Regulation of the private health sector by a governmental agency in Brazil: Public policy for social justice and good health care delivery

Brazilian Health System is composed of a universal system (SUS) and the private sector including health plan operators/insurances, composed of nearly 50 million beneficiaries. ANS, Federal Regulatory Agency for Health Plans and Insurances, established in 1998, with an institutional mission of promoting the defense of public interest in the private health system, is comprised of five divisions intended to regulate different dimensions of the sector. One of these dimensions refers to the identification of the use, by a health plan beneficiary, of SUS health services for procedures covered by the health plan purchased. To perform such identification, ANS has established a regulatory tool name “reimbursement” of the private sector to the public one with the objective of preventing health plan operators from illicit enrichment and to promote social justice, assuring that public investments are used accordingly to public needs. ANS matches its beneficiary’s database with the public hospitalizations one, using a technology named record linkage, in order to identify which individuals from which health plan operators have used public resources instead of the private ones hired from the operators. It involves collecting enough data to enable ANS evaluation regarding the amount of beneficiaries per operator, identifying a profile of usage that can relate provider net insufficiency, coverage denial, illegal gate-keeping, in the operator perspective, or misuse of public resources by private health care providers hired by both systems. Private reimbursement to public health sector has only recently been acknowledged as a powerful regulatory tool inside the agency itself and has increasingly been used by other departments as performance measurement of health plan operators. Such piece of information analyzed with other quality indicators seems to bring the agency towards an evolutionary regulation perspective once limited to economical perspective evolving to guaranteeing good health care delivery/results to a quarter of Brazil’s population.