact of ROA, debt ratios, and the surplus in the liquidity ratios, a crucial aspect to evaluate the going concern basis of CHPOs. The second avenue of research studies the effect of the Covid-19 pandemic crisis on liquidity and debt to equity ratios from CHPOs. Methodologically, a fixed-effects panel and a difference-in-differences model were used to measure the determinants of liquidity ratios and impacts of COVID-19 on CHPOs, respectively. The results pointed out a positive effect of ROA, debt-to-equity ratio, and surplus of CHPOs' liquidity, reinforcing their crucial role in the continuity of these health operators. Additionally, the impact of COVID-19's findings remarks on the significant positive effect of the sanitary crisis on the finances of the CHPOs.

Desempeño financiero del sector suplementario de salud

O mercado de saúde suplementar no Brasil é regulado pela Agência Nacional de Saúde Suplementar. Dentre suas atribuições, cabe à Agência promover a defesa do interesse público na assistência suplementar à saúde e contribuir o desenvolvimento das ações de saúde no País. Para cumprir suas atribuições, o regulador deve manter base de informações continuamente atualizada. Ainda que não regule diretamente os preços no mercado, a Agência deve acompanhar o desempenho financeiro de operadoras de planos de saúde - OPS. Este estudo traz uma análise da rentabilidade de 14 OPS no Brasil, no período de 2007-2016, por meio da técnica de decomposição da variância do retorno sobre ativo. A modelagem baseia-se no estudo pioneiro de Schmalensee(1). Foram testados quatro efeitos: abrangência, bandeira, corporativo e ano. A inovação mais importante do estudo consiste em introduzir o efeito abrangência como proxy para ganhos de escala e/ou de escopo na atividade. Constatou-se que o efeito abrangência é consideravelmente mais importante para a rentabilidade das operadoras, seguido do efeito bandeira; o efeito ano foi significativo, mas relativamente inexpressivo; por fim, o efeito corporativo foi estatisticamente insignificante.

Prenatal care for normal-risk pregnant women by obstetric nurses and midwives: cost-effectiveness from the perspective of the Supplementary Health System in Brazil

In several countries, primary care for pregnant women is performed by obstetric nurses and/or midwives. In Brazil's Supplementary Health System (private health insurance and out-of-pocket care), coverage of prenatal care is mandatory and is performed by medical obstetricians. The objective of this study is to conduct a cost-effectiveness analysis, comparing clinical outcomes and costs associated with the incorporation of prenatal care by obstetric nurses and midwives in the Supplementary Health System, from the perspective of the operator of health plans as the payment source. A decision tree was built, based on data from a Cochrane Collaboration meta-analysis that showed a reduction in the risk of premature birth in the group of normal-risk pregnant women accompanied by obstetric nurses and midwives. The analysis only considered the direct medical costs covered by health plan operators for essential appointments and tests, according to the prevailing Ministry of Health protocol. The study assumed equal unit costs of consultations by medical professionals and applied an increase in the overall cost of prenatal tests associated with medical follow-up, based on data from the literature. Incremental cost-effective ratio was estimated at -BRL 10,038.43 (savings of BRL 10,038.43) per premature birth avoided. This result was consistent with the sensitivity analyses, with savings associated with the substitution ranging from -BRL 2,544.60 to -BRL 31,807.46 per premature death avoided. In conclusion, prenatal care provided by obstetric nurses and midwives was superior to that provided by medical obstetricians for the prevention of premature birth, besides resulting in cost savings.

Determinants of leverage and regulation: an analysis in dental health plan operators

Purpose – This paper examines the determinants of debt levels of Brazilian dental health plan operators (OPS) under the National Supplementary Health Agency (ANS) regulation.Design/methodology/approach – It is an empirical article based on quantitative and causal research. The sample consisted of data from 2010 to 2018 available on the ANS website. The techniques of content analysis, descriptive statistics and panel regression were used for data analysis.Findings – We found that several variables related to the ANS regulation influence dental OPS debt levels. Furthermore, there are also several similarities between the two categories under analysis: dental cooperatives and group dentistry, despite the differences in the legal nature of such organizations.Research limitations/implications – The present study suffers from some limitations: (a) the sample investigated is restricted to OPS public data; and (b) regulation variables are limited due to the data available for calculation, despite our efforts to show otherwise.Originality/value – The present research offers a range of contributions to the literature on dental operators’ capital structure. Firstly, it emphasized the impact of regulation in dental operators’ financial decisions in Brazil. Moreover, it confirmed the important role of companies’ determinant variables of capital structure in explaining OPS debt levels. Lastly, the study introduced regulatory variables as determinants of OPS debt ratios.

Modelo de insolvência aplicado a organizações cooperativas médicas: análise do mercado brasileiro

As cooperativas médicas Operadoras de Planos de Saúde brasileiras, estão sujeitas, como toda e qualquer Operadora de Plano de Saúde, aos riscos inerentes ao mercado de Planos de Saúde Suplementar, além de uma rígida regulação deste segmento tão importante aos brasileiros. Nesse contexto, o presente artigo, tem como objetivo identificar dentre os modelos de insolvência comumente aplicados às empresas, qual teria o melhor desempenho em prever a Insolvência de Cooperativas Médicas Operadoras de Planos de Saúde. Como base de dados, foram utilizadas as demonstrações financeiras das Cooperativas Médicas Brasileiras que enviaram dados à Agência Nacional de Saúde (ANS) no período de 2010 a 2017, totalizando a média de 310 instituições por ano. Foram aplicados 6 modelos clássicos de previsão de Insolvência. Como resultado, os modelos com melhor desempenho, foram: O proposto por Matias, Altman, Baidya e Dias e em seguida Guimarães e Alves. Os modelos apresentaram forte equiparação de análises focados no trabalho com destaque para o modelo que tinha tecnicamente regressão logística direcionado a análise de Operadoras de Planos de Saúde (OPS). Porém apresentando baixa sensibilidade em classificação de insolventes, necessitando analisar este outro ponto com outro modelo mais aderente ao processo.

Managed care and innovation in healthcare management: a Brazilian experience

ABSTRACT This work analyses how Brazilian health insurance operators and hospitals apply Managed Care (MC) and innovation-related criteria upon managing healthcare operations. Four health plan operators and two internationally accredited hospitals in Southern Brazil were analysed. Semi-structured interviews were performed with managers appointed by the selected organisations. A framework based on MC and innovation management criteria was used as a reference for data collection. The surveyed hospitals have shown to be more compliant with the MC criteria whereas the surveyed health plan operators are less compliant to these criteria. The highest compliance rate for both types of organisations was on the management of medical services criterion. No evidence was found about adoption of the selected concepts of innovation in healthcare management. MC and Innovation criteria may produce an integrated focus on the client (patient), considering a systemic view of the value chain and of innovation in healthcare management as ways of increasing the quality of services provided while reducing costs. Managers would have benefited from taking this approach.

O AVANÇO DO COVID-19 E SEUS REFLEXOS NO ROL DE PROCEDIMENTO DA AGÊNCIA NACIONAL DE SAÚDE REGULAMENTANDO OS PLANOS DE SAÚDE

O presente periódico teve por escopo averiguar a abrangência do COVID-19 e verificar as medidas que têm sido empregada no setor privado, especificamente nas operadoras de planos de saúde, possibilitando inclusive a constatação da importância da adstrição ao rol de procedimentos da Agência Nacional de Saúde - ANS. Essa produção foi elaborada por meio de periódicos que enfrentaram temática similar; sites de pesquisas e jornais informativos sobre o número de infectados e mortos, em decorrência do vírus; além de decisões judiciais de processos nos quais foi constatado o papel importante do Rol da ANS, bem como a necessidade de adstrição a este. Nesse sentido, são elencadas informações quanto ao número de mortos nos países e quais deles foram mais afetados. Igualmente, é demonstrado que os sintomas do vírus podem variar, ou mesmo, não se apresentar, o que contribui para sua rápida disseminação global, ensejando medidas preventivas e repressivas como informativos sobre o vírus, determinação de utilização de máscaras e de lockdown. O cenário da pandemia têm ensejado a implementação de medidas que também alcançam o setor privado, especificamente as operadoras de planos de saúde e ANS que as regulamenta. Assim, neste texto são citadas algumas das implementações realizadas pela ANS, no intuito de possibilitar amplo acesso àsaúde neste período, podendo-se inclusive constatar alterações no Rol de procedimentos obrigatórios que corroboram a importância da eficácia deste.

DETERMINANTES DO DESEMPENHO ECONÔMICO-FINANCEIRO DE OPERADORAS DE PLANOS DE SAÚDE

O desempenho econômico-financeiro de organizações é amplamente estudado em finanças. Entretanto, o desempenho econômico-financeiro das Operadoras de Planos de Saúde (OPS) brasileiras não tem o destaque que merece frente à sua representatividade para a população. O setor de saúde suplementar brasileiro movimenta, em termos de receita bruta, cerca de 132 bilhões de reais anualmente e é responsável pela cobertura de saúde de mais de 24% da população do país. Diante desse contexto, a presente pesquisa teve como objetivo analisar o desempenho econômico-financeiro das OPS, de diferentes características institucionais, com base em um conjunto de variáveis-chave. Para tanto, utilizaram-se as seguintes técnicas de análise: teste de Kolmogorov-Smirnov e teste de Kruskal-Wallis. Foram encontradas fortes evidências de que os indicadores econômico-financeiros estão relacionados, principalmente, com a modalidade das OPS analisadas. Esse resultado pode representar uma contribuição valiosa para a análise econômico-financeira de OPS, ao indicar que elas não podem ser avaliadas/comparadas conjuntamente, sem a separação por modalidade.

Relação entre Indicadores Financeiros e Não Financeiros das Operadoras de Planos de Assistência à Saúde

Objective: This study seeks to investigate the relationship between economic-financial indicators and non-financial indicators of Health Plan Operators (HPO) for the Health Qualification Program (HQP) of the National Health Agency (NHA) We analyzed the period from 2011 to 2014 to verify whether financial performance is determinant in terms of the operational performance of 916 Health Plan Operators during the following period and vice-versa. Method: Five statistical regression models were constructed based on Ordinary Least Squares (OLS) with robust standard errors. Originality/relevance: This article highlights the importance of the performance measurement system for Health Plan Operators from the perspective of regulatory obligations and the possibility of citizens/users effectively using these indicators when they choose their health plans. Results: The results confirm that the financial index has a positive relationship with the non-financial indicators during the following period. An exception is the beneficiary satisfaction indicator, and in this case, the non-financial indicators were capable of explaining the financial index. Theoretical and methodological contributions: This study has the potential to raise new questions about the implementation of the Health Qualification Program and whether the Health Qualification Index (HQI) supplies significant informative content to inform the selection of health plans by future beneficiaries.

Aplicação do Analytic Hierarchy Process na escolha de planos de saúde

O mundo contemporâneo em que vivemos nos leva a um ritmo de vida de constante movimentação e necessidades diversificadas, com isso, quando se trata de atendimento médico, as necessidades são muito diversificadas. Por esse motivo, quando se está procurando um plano de saúde, é preciso analisar diversos fatores para se tomar uma decisão, como uma cobertura que funcione com o estilo de vida pessoal e familiar, quantidade de unidades de atendimento disponível, localização destas unidades, e, uma relação custo benefício atrativa. Este artigo tem por objetivo apresentar uma proposta de abordagem para identificar fatores que usuários julgam como mais relevantes na escolha de um serviço de plano de saúde. O método multicritério Analytic Hierarchy Process (AHP) foi utilizado para auxiliar a identificação de fatores relevantes empregados na seleção de planos de saúde. E, como unidade de pesquisa foi realizada uma aplicação com um grupo de pessoas usuárias, com a intenção de compreender as perspectivas enquanto tomadores de decisão. Como resultados, ao ser feita uma análise de sensibilidade dinâmica, observou-se que os fatores considerados mais relevantes no momento da tomada de decisão foram qualidade e a rapidez no atendimento, estas receberam os maiores pesos, 33,9% e 23,6%, respectivamente. Abordagem proposta fornece uma importante ferramenta de planejamento e operação a empresas operadoras de planos de saúde, que, a partir disso, têm possibilidade de examinar quais fatores são considerados mais importantes nas visões do usuário e, assim, formular estratégias competitivas e posicionamento de mercado.

A governança de tecnologia da informação em operadoras de planos de saúde suplementar no estado do Ceará

As organizações modernas dependem cada vez mais da tecnologia da informação (TI) para suportar seus processos transacionais e suas estratégias de negócio. O objetivo deste artigo é avaliar os impactos da implantação da governança de TI no segmento de operadoras de plano de saúde (OPS) com sede no estado do Ceará como suporte para o atendimento às normas da Agência Nacional de Saúde (ANS), por meio de estudo de caso qualitativo de finalidade descritiva e aplicada. O referencial teórico baseou-se na revisão da literatura sobre frameworks importantes de governança de TI aplicados no mercado de saúde suplementar no Brasil e a regulação imposta pela ANS no tocante à TI. Foram realizadas entrevistas semiestruturadas com os gestores de TI e das áreas usuárias de TI destas empresas. Os resultados foram obtidos a partir da triangulação das entrevistas, observações diretas e análise documental, cujas evidências foram tratadas pela análise de conteúdo. As conclusões indicaram que a governança de TI tem forte impacto na qualidade e planejamento no atendimento às normas da ANS, mas as operadoras pesquisadas ainda não utilizam todo potencial disponível, com vários níveis de maturidade e muitas oportunidades de evolução.

Cost-effectiveness analysis of natural birth and elective C-section in supplemental health

ABSTRACTOBJECTIVE To conduct a cost-effectiveness analysis of natural childbirth and elective C-section for normal risk pregnant women.METHODS The study was conducted from the perspective of supplemental health, a health subsystem that finances private obstetric care, represented in Brazil by health plan operators. The reference populations were normal risk pregnant women, who could undergo natural childbirth or elective C-section, subdivided into primiparous and multiparous women with previous uterine scar. A decision analysis model was constructed including choice of delivery types and health consequences for mother and newborn, from admission for delivery to maternity hospital discharge. Effectiveness measures were identified from the scientific literature, and cost data obtained by consultation with health professionals, health plan operators’ pricing tables, and pricing reference publications of health resources.RESULTS Natural childbirth was dominant compared with elective C-section for primiparous normal risk pregnant women, presenting lower cost (R$5,210.96 versus R$5,753.54) and better or equal effectiveness for all evaluated outcomes. For multiparous women with previous uterine scar, C-section presented lower cost (R$5,364.07) than natural childbirth (R$5,632.24), and better or equal effectiveness; therefore, C-section is more efficient for this population.CONCLUSIONS It is necessary to control and audit C-sections without clinical indication, especially with regard to primiparous women, contributing to the management of perinatal care.

New services development: a study in the context of a health organization

PurposeThe purpose of this study is to highlight the understanding of the consequent factors of new services development (NSD) in the literature owing to the impact on organizational competitiveness, especially in professional services, such as that investigated by health plan operators in the present study.Design/methodology/approachThe sample (customer of family health plans) consisted of 255 valid cases. For the analysis of the data, multivariate statistical techniques were used through the modeling of structural equations.FindingsThe results found evidence of the significant relationships between the NSD considering the constructs, client orientation, reputation, professional competences and customer retention, as consequences of the NSD, which impact on the success of the new services launched by the health plan operator from the perception of the customer.Practical implicationsThis implies that health plan operators need to develop new customer-oriented services by investing in new technologies and having more trained and qualified staff so that they can deliver superior services and, as a consequence, have a more profitable relationship with customers.Originality/valueThe new services may result in greater organizational performance and greater competitiveness for health service providers.

Regulação dos serviços de radioterapia e quimioterapia pelas operadoras de planos de saúde no Brasil

This paper characterizes regulatory procedures applied by private health plan operators on their outpatient radiotherapy and chemotherapy services, especially via contracts, and outlines the health care providers’ perception on regulation. The study relied on primary data, taking into consideration 638 hospitals and outpatient health care units with the services in question. A stratified random sample was selected, resulting in the inclusion of 54 units that are representative of the population, excluding hospitals that only provide radiotherapy. Private chemotherapy services are largely funded by health insurance plans (75.0%), while radiotherapy services are predominantly covered by the public health system (49.0%). Contracts are not applied by third part payers, in their potential, as regulatory and health care coordination instruments. The mechanisms of regulation applied by third part payers are centered on services use control and administrative aspects. It is recognized the need of adjustments for a health care quality focus, and contracts may contribute in this sense.