Movement for the Professional Defense of Radiologists in Pernambuco, A Success Story

On several occasions I was asked how we managed to have a balanced relationship in the negotiations between the different private health plan operators and the Radiology class in Pernambuco. So that we can understand how we arrived at the results achieved, I will make a brief history here, contextualizing the various nuances that brought us to the current situation. According to the National Agency for Supplementary Health (ANS), supplementary health in Brazil emerged in 1956, when a polyclinic created a health plan to serve Volkswagen employees. After it, other health operators and insurers emerged, proving to be a growing market, since there was dissatisfaction with public health care, as well as with the various health institutes created by companies and state-owned companies. Supplementary health, from then on, only expanded. In the 1960s, the first health cooperatives in the country were born. On the initiative of the Brazilian Medical Association (AMB), in 1967, the first Unimed was created in the city of Santos SP, which later became a system spread throughout the country. With this growth in supplemental health, many people began to be interested in individual plans, even if they were not connected to a company. Then, insurers saw the opportunity to start investing in the health area – something that was actually only regularized in the 1980s. In 1998, with the creation of Law No. 9656, there was a regulation of supplementary health, formalizing responsibility of the operators, towards their beneficiaries. This legislation gave a certain order to the market. From 1998, the supplementary health sector grew again, this time in a more adequate way. In 2000, the ANS was born, which began to regulate the sector. However, the market had to “step on the brakes” again in 2014, when the country faced a serious economic and social crisis. With the increase in unemployment, reaching numbers never seen in the country, many users lost their health plans, because they were corporate collective plans or because they did not have the financial conditions to bear the costs of an individual plan. Speaking now a little about the reality of radiologists, in the 1980s and 1990s health operators realized that the growth potential of this market would be significant. During this period, there was an incessant search for the accreditation of several new services, including radiology services. At the time, there was a shortage of services in radiology and consequently there were good negotiations for diagnostic imaging services. However, the market was settling down and health operators realized that their service network was already adapting. When there was a need for expansion, they saw that in several situations, especially in large centers, there was a greater supply of radiology services than the real demand. Faced with this finding, health operators realized that they could make adjustments to the contracts with the various diagnostic imaging services, in part by reducing the amount paid for the services or even not offering readjustments. We have reports from colleagues who claimed to be approached by operators who requested a discount on the current values in order to renew the contract, with the argument (threat) that if they did not want to, there would be those who would accept that value. In a capitalist society competition has existed and will always exist. The field of radiology has always shown to be a promising and lucrative market, an aspect that, among other reasons, has led many physicians to work in this area and even investors in related areas, who understood that it would be interesting to set up radiology services. Services proliferated, mainly in the capitals and larger cities, until reaching a point where the offer would be greater than the demand. Beginning of the new radiology movement in Pernambuco - 2013 Faced with this scenario and seeking their survival, several services began to negotiate with health insurance companies, making agreements with them that, although at first seemed to be satisfactory, would have a negative impact on the radiology market. This situation was part of the reality of several regions throughout Brazil. Noticing a decline in billing and in the adopted tables, a group of radiologists sought the Pernambuco Radiology Society (SRPE) in order to obtain information and guidance on what could be done. In this group there were representatives of several diagnostic imaging services. Some meetings were held when the following data were collected:

The. Inflation for the period between 2000 and 2012 - 125.55% b. Increase allowed by ANS for health plans - 170.78% c. Readjustment of health plan tables in this period - 0%

Everyone realized that that situation would be unbearable and that if no action was taken, several services would be closed, as well as the compromise of several jobs. We had already tried to organize ourselves in some way to try to counteract the leonine contracts offered by health operators, but we always ran into the obstacle where we could be identified as a cartel and consequently suffer serious legal and CADE sanctions. It seemed that we were at a dead end, when we became aware of a professional defense movement for the medical profession, led by the Union of Doctors of Pernambuco, in the person of our mentor Dr. Mário Fernando Lins, since that time, President of the State Commission of Medical Fees of PE (CEHM-PE). This entity also had in its formation the Regional Council of Medicine of Pernambuco, the Medical Association of Pernambuco and some professional medical societies. CEHM-PE had been having these negotiations directly with the Directorates of the health operators, representing the doctors (Individuals), who could not suffer legal sanctions or even be classified as a cartel, since they were exercising a legitimate right of the category to fight for better working conditions and pay. We were aware of some favorable negotiations for pediatricians, among other specialists. The Society of Radiology of Pernambuco met with the president and members of the honorary committee and requested guidance for negotiations in this category. The SRPE already had its Professional Defense Board, which promptly found out how the movement worked and brought the negotiation model to the category. Now follows a brief history of how this model of the commission of medical fees works and, in sequence, the benefits achieved for the category of radiologists in Pernambuco.

Phases: i. The Physicians' Union convenes an Extraordinary General Assembly (AGE) for the category, through a public notice published in a widely circulated newspaper, as per its statute II. Technical directors sign solidarity letter* III. Solidarity statement from the specialty society** IV. CEHM sends letters communicating the results of the AGE deliberations, with a deadline for response and date of the next AGE v. CEHM awaits responses to letters sent within the stipulated period SAW. Evaluation of proposals* in a new AGE *important: analysis of proposals by a professional with a background in finance and knowledge of CBHPM or tables of Health Plan Operators (OPS) VII. Beginning of the category's legitimate movement - under the Federal Constitution (CF) and the Code of Medical Ethics (CEM) VIII. Negotiations IX. Results evaluated in a new AGE for the category.

Start of movements in defense of our category (Radiologists): 2013 One of the pillars of the medical professional defense movement is to try our best to negotiate peacefully, always aiming to reach an agreement to avoid conflict. However, if the conflict is unavoidable, it is important that we try to resolve the impasses: one operator at a time! As of 2013, some actions were carried out as a result of difficulties imposed by the operators during the negotiations. There was a need to suspend calls to several operators, always, one at a time. To do so, we always gave prior notice that this could happen, safeguarding the care of urgent, emergency, hemotherapy, hemodialysis, oncology, hospitalized patients and the like. Initially, the operators did not think that we would reach the point of suspending elective care. And that's why they even refused to negotiate. With the start of the stoppages, several billboards and outbuses were placed in the city, articles in newspapers with wide circulation and even daily calls on the radio with the highest audience in the city explaining to users the reason for the suspension of service to a certain operator.   Subtitle: Example of billboard placed in Recife With these actions, we were approached by the operators to sit at the negotiation table and reach a fair agreement. In 2013 and 2014, there were some clashes, including lawsuits by operators against radiological clinics, but which were all withdrawn, as they realized that it was not the clinics that were suspending care, but the doctors (individuals), duly represented by the Union of Doctors of Pernambuco, through the State Commission of Medical Fees. As an initial result, in 2013 we had approximately 25% of readjustments in practically all areas of activity in diagnostic imaging. The accumulated until 2017 was something around 60% of readjustments. Since then, we have had, for the most part, fair negotiations for the category, with the replacement of inflation indices (IPCA). We emphasize that the year 2020 was atypical, due to the pandemic. In view of the above, I would like to leave the message that, in order for us to be valued by those who pay us, we have to unite in order to have a voice on issues that have such an impact on our lives.  

Álvaro Campos Radiologist doctor; Director of Professional Defense at SRPE

Director of the PE Doctors Union Member of the CBR Professional Defense Commission

Member of the PE Medical Fees Committee