The increasing judicialization of private health and the pursuit of increasingly well-reasoned decisions based on technical and scientific criteria were central to the discussions of the seminar "Judicialization of Private Health: Contemporary Challenges and Evidence-Based Decisions," organized this Thursday (September 24th) by the State Health Committee of the Ceará State Court of Justice (TJCE), in the General Court of Justice.
At the opening of the event, the President of the TJCE, Justice Heráclito Vieira de Sousa Neto, emphasized the importance of adopting technical criteria to assist in decision-making in processes related to private health and highlighted the role of the Judicial Technical Support Centers (NatJus) in this process, highlighting the creation of NatJus – Private Health, in partnership with the University of Fortaleza (Unifor), focused on producing technical notes and/or opinions that assist judges in decisions related to private health matters.
"It is necessary for a decision to be made that preserves health, preserves the life of the citizen and the citizen, but also maintains the system in operation, because if it collapses, it will not only be that patient who will suffer the consequences," he emphasized.
The program began with the keynote conference "Judicial Decision-Making in Health: What is High-Level Evidence," delivered by Dr. Rachel Riera, medical coordinator of the Technology in Health and Evidence Nucleus of the Sírio-Libanês Hospital. The lecture was moderated by the President of the Ceará Association of Judges (ACM), Judge José Hercy Ponte de Alencar.
During the presentation, the expert addressed the evolution of methods used for evaluating scientific evidence and advocated for the use of tools that enhance the security of judicial and assistance decisions in the health sector.
"When we talk about supplementary health, we must remember that we live in a country with a single health system, which is the SUS. This single health system is made up of supplementary health and public health. Therefore, when we care about supplementary health, we also care about public health," he observed.
Subsequently, Judge Cristiano Rabelo Leitão, head of the 37th Civil Court, moderated the panel "Regulation of Supplementary Health and Interfaces with the Judiciary," which featured the coordinator of the National Supplementary Health Agency (ANS) in Ceará, Fernanda Gomes Pinto, and the manager of Good Practices from the ANS's Fiscalization Directorate, Frederico Villela Chein Cortez.
On this occasion, the coordinator of the ANS in Ceará, Fernanda Gomes, highlighted the institutional partnership between the Agency and the TJCE for strengthening initiatives aimed at qualifying the analysis of demands related to supplementary health.
"Every day, we have a new development, whether it's a scientific or technological innovation. It happens very quickly, and that influences the work of the ANS and also the work of the judiciary. Regarding this collaboration, we have a long-standing partnership agreement with the Court of Justice. We have made several exchanges, continuously, including participating in the development of NatJus Suplementary Health," he stated.
Frederico Villela Chein Cortez spoke about the relevance of the Preliminary Intermediation Notification (NIP) as a tool for extrajudicial resolution of conflicts between beneficiaries and health insurance companies. "The NIP is a great tool that we understand helps with this issue of judicialization, which can reduce and speed up the judicialization process because we have a very high volume of resolution," he emphasized.
In the morning, the panel "Prescribing Medicine, Clinical Need, and Coverage in Health Plans" was held, led by Judge Zanilton Batista Medeiros, head of the 39th Civil Court, and featuring the participation of psychologist Silviane Andrade. The discussion addressed aspects related to the indication of treatments, the clinical needs of patients, and the coverage criteria adopted by health insurance companies.
By bringing up the challenges related to the care of people with autism spectrum disorder (ASD), the expert defended a more technical role for the Judiciary. "The judicial decision must be increasingly qualified. But how can a judge make a decision in a few hours about this treatment, which we are still in the process of discussing?" she questioned.
The speaker also pointed out criteria that should guide the analysis of claims in the health area, with the use of scientific evidence in decision-making. "We must be very careful with the issue of scientific evidence, because without evidence, we don't know whether it works or not," she said.
OPMEs, PAPEL DO NATJUS E NOVAS PERSPECTIVAS
In the afternoon, three more presentations continued to highlight the theme of judicialization in private health. The first session featured a discussion on “Orthotics, Prosthetics and Special Materials (OPMEs) in Private Health: Technical and Coverage Criteria and Judicialization”, moderated by Judge Fabiana Silvia Félix da Rocha, head of the 17th Civil Court of the Comarca of Fortaleza, and led by consultant and OPME specialist Andréia Cristina de Andrade Bergamini.
During the presentation, the consultant addressed changes in the OPME market, technical and assistance discrepancies, extra-Rol technology, and other issues that can lead to judicialization. “The disputes related to OPMEs are unfortunately linked to high complexity, high financial value, and unfortunately, there are still fraud and waste in these procedures,” the consultant detailed.
The current challenges faced in the context of judicialization in private health and the role of NatJus were the subject of a subsequent panel, moderated by the Executive Secretary of the State Health Committee of Ceará and coordinator of NatJus at the TJCE, Yury Trindade, with the participation of biomedical Daniela Cristina Sensato Monteiro and cardiologist Ítalo Martins de Oliveira, who works at NatJus at the TJCE.
The discussion that concluded the event focused on "Judicialization of Healthcare from a New Perspective: Analyses after ADI 7265." Conducted by Judge Vanessa Maria Quariguasy of the 19th Civil Court, the panel featured Federal Judge Clenio Jair Schulze of the 4th Regional Federal Court (TRF4) and deepened knowledge of the Supreme Court of Justice (STF) decision that established criteria for coverage of treatments outside the ANS (National Health Service) list.
The seminar was part of the State Committee for Health's actions aimed at improving judicial performance in healthcare-related lawsuits, promoting the exchange of experiences between judges, healthcare professionals, representatives of regulatory bodies, and experts, with a focus on building decisions that are increasingly aligned with scientific evidence and the norms governing supplementary healthcare in the country.