Uso da rede pública de hemodiálise pelo beneficiário de plano privado de assistência à saúde: 2012 a 2019

Abstract

Introduction: In the Brazilian health system, beneficiaries of private health care plans use the Unified Health System (SUS), even for procedures covered by their care contracts. When provided for in the contract, this assistance must be reimbursed by the health operators, with hemodialysis being the most frequent outpatient procedure that mobilizes the greatest financial volume of this reimbursement. Objective: To investigate the association between the trajectories of beneficiaries of private health care plans who underwent hemodialysis in the SUS, between 2012 and 2019, and the characteristics of their contracts, the type of operators and the region of assistance provided to them. Method: An individual-centered database was constructed from data on reimbursement to the SUS provided by the National Supplementary Health Agency (ANS). Information on existing beneficiaries in Brazil was consulted with the ANS Tabnet. In the case of the characteristics of the contracts and the modality of the operators of the beneficiaries who underwent hemodialysis in the SUS, the raw frequencies were standardized by age and sex, using the direct adjustment method. Frequency distributions were used to summarize the data. To compare frequencies, the ratio between them was used. Results: A total of 31,941 beneficiaries underwent hemodialysis at SUS within the period studied. About 35% of the beneficiaries underwent hemodialysis outside their municipality of residence and more than 20% of the beneficiaries used the SUS for 25 months or more. The frequency of beneficiaries entering the bank for reimbursement to the SUS showed a downward trend within the period studied, assuming a lower value in 2015 (2.13 thousand). However, the chronic hemodialysis care provided by the SUS to at least 70.22% of beneficiaries should have been guaranteed by the operators. If compared to the other existing beneficiaries in Brazil, the beneficiaries who underwent hemodialysis in the SUS were more often linked to old contracts (ratio=2.41), collective adhesion (ratio=1.76), individual/family (ratio=1, 36), with outpatient segmentation (ratio=4.66), municipal coverage (ratio=3.88) and/or philanthropic operators (ratio=7.32). A total of 90.81% of the beneficiaries had a continuous trajectory and, among these, those linked to old contracts, without the provision of franchise, state coverage and/or self-management operators, compared to other beneficiaries of the same trajectory, were more frequent in the time of SUS use of 25 months or more. Regardless of the type of trajectory, beneficiaries assisted in the South region were more frequent in the time of use of the SUS up to 3 months and those linked to individual/family contracts were more frequent in the time of use of the SUS of 25 months or more, when compared to beneficiaries in other regions of the country and with other types of contracting. Conclusion: The charge for reimbursement to the SUS may have been an important tool in inducing health operators to assume at least part of the responsibility offered in the contract with their beneficiaries who underwent hemodialysis in the public sector in that period. On the other hand, the SUS Reimbursement Valuation Index may have lost, over time and to a certain extent, its importance and capacity for economic correction on a gradually outdated public table. Thus, the obligation to reimburse the SUS, sometimes, may have a balanced and even advantageous cost/benefit, being insufficient to discourage the use of the SUS network as a complement to the network of health operators. The region of assistance, some characteristics of the contracts of private health care plans and the modality of the operators may have meant additional restrictions on the access of beneficiaries who underwent hemodialysis in the SUS to the health networks accredited in their plans, to the point of having influenced their trajectories in the public network, either in relation to the number of periods/breaks (continuous or discontinuous trajectory) and/or the total time of use of the SUS. However, even with more restrictive characteristics in relation to access to hemodialysis, private health care plans may be sufficient for their beneficiaries to perform simpler and cheaper procedures, offering them a certain advantage over other SUS users and accentuating inequalities. access within the Brazilian health system. In this way, the expansion of affordable private health care plans, with lower monthly fees and restricted coverage, may not be a good justification for unburdening the public network, much less for balancing the public-private relationship in its most expensive part because, when the beneficiary needs a more expensive procedure, he may end up being induced to use the SUS.