The blackmailed SUS



It is urgent to review the role of “tables” in the remuneration of health work and provide transparency to the revenues and expenses of any organization that uses SUS resources

“If it were an isolated fact, it would be easy to solve. The problem is that it's blackmail all the time” – I heard from an experienced manager, when we commented on the decision taken by the management of the AC Camargo Hospital, specialized in cancer treatment, to suspend the care of “SUS patients” from December , in Sao Paulo, announced in mid-August 2022.

The announcement was followed by understandable widespread outrage.

The perplexity was justified, because the AC Camargo Cancer Center, “specialized in life”, as the institution's slogan says, has been in existence for more than half a century and, during its almost 70 years of activities, has had its performance marked by the needs of people with cancer, regardless of their socioeconomic conditions. The unusual decision disregarded the history of the hospital itself, which opened in 1953.

The history of the “AC Camargo Cancer Center” originates from a beautiful love story between a young oncologist and a polyglot journalist, also united by their belief in philanthropy as a useful tool to alleviate the suffering of sick human beings. The work of Antônio Prudente Meireles de Moraes and Carmen Annes Dias resulted in the São Paulo hospital, which is today a national and international reference in cancer treatment and scientific research.

Carmen, who would be better known as Carmen Prudente, led the São Paulo community to obtain donations to fight cancer. The first Campaign Against Cancer took place shortly after the end of World War II, in 1945, promoted by the Associação Paulista de Combate ao Câncer (APCC), chaired at the time by Antônio Cândido de Camargo. This story records important community efforts to pool resources to build a specialized cancer hospital. According to the institution, the AC Camargo it was “the first hospital in São Paulo built with the population’s money, and destined for it, with no connection to any official Brazilian health institution, without financial support from any religious organization, nor sponsorship from immigrant colonies, as was usual”.

However, as invariably happens, in Brazil and in other countries, institutions of this scale are not viable only with donations. Charity and philanthropy are sufficient to finance the work and erect the physical building. But donations are insufficient to keep it running. And when the accounts do not close, managers knock on the doors of governments, in search of public resources. They tend to want contributions but reject public controls. They treat their accounting as a private business, as the private property that they effectively are. But therein lies the core of the problem.

At present, the “AC Camargo Cancer Center” – which this columnist prefers to call AC Camargo Hospital – is a unit dependent on public resources, as the August announcement about “SUS patients” made clear. The hospital could even, with some effort, be economically viable without SUS resources, failing to care for what has been inappropriately called “SUS patients”, but, in order to continue producing the scientific investigations it carries out, it would continue to depend – very much – funds that finance scientific research. Public funds. And would it be ethical to make use, on the one hand, of public resources and, on the other hand, select patients under the criteria “SUS”, “non-SUS”?

What would Carmen and Antônio Prudente say about this?

Leaders of AC Camargo claim that “the SUS table” for consultations, procedures and surgeries would be “outdated”, which requires that annually “the hospital has to contribute its own resources to cover the gap”.

The concepts of “SUS patient” and “SUS table” deserve some consideration before proceeding with the analysis of the episode.

Health facilities, financed in whole or in part by public resources, must provide assistance to anyone in need of health care, without any type of discrimination, under the constitutional principles of health as “the right of all” and “universal access”. ” (art. 196), so compatible with the level of attention in which they work, which should be the only ethically valid restriction to refuse assistance, even under certain conditions. For this reason, the expression “SUS patient” corresponds to a categorization of people that has been done illegally, illegitimately and unethically and, even if it has “only administrative” purposes, it must be opposed by all defenders of the SUS and the right to health, because a patient is, above all, someone who needs health care, no matter who they are – an understanding that, by the way, is in full compliance with the humanist values ​​that animated the actions of Antônio and Carmen Prudente.

The expression “patient of the SUS” serves, therefore, as I heard, only to blackmail public administrators, responsible for the SUS. The term blackmail seemed to me, at first, exaggerated. But I found that in these cases its use is technically correct. The two most frequent meanings for the term corroborate this understanding and refer to: (1) the attempt to obtain money or favors with the threat of scandal or other harmful consequences, in case of refusal; and, (2) the pressure to get something. It is therefore of bribery that's about yes.

The practice, by the way, is widespread and consolidated in Brazil. See the case of Santas Casas. It is estimated that the country has more than 2.500 hospitals that are characterized by this name. They constitute an important social capital and an invaluable health resource, built over decades and, in some cases, centuries. But this remarkable heritage coexists with serious and chronic management problems.

Sometimes, some Santa Casa closes its activities, harming the communities they served. But instead of integrating even more strongly into the SUS, many of these companies (privately owned, register) choose to create “health plans”, with the illusion that the solution to their problems is in the market. Shipwrecked in debt, they knocked on the doors of governments, with a special predilection for the federal government. Helpful parliamentarians, with their amendments to the budget, both public and secret, complete the disservice to public health policy and contribute to disorganize SUS governance, trampling sectoral planning and imposing guidelines disconnected from health needs to loco-regional managers of the populations of these territories.

The Council of Municipal Health Secretariats of São Paulo (Cosems-SP) recently commented on this, publishing a harsh criticism of the so-called “secret budget”, according to which a deputy or senator, using parliamentary amendments to the budget, can allocate federal resources without the need to specify where the money should be applied. This mechanism distorts health planning. An eloquent example occurred, according to journalist Breno Pires, in the report “unlimited binge” (Revista Piauí, n°.190, p.14), in Quarries, in Maranhão. To try to justify the allocation of public money to health, the City Hall reported having carried out 540,6 dental extractions in its population of around 39 inhabitants. This number, of more than half a million dental surgeries, corresponds to more than four times that performed by the SUS in the city of São Paulo, the largest in the southern hemisphere.

This is obviously a spurious data. For this reason, among other reasons, Cosems-SP stated that “this process of deregulation, flexibility and representative growth of parliamentary allocation in the public budget in the SUS has been weakening the foundations of the system, eroding the competences of the spaces of interfederative agreement and social participation and creating new obstacles to the implementation of SUS principles, especially equity”.

Privately owned companies that are related to the SUS in some way, contracted to produce health care, receive public funds for this purpose. They assume, therefore, the management of the exercise of a social right (Constitution of the Republic of 1988, art. 6) and propose to produce “health actions and services” that the constitutional text defines as being of “public relevance” (art. 197). Such legal entities therefore operate with something (health care) that is not a commodity, but a social right and that, due to its characteristics, cannot be managed as any other good or service. Health managers are not equivalent, in this aspect, to managers of supermarkets, gas stations, administrators of a highway, or any other store. To make decisions they need much more than spreadsheets and some graphs.

The deeper meaning of this objection to spreadsheets as an administrative-financial resource in the health sector was masterfully enunciated by Carlos Gentile de Mello, still in the 1980s, when the personal microcomputer had not even been invented. When criticizing the remuneration system for actions and health services adopted at the time by the extinct National Institute of Medical Assistance of Social Security (Inamps), Gentile used to repeat that the financing of services according to the number of units of medical services performed was “a factor uncontrollable corruption”. In the book "SUS: a revolutionary reform”, a record that Gentile always told, good-humored in his lectures, that from hearing him say so often that “payment per unit of service is an uncontrollable factor of corruption”, when someone looked for him on the phone and he was not there, all at his house they explained that he was not there and added: “but he sent word that payment per unit of service is an uncontrollable factor of corruption”.

His scathing and repeated criticism of the model that had consolidated itself in the so-called “pension medicine”, and which decades later remains essentially unchanged in the SUS, was mentioned in an excerpt of the news about his death, on 28/10/1982, by the newspaper FSP, for which Carlos Gentile de Mello was a columnist: “A critic of the social security medicine model adopted in Brazil, Gentile understood that the form of remuneration of private hospitals associated with Inamps, based on payment per Unit of Service, leads to overbilling and the proliferation of unnecessary medical acts causing the exhaustion of resources destined to medical assistance”.

the model inampian of remuneration for actions and health services is currently reproduced as a metastasis and the case of Hospital AC Camargo is just one of them, in the form of the “SUS table”. The model is also adopted in relations with Santas Casas.

The problem is that the remuneration model for the production of health care based on a “procedure table” is terrible, as it brings to the interior of the SUS and to the relations between federative entities and organizations of the so-called complementary health, what there is of the worst in supplementary health – precisely the idea that health care can be “planned” based on service price estimates defined by the market, added by profit margins and other deformations that bias the calculation of costs of health actions and services. health.

The “SUS table” originates from the “Inamps table”, which is also, in a certain way, the mother of the former Health Procedures and Events List (RPES), a list of procedures, exams and treatments with mandatory coverage by “plans”. of health", currently transformed into TUSS, the Unified Terminology of Supplementary Health, a kind of glossary containing names and descriptions of health procedures according to the nomenclature standard established by the business segment that operates in supplementary health, under the auspices of ANS. The RPES/TUSS is what is known as the “table of plans”, or of supplementary health, as values ​​are set for each item in the table based on prices defined by the market.

Brandishing the “table of plans” on the foreheads of SUS managers, as Hospital AC Camargo did in São Paulo, asking them for more money, is not only inappropriate, but above all unfair.

It is inappropriate, as price and cost are very different concepts. The calculation of the costs of actions and health operations based on amounts involved in these activities in the public services of the SUS, including the part related to the remuneration of health professionals and administrative personnel, usually results in values ​​that are very different from those shown in the “tables of plans”. But the practice of blackmailing SUS managers is, in addition to being inadequate, also unfair, as one must operate with the assumption that the public service remunerates professionals (health professionals, in this case), based on the social need for this work, which must be carried out under suitable conditions, under the principle of decent work, and having as a reference not the sale of a commodity, but the fulfillment of a social need. This means that, within the scope of the SUS, professional remuneration must be waged and not fragmented according to procedures or tasks performed.

In SUS, the table inherited from Inamps should only serve as a kind of calculation memory for the costs of actions and operations within the system, with a view to estimating resources to be transferred to states and municipalities, related to the federal part of the system. SUS funding, but always taking into account the other aspects referred to in art. 35 of Law 8.080/90, such as the demographic and epidemiological profiles of the population in the region, the quantitative and qualitative characteristics of the health network in the area, the performance (technical, economic and financial) in the previous period, the forecast of investments in the health network attention, among others. However, private providers, such as the administrators of Hospital AC Camargo in São Paulo, feel free to compare “tables” and complain about the “lag” of the SUS. They err in doing so, as they compare “tables” as if their contents were comparable. They are not. They shouldn't be, because they have very different purposes and are concerned with very different objects.

It is worth reaffirming, however, how it was emphasized by the Sanitary Reform movement in the historical period of creation of the SUS, in which the credibility of Inamps was very low due to the deformations of the financing derived from employment and the distortions of its “table”, that the main problem with remuneration for health care based on individual procedures is that this mechanism does not take into account that the production of care is also a collective work process. From the beginning, the main leaders of the Sanitary Reform frontally rejected that the SUS reproduced the practices of remuneration for health care consolidated in social security medicine.

But this reproduction is precisely what has been seen in these 34 years of existence of the SUS, whether to transfer resources from the Union to states and municipalities, or to “pay” private providers, such as Santas Casas, Social Health Organizations, among others. . The consequent dispersion of resources, and their misallocation, further aggravates the scenario of chronic underfunding of the SUS.

For this reason, specialists around the world converge on the need for health work to be remunerated in the form of a salary, with solid employment relationships, functional stability defined in careers managed by professionals in the sector, salary standards compatible with the economy of each country, respect for the legislation that must be oriented to the protection of professionals, assuring them dignified working conditions. In the Brazilian case, all of this must take place under the public control of conferences and health councils.

This perspective has nothing to do, certainly, with privatizations, outsourcing and outsourcing. Much less with the “uberization” of work in the SUS, under the reference of “price lists” of procedures. This path, if followed in the coming years, giving in to the blackmail of the “outdated table” is the path of financial unsustainability of the SUS, that is, of making the right of everyone to health unfeasible, as enshrined in the Brazilian Constitution.

It is urgent to review the role of “tables” to remunerate work in health. As urgent as this is to provide transparency to the revenues and expenses of any organization, whether privately owned or state-owned, that uses public resources to carry out its activities. SUS authorities and health councils should be officially informed, periodically, about the application of public resources, including the payroll of these organizations, under the terms of the law, improving the legislation on this matter. It remains to be seen whether any senator or federal deputy will take any initiative in this direction.

In São Paulo, the blackmail was effective: the state and capital governments announced that they had assumed the commitment to “compensate financially” the hospital that prides itself on having no connection with “any official Brazilian health institution”.

*Paulo Capel Narvai is senior professor of Public Health at USP. Author, among other books, of SUS: a revolutionary reform (authentic).


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