The integrated system of inspection (ISI) as a tool for performance management in the supplementary health sector, Brazil

The main task assigned to the Brazilian National Agency of Supplementary Health (ANS, in Portuguese) is to regulate private health plans. Accordingly, the ANS´s Inspection Directory has implemented an Integrated System of Inspection (ISI) consisting of management tools, based on registers of consumers’ inquiries and complaints, for inspection and evaluation of carriers´ performances. This mechanism enables anticipating problems that might motivate Special Direction Regimes (SDR) and Extrajudicial Liquidation (EL), thus causing license cancellation as well as damaging consumers’ assistance. This study aims to identify markers or sentinel events that are associated with SDR and later EL, using registers maintained by the ISI. The data contain consumers’ complaints from 2004 to 2006. A retrospective 1:3 matched case-control study design was used to examine risk factors for EL. Cases were all carriers facing EL from 2005 to 2007 whilst controls were active carriers selected at random, and matched to organizational modality and size. Univariate and multivariate conditional logistic regression models were fitted to select potential risk factors. Stepwise procedures were applied to the latter, regarding p-values of 0.2 and 0.1. A thorough residual diagnostics analysis was carried out. The sample consisted of 20 cases and 60 controls. The most prevalent complaints for cases concerned providers (70.3%), coverage (9.8%), health plans (6.1%), contracts (3.8%), and preexisting conditions (3.2%). As for controls, they were coverage (21.2%), contracts (20.3%), providers (15.8%), preexisting conditions (14.5%), and raising premiums (11.4%). The rate of complaints (per 10,000 consumers) concerning providers was the only factor statistically significant (OR=1.18, CI 95% 1.03-1.34). Model check techniques revealed outliers that strongly influenced some results. Complaints concerning providers seem to be a good indicator as to whether or not carriers are in financial difficulties, thus allowing preventive inspection in order to minimize damage to consumers assistance caused by SDR and EL.