Access to health goods and services in health plans through the judicialization: a study of the State of São Paulo
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Data de Publicação: | 2022 |
Outros Autores: | |
Tipo de documento: | Artigo |
Idioma: | por |
Título da fonte: | Cadernos Ibero-Americanos de Direito Sanitário (Online) |
Texto Completo: | https://www.cadernos.prodisa.fiocruz.br/index.php/cadernos/article/view/859 |
Resumo: | Objective: to analyze access to health goods and services of health plans through judicialization, describing the profile of actions, implications of the right to health and health management. Methods: exploratory, descriptive research, in which 513 judgments of the São Paulo Court of Justice were analyzed, from 2007 to 2017. Results: the results indicate negative coverage (42.45%), and problems related to contracts (26.20 %), readjustments (16.50%), accredited network (7.20%), retired and dismissed workers (7.00%) and moral damages (0.65%). Among the exclusions from coverage, 46% of health plan users sought access to coverage for the treatment of diseases or health-related events: medications (28.7%), exams (18.5%), orthoses and prostheses (12.5%) and hospitalization (12.00%). In 82% of the judgments, the court decisions were favorable to the users. Conclusion: judicialization for access to health goods and services from health plans mainly involves denials of coverage (exclusions and limitations of coverage) and contractual conflicts (mainly old contracts). Within the limits of this research, it can also be concluded that there are indications that health supplement managers need to think about redirecting some of their behaviors, verify faults and dysfunctions, and observe possible gaps in rules or laws for the regulation of consumption in the supplementary health care system, seeking as well to minimize judicialization and achieve more comprehensive health care practices in this segment. |
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Access to health goods and services in health plans through the judicialization: a study of the State of São PauloAcceso a bienes y servicios de salud en planes de salud a través de la judicialización: un estudio del estado de São PauloAcesso a bens e serviços de saúde dos planos de saúde por meio da judicialização: um estudo do estado de São PauloJudicialização da saúdeSaúde suplementarDireito à saúdePolíticas de saúdePlanos de pré-pagamento em saúdeJudicialización de la saludSalud complementariaDerecho a la saludJudicialización de la salud. Federalismo Políticas de salud pública. Financiación de la asistencia sanitaria. Poder Judicial.Planes de prepago de saludJudicialization of healthSupplementary healthRight to healthHealth policiesHealth prepayment plansObjective: to analyze access to health goods and services of health plans through judicialization, describing the profile of actions, implications of the right to health and health management. Methods: exploratory, descriptive research, in which 513 judgments of the São Paulo Court of Justice were analyzed, from 2007 to 2017. Results: the results indicate negative coverage (42.45%), and problems related to contracts (26.20 %), readjustments (16.50%), accredited network (7.20%), retired and dismissed workers (7.00%) and moral damages (0.65%). Among the exclusions from coverage, 46% of health plan users sought access to coverage for the treatment of diseases or health-related events: medications (28.7%), exams (18.5%), orthoses and prostheses (12.5%) and hospitalization (12.00%). In 82% of the judgments, the court decisions were favorable to the users. Conclusion: judicialization for access to health goods and services from health plans mainly involves denials of coverage (exclusions and limitations of coverage) and contractual conflicts (mainly old contracts). Within the limits of this research, it can also be concluded that there are indications that health supplement managers need to think about redirecting some of their behaviors, verify faults and dysfunctions, and observe possible gaps in rules or laws for the regulation of consumption in the supplementary health care system, seeking as well to minimize judicialization and achieve more comprehensive health care practices in this segment.Objetivo: analizar el acceso a los bienes y servicios de salud de los planes de salud a través de la judicialización, describiendo el perfil de las acciones, las implicaciones del derecho a la salud y la gestión de la salud. Metodología: investigación exploratoria, descriptiva, en la que se analizaron 513 sentencias del Tribunal de Justicia de São Paulo, de 2007 a 2017. Resultados: los resultados indican cobertura negativa (42,45%), y problemas relacionados con los contratos (26,20%), reajustes ( 16,50%), red acreditada (7,20%), trabajadores jubilados y despedidos (7,00%) y daños morales (0,65%). Entre las exclusiones de cobertura, el 46% de los usuarios de planes de salud buscaron acceder a coberturas para el tratamiento de enfermedades o eventos relacionados con la salud: medicamentos (28,7%), exámenes (18,5%), órtesis y prótesis (12,5%) y hospitalización (12,00%). En el 82% de las sentencias, las decisiones judiciales fueron favorables a los usuarios. Conclusion: la judicialización para el acceso a bienes y servicios de salud de los planes de salud involucra principalmente denegaciones de cobertura (exclusiones y limitaciones de cobertura) y conflictos contractuales (principalmente contratos antiguos). Dentro de los límites de esta investigación, también se puede concluir que existen indicios de que los gestores de salud complementarios necesitan pensar en reorientar algunos de sus comportamientos, verificando fallas y disfunciones, y observar posibles vacíos en las normas o leyes para la regulación del consumo en la de atención complementaria a la salud, buscando así minimizar la judicialización y lograr prácticas más integrales de atención a la salud en este segmento.Objetivo: analisar o acesso a bens e serviços de saúde dos planos de saúde por meio da judicialização, descrevendo o perfil das ações, implicações do direito à saúde e da gestão da saúde. Metodologia: pesquisa exploratória, descritiva, na qual foram analisados 513 acórdãos do Tribunal de Justiça de São Paulo, de 2007 a 2017. Resultados: os resultados apontam negativas de coberturas (42,45%), e problemas relacionados a contratos (26,20%), reajustes (16,50%), rede credenciada (7,20%), aposentados e demitidos (7,00%) e danos morais (0,65%). Dentre as exclusões de cobertura, 46% dos beneficiários de planos de saúde buscaram acesso à cobertura para o tratamento de doenças ou eventos relacionados à saúde: medicamentos (28,7%), exames (18,5%), órteses e próteses (12,5%) e hospitalização (12,00%). Em 82% dos acórdãos, as decisões judiciais foram favoráveis aos beneficiários. Conclusão: a judicialização para acesso a bens e serviços de saúde dos planos de saúde envolve principalmente negativas de cobertura (exclusões e limitações de cobertura) e conflitos contratuais (principalmente contratos antigos). Nos limites desta pesquisa, pode-se concluir também que há indícios de que os gestores da saúde suplementar precisam pensar em reorientar algumas de suas condutas, verificar falhas e disfunções, e observar possíveis lacunas de regras ou leis para a regulamentação de consumo no sistema de saúde suplementar de atenção à saúde, buscando assim minimizar a judicialização e alcançar práticas mais integrais de assistência à saúde nesse segmento.Fundação Oswaldo Cruz Brasília2022-03-15info:eu-repo/semantics/articleinfo:eu-repo/semantics/publishedVersionapplication/pdfhttps://www.cadernos.prodisa.fiocruz.br/index.php/cadernos/article/view/85910.17566/ciads.v11i1.859Iberoamerican Journal of Health Law; Vol. 11 No. 1 (2022): (JAN./MAR. 2022); 183-202Cuadernos Iberoamericanos de Derecho Sanitario; Vol. 11 Núm. 1 (2022): (ENE./MAR. 2022); 183-202Cadernos Ibero-Americanos de Direito Sanitário; v. 11 n. 1 (2022): (JAN./MAR. 2022); 183-2022358-18242317-839610.17566/ciads.v11i1reponame:Cadernos Ibero-Americanos de Direito Sanitário (Online)instname:Fundação Oswaldo Cruz (FIOCRUZ)instacron:FIOCRUZporhttps://www.cadernos.prodisa.fiocruz.br/index.php/cadernos/article/view/859/885Copyright (c) 2022 Beatriz Cristina Freitas, Dagmar de Paula Queluz (Autor)https://creativecommons.org/licenses/by-nc-sa/4.0info:eu-repo/semantics/openAccessFreitas, Beatriz CristinaQueluz, Dagmar de Paula Freitas, Beatriz CristinaQueluz, Dagmar de Paula Freitas, Beatriz CristinaQueluz, Dagmar de Paula 2022-10-17T17:54:16Zoai:ojs.cadernos.prodisa.fiocruz.br:article/859Revistahttp://www.cadernos.prodisa.fiocruz.brPUBhttp://www.cadernos.prodisa.fiocruz.br/index.php/cadernos/oaicadernos.direitosanitario@fiocruz.br2358-18242317-8396opendoar:2022-10-17T17:54:16Cadernos Ibero-Americanos de Direito Sanitário (Online) - Fundação Oswaldo Cruz (FIOCRUZ)false |
dc.title.none.fl_str_mv |
Access to health goods and services in health plans through the judicialization: a study of the State of São Paulo Acceso a bienes y servicios de salud en planes de salud a través de la judicialización: un estudio del estado de São Paulo Acesso a bens e serviços de saúde dos planos de saúde por meio da judicialização: um estudo do estado de São Paulo |
title |
Access to health goods and services in health plans through the judicialization: a study of the State of São Paulo |
spellingShingle |
Access to health goods and services in health plans through the judicialization: a study of the State of São Paulo Freitas, Beatriz Cristina Judicialização da saúde Saúde suplementar Direito à saúde Políticas de saúde Planos de pré-pagamento em saúde Judicialización de la salud Salud complementaria Derecho a la salud Judicialización de la salud. Federalismo Políticas de salud pública. Financiación de la asistencia sanitaria. Poder Judicial. Planes de prepago de salud Judicialization of health Supplementary health Right to health Health policies Health prepayment plans |
title_short |
Access to health goods and services in health plans through the judicialization: a study of the State of São Paulo |
title_full |
Access to health goods and services in health plans through the judicialization: a study of the State of São Paulo |
title_fullStr |
Access to health goods and services in health plans through the judicialization: a study of the State of São Paulo |
title_full_unstemmed |
Access to health goods and services in health plans through the judicialization: a study of the State of São Paulo |
title_sort |
Access to health goods and services in health plans through the judicialization: a study of the State of São Paulo |
author |
Freitas, Beatriz Cristina |
author_facet |
Freitas, Beatriz Cristina Queluz, Dagmar de Paula |
author_role |
author |
author2 |
Queluz, Dagmar de Paula |
author2_role |
author |
dc.contributor.author.fl_str_mv |
Freitas, Beatriz Cristina Queluz, Dagmar de Paula Freitas, Beatriz Cristina Queluz, Dagmar de Paula Freitas, Beatriz Cristina Queluz, Dagmar de Paula |
dc.subject.por.fl_str_mv |
Judicialização da saúde Saúde suplementar Direito à saúde Políticas de saúde Planos de pré-pagamento em saúde Judicialización de la salud Salud complementaria Derecho a la salud Judicialización de la salud. Federalismo Políticas de salud pública. Financiación de la asistencia sanitaria. Poder Judicial. Planes de prepago de salud Judicialization of health Supplementary health Right to health Health policies Health prepayment plans |
topic |
Judicialização da saúde Saúde suplementar Direito à saúde Políticas de saúde Planos de pré-pagamento em saúde Judicialización de la salud Salud complementaria Derecho a la salud Judicialización de la salud. Federalismo Políticas de salud pública. Financiación de la asistencia sanitaria. Poder Judicial. Planes de prepago de salud Judicialization of health Supplementary health Right to health Health policies Health prepayment plans |
description |
Objective: to analyze access to health goods and services of health plans through judicialization, describing the profile of actions, implications of the right to health and health management. Methods: exploratory, descriptive research, in which 513 judgments of the São Paulo Court of Justice were analyzed, from 2007 to 2017. Results: the results indicate negative coverage (42.45%), and problems related to contracts (26.20 %), readjustments (16.50%), accredited network (7.20%), retired and dismissed workers (7.00%) and moral damages (0.65%). Among the exclusions from coverage, 46% of health plan users sought access to coverage for the treatment of diseases or health-related events: medications (28.7%), exams (18.5%), orthoses and prostheses (12.5%) and hospitalization (12.00%). In 82% of the judgments, the court decisions were favorable to the users. Conclusion: judicialization for access to health goods and services from health plans mainly involves denials of coverage (exclusions and limitations of coverage) and contractual conflicts (mainly old contracts). Within the limits of this research, it can also be concluded that there are indications that health supplement managers need to think about redirecting some of their behaviors, verify faults and dysfunctions, and observe possible gaps in rules or laws for the regulation of consumption in the supplementary health care system, seeking as well to minimize judicialization and achieve more comprehensive health care practices in this segment. |
publishDate |
2022 |
dc.date.none.fl_str_mv |
2022-03-15 |
dc.type.driver.fl_str_mv |
info:eu-repo/semantics/article info:eu-repo/semantics/publishedVersion |
format |
article |
status_str |
publishedVersion |
dc.identifier.uri.fl_str_mv |
https://www.cadernos.prodisa.fiocruz.br/index.php/cadernos/article/view/859 10.17566/ciads.v11i1.859 |
url |
https://www.cadernos.prodisa.fiocruz.br/index.php/cadernos/article/view/859 |
identifier_str_mv |
10.17566/ciads.v11i1.859 |
dc.language.iso.fl_str_mv |
por |
language |
por |
dc.relation.none.fl_str_mv |
https://www.cadernos.prodisa.fiocruz.br/index.php/cadernos/article/view/859/885 |
dc.rights.driver.fl_str_mv |
Copyright (c) 2022 Beatriz Cristina Freitas, Dagmar de Paula Queluz (Autor) https://creativecommons.org/licenses/by-nc-sa/4.0 info:eu-repo/semantics/openAccess |
rights_invalid_str_mv |
Copyright (c) 2022 Beatriz Cristina Freitas, Dagmar de Paula Queluz (Autor) https://creativecommons.org/licenses/by-nc-sa/4.0 |
eu_rights_str_mv |
openAccess |
dc.format.none.fl_str_mv |
application/pdf |
dc.publisher.none.fl_str_mv |
Fundação Oswaldo Cruz Brasília |
publisher.none.fl_str_mv |
Fundação Oswaldo Cruz Brasília |
dc.source.none.fl_str_mv |
Iberoamerican Journal of Health Law; Vol. 11 No. 1 (2022): (JAN./MAR. 2022); 183-202 Cuadernos Iberoamericanos de Derecho Sanitario; Vol. 11 Núm. 1 (2022): (ENE./MAR. 2022); 183-202 Cadernos Ibero-Americanos de Direito Sanitário; v. 11 n. 1 (2022): (JAN./MAR. 2022); 183-202 2358-1824 2317-8396 10.17566/ciads.v11i1 reponame:Cadernos Ibero-Americanos de Direito Sanitário (Online) instname:Fundação Oswaldo Cruz (FIOCRUZ) instacron:FIOCRUZ |
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Fundação Oswaldo Cruz (FIOCRUZ) |
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FIOCRUZ |
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FIOCRUZ |
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Cadernos Ibero-Americanos de Direito Sanitário (Online) |
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Cadernos Ibero-Americanos de Direito Sanitário (Online) |
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Cadernos Ibero-Americanos de Direito Sanitário (Online) - Fundação Oswaldo Cruz (FIOCRUZ) |
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cadernos.direitosanitario@fiocruz.br |
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