The Evolution of HTA in Emerging Markets Health-Care ... - TREE

OHE Consulting Report for PhRMA
5 January 2011
Currently, services are offered by more than 64,000 primary care units (performing 2.7 billion
ambulatory visits per year), and 5,900 hospitals (performing 12 million hospital admissions).
Providers are paid on a fee-­‐for-­‐service basis for ambulatory care, including outpatient visits, exams
and ambulatory procedures. Currently, there are a large number of procedure codes for these
services in SUS. For inpatient hospital care and for cancer treatment, facilities are reimbursed under
a prospective payment system, using diagnosis-­‐related groups (DRGs). Hospital providers, including
physicians, are usually paid a salary.
A1.3 Private Health Care System
Financing
Most of the financing for private insurance comes from employers and employees, who pay for
different shares of private insurance costs. Individuals may also purchase individual health plans out
of pocket. The maximum value to be charged for individual health plans is regulated by the National
Agency for Supplementary Health (ANS). The premiums charged to companies for executive health
plans are not regulated and open to negotiation between private HMOs and companies. That is why
most HMOs are stimulating the growth of executive plans instead of individual plans.
ANS also defines the prohibition of HMOs to refuse coverage for any patient due to their risk profile.
Premiums may vary by age for individual plans.
Provision and Reimbursement
ANS defines every two years the list of procedures covered by private payers. As a general rule, all
treatments registered in Brazil for the indications covered by International Classification of Disease
codes and provided in ambulatory or in-­‐hospital should be reimbursed by HMOs. Treatments
received at home and oral drugs are not covered by the private system. Originally, when this rule
was created, it did not cover drugs for high cholesterol, hypertension, etc., that could be purchased
by patients out of pocket. There is now a controversy over oral drugs for oncology treatment due to
their high cost and the impossibility of most patients to pay for these treatments out of pocket.
Provision of services is through private hospitals and outpatient clinics that are dedicated providers
to specific HMOs. Providers may be dedicated to more than one HMO, which is the usual practice.
Individual physicians may also own their offices and provide outpatient visits to patients. In the
majority of cases, services are charged on a fee-­‐for-­‐service basis. The reference reimbursement
values for exams and surgical procedures come from reference lists like the Brazilian Hierarchical
Classification of Medical Procedures (CBHPM) and the list of the Brazilian Medical Association
(AMB99).
Drugs and materials are reimbursed based on their listed Maximum Prices to Consumer registered
by the Chamber for Regulation of the Pharmaceutical Market (CMED). Discounts over the reference
values may be negotiated between HMOs and providers on a case-­‐to-­‐case basis.
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