Single line for ICU beds? Proposals to close the account of inequality between SUS and health plans – Época Negócios

With ICU beds in Brazil reaching full capacity, the country will need to find alternatives to receive critically ill patients with covid-19, a disease caused by the coronavirus.

Experts speak of creating a “single row” of beds in public and private systems, or otherwise “loans” of some private beds by the public administration, since there is a large imbalance between the proportion of users and beds in both systems.

+ Podcast: the vaccine in development by Brazilian scientists

know more

As of Wednesday (04/22), there were more than 45,700 cases and 2,900 deaths in the country due to illness caused by the virus.

Isolation and social distance were imposed throughout the world and in the Brazilian states to try to save time and prevent the system from reaching this point and becoming overloaded.

But hospitals in different regions of Brazil are already experiencing overcrowding in ICUs. This is serious because intensive care units provide the care that covid-19 patients in the worst situations may need to survive. The lack of beds in Italy, for example, forced doctors to choose patients with better chances of survival.

So what are the mechanisms to keep enough beds in the ICU for the number of severe cases of covid-19 in Brazil?

BBC News Brazil spoke to experts to understand what are the practical alternatives for this in Brazil and how they would work.

Health system in Brazil
To understand the problem of distributing hospital beds in Brazil, it is necessary to first understand the Brazilian health system.

Brazil has SUS (Sistema Único de Salud), a universal public health system that provides free support to all the approximately 210 million Brazilians, and complementary health, represented by health plans.

According to data from the Supplementary Health Agency (ANS), in early 2020, 47 million Brazilians had health plans. The number represents almost a quarter of the population, which pays for care and hospitalization in private hospitals. Still, users of the health plan still retain the right to access SUS benefits.

Taking into account that more than three quarters of the Brazilian population depends solely on SUS and compares the number of beds in public and private services, it is easy to understand why there is an imbalance in access to services in Brazil.

Consider the number of ICU beds. Brazil has 55,101 of these beds, according to the Ministry of Health. Of this total, 49.8% are from SUS.

In other words, three quarters of the population have access to only half of the ICU beds in Brazil. The other half is reserved for a quarter of the population with health insurance.

It does not necessarily mean that they are insufficient. “In the absence of the epidemic, the dimension we have of SUS beds would, in general, be sufficient,” says Pedro Amaral, professor at the Department of Economics at the Federal University of Minas Gerais (UFMG), who studies the regional distribution of supply. of health teams in Brazil.

With the epidemic, history changes. Now, with the “great additional demand that the system is suffering, the fat from the bed supply, where there was fat, because many places do not have it, is over or will end,” says Amaral. “And the public health system reaches its capacity much faster than the private system.”

Another problem, Amaral points out, is the distribution of beds.

According to a survey carried out by the Institute for Health Policy Studies, almost 15% of the Brazilian population that depends exclusively on SUS does not have beds in the ICU in the region where they live.

In Amazonas, for example, there are only ICU beds in the capital Manaus. The occupation of ICU beds for covid-19 in the city has already reached 100%.

The Ministry of Health says that 3,000 fast-installing ICU beds in Brazil are under leasing. But the portfolio has not disclosed the rate of ICU bed use in public or private hospitals. However, it reports that prior to the pandemic, the bed occupancy rate was 78%.

Only States are updating ICU bed occupancy numbers, but not always on a daily basis. The São Paulo State Health Department, for example, announced on Friday (17) that the Emílio Ribas Institute of Infectology reached 100% occupancy in its ICU; Hospital das Clínicas, 84.5%, Mário Covas, 89%.

The state’s health secretary, José Henrique Germann, said last week that the folder estimates that public hospitals in the state will be filled from May, and that the new beds to be installed will be occupied in July.

Single row of beds
That is why specialists advocate a single line for ICU beds.

The idea, defended so far by at least two academic groups studying the health insurance market in Brazil, would be to use the power, provided by law in this case, to request “goods and services” (paying subsequent compensation) to unify the beds. ICU of the public and private network.

The seriously ill covid-19 patient who needs a place in the ICU would enter a single row of beds, regardless of whether he is a public or private user. It would work more or less as the National Transplant System works. The resources would be coordinated by the public system, which would pay the private sector for it.

The method was already used in other countries during the coronavirus pandemic. In Spain, for example, the government has provisionally nationalized all private hospitals.

In Brazil, the proposal is defended by the Study Group on Health Plans, linked to the University of São Paulo (USP), and by the Research and Documentation Group on Health Entrepreneurship, at the Federal University of Rio de Janeiro ( UFRJ).

“Brazil has a sophisticated private medicine for very few. At the moment, these resources must be better distributed,” says São Paulo state doctor Ligia Bahía, a professor at UFRJ who is defending the proposal. “We will correct this inequality, considering that we are in a health emergency.”

“The idea is that all critically ill patients have the same chances of receiving intensive care. Most of the ICU beds in Brazil are not public. People without health insurance will die without care.”

She admits that the proposal will hardly be adopted, due to the lack of interest from the private sector. For this reason, he says, the group has reached out to state prosecutors and courts of law.

For UFMG’s Amaral, it is necessary to face the pandemic as an “absolutely non-standard shock in the system, totally atypical”. So “it makes sense that the solution is atypical.”

And he adds that “it is not even that unusual”, since there is already a single line for emergencies. “If a person comes to a private hospital in an emergency, they should be cared for, at least until they stabilize and transfer. We have to consider it as an emergency. If it is an emergency, the queue is unique,” he says.

However, it considers that this solution is a short-term solution, which does not solve everything, since the regions outside the large centers, with a population dependent on the SUS, have, in any case, few private beds.

“The spatial distribution of the private network is market-oriented. If the population does not have the income to pay for health insurance, the private network does not offer services there because there is no public,” he explains. The ideal solution, according to him, would be the expansion, by the public administration, of the number of beds and human resources, since “it does not make sense to have beds if there are no health professionals to operate them,” he recalls.

The executive secretary of the Ministry of Health, João Gabbardo, has already stated that the Ministry of Health was monitoring public and private beds. The Minister of Health dismissed by President Jair Bolsonaro (without party), Luiz Henrique Mandetta, had also stated that if SUS needed more private beds, it would use them.

One of the covid-19 outbreaks in Brazil, the State of Ceará began using a private hospital that had been closed for 20 years. The Pernambuco State Health Department has also reached agreements with private hospitals to obtain new beds, and the Health Secretary, André Longo, has already said that the State can request beds.

Mixed system
A second proposal for stagnation in the number of ICUs is a kind of mixed system: transfer only part, and not all, beds from the private system to the public system.

This is what the defender Frederico Barbosa, regulatory consultant and specialist in public-private partnerships of the BPGA firm defends.

The idea is to create “equity” in this system that is uneven. In other words, a measure that guarantees beds proportional to the number of users of each system. In this model, 75% of the total beds available in the two systems would be for SUS and 25% for the private network.

This means that SUS would “borrow” only the number of beds needed from the private system to meet its demand. A proportional waiting rule would be established in the SUS and the health plans.

“It is much less traumatic to transfer additional service capacity to SUS than to create a single line,” says Barbosa. “Whoever has a health plan does not even know what public hospital to look for. It is a complex problem to create a totally public health system overnight, which is a conversation that Brazil still needs to have: if it is going to create a system public health or keep this system competitive today. “

In addition, he says, health plans “have a much greater strategic vision of the hospital’s service capacity, where there are no vacancies, where there is a surplus, you know the capacity of the hospital that you have hired for years, you already have the map ready for it ” facilitating this transfer of beds.

In addition to transferring ICU beds to the public system, it is also necessary, as already seen in the Union and in many States, to increase the number of ICU beds. This can be done by reorganizing the hospital structure of private hospitals, many with spaces now less occupied due to cancellation of surgeries.

Therefore, the next step, in Barbosa’s opinion, would be SUS and health plans to buy hospital capacity together. “We would create working groups adding the capacities of the health plans and the SUS. The beds they obtained would be distributed in a proportion that would represent equity in the tail of each one,” he says. “We would regulate competition in times of scarcity.”

Through a partnership between SUS and health plans, both would be better able to negotiate with private hospitals, reducing the costs of each ICU bed. “If the government goes directly to private hospitals to get beds, it will have to pay the price that health plans would pay.” For this reason, he advocates that local governments seek health plans. “If you talk to 30 health plans, you solve 90% of the problem.”

For him, however, health plans are not interested in the conversation: the government would have to force them to negotiate. “Much more money is spent to get an additional bed. It is easier for the health plan to say that it does not have capacity. Forcing the negotiation and placing the systems in the same waiting hierarchy can prevent health plans from being omitted and forcing them to expand capacity. “

“This will be essential for the return (to normal) of the country. The availability of the ICU will set the pace of return. Imagine if private hospitals undergo plastic surgery again instead of caring for patients with covid-19? Suffer damage cheaper for longer. The more the capacity to care for patients with coronavirus increases, the higher the country’s performance. ”

Did you like our article? Click here to subscribe to our newsletter and receive more content.