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Customers' Unmet Needs and Pains

Private Health in Brazil Current Pains Analysis

The Brazilian private health ecosystem delivers care to more than 52 million medical-hospital beneficiaries and some 34 million dental plan users, yet it is beset by structural and day-to-day pains that directly affect final customers (individual beneficiaries and the workers covered by employer/association plans).
Analysis of customer-focused data from the four foundational reports points to four dominant, inter-connected pain clusters:

  1. Premium Affordability & Overall Cost Pressure
    • Medical inflation (driven by input price rises, ageing, utilisation growth and expensive new technologies) has outpaced broad consumer inflation for more than a decade.
    • ANS price-adjustment caps, although designed for consumer protection, regularly authorise double-digit premium increases. As a result, families downgrade coverage, raise deductibles or exit the private system.
    • Out-of-pocket spending on co-pays, uncovered drugs and dental/vision procedures accentuates the burden, especially for the emerging middle class that joined the market after COVID-19.

  2. Access Limitations & Geographic Inequities
    • Private hospital-bed density varies almost four-fold between São Paulo and North/North-East states.
    • A shortage of intensivists, nurses, oncology specialists and diagnostic technicians disproportionately affects secondary cities and rural areas, leading to appointment delays, forced travel and diminished perceived value of insurance.
    • Verticalised operators concentrate their own hospitals and clinics in richer metropolitan areas, deepening the regional gap.

  3. Slow Diffusion of Innovations & Coverage Delays
    • ANVISA device-registration queues lengthened in 2024 due to inspector vacancies; median approval time for Class III devices exceeded 14 months.
    • After market approval, inclusion in the ANS mandatory coverage list (Rol) can take a further 12-18 months; until then, operators may deny requests or impose high co-pays.
    • Patients with rare diseases and oncology cases perceive the gap most acutely when comparing Brazil with OECD peers.

  4. Bureaucracy, Fragmented Digital Records & Service Friction
    • Prior authorisations, paper-based referrals and claim audits create time-consuming loops for members and providers.
    • Lack of interoperability among electronic medical record (EMR) systems forces patients to repeat exams, raising costs and frustration.
    • Contact-centre complaints compiled by ANS show rising dissatisfaction with denied authorisations and call-centre wait times.

These pains erode customer satisfaction despite overall market growth and contribute to the observed churn toward cheaper or no-plan alternatives.

Unmet Needs and Pains

The synthesis of customer identification, challenges analysis, social listening and demand-behaviour insights uncovers a set of unmet needs that go beyond the currently acknowledged pains. These needs describe what beneficiaries still lack or feel is insufficiently addressed by Brazil’s private health value chain:

  1. Affordable, Predictable Total Cost of Care
    • Need: Plans whose total yearly spend (premium + co-pay) grows in line with wage inflation, with transparent projection tools.
    • Observed Gap: Double-digit annual readjustments; unpredictable extra costs for labs, high-cost drugs and dental work.
    • Implications: Middle-income families skip preventive visits, delay exams and expose insurers to higher downstream claims.

  2. Equitable Geographic Access to Core & Specialised Services
    • Need: Reasonable travel distance (<50 km or <2 h) to ICU beds, dialysis, oncology infusion and advanced imaging.
    • Observed Gap: North and rural Midwest have <0.8 private beds/1,000 inhabitants versus >3.0 in São Paulo; shortage of specialists persists.
    • Implications: Adverse clinical outcomes, reputational damage to brands and potential ANS interventions.

  3. Rapid Adoption & Coverage of Evidence-Based Innovations
    • Need: Time-to-patient for new drugs/devices <12 months after international launch; transparent criteria for inclusion in benefit design.
    • Observed Gap: Two- to three-year lag common; patients resort to lawsuits (“judicialização”) to obtain therapy.
    • Implications: Higher legal costs, uneven access favouring wealthier litigants, erosion of trust.

  4. Seamless, Digitally-Enabled Care Journeys
    • Need: One-click appointment scheduling, EMR portability, digital prescriptions and real-time authorisation tracking.
    • Observed Gap: Siloed platforms, non-standardised HL7/FHIR adoption and fax/PDF workflows between operator and provider.
    • Implications: Redundant exams, longer care cycles, rising administrative overhead (≈7–10 % of claim cost).

  5. Clear, Timely Communication & Customer Education
    • Need: Plain-language explanation of coverage, co-pay rules, preventive-care reminders and network updates pushed proactively.
    • Observed Gap: Jargon-heavy policies; ANS complaint data show frequent “informational deficiency”.
    • Implications: Mis-use of ER, low vaccine uptake, preventable chronic-disease escalation.

  6. Integrated Mental-Health & Preventive-Wellness Offerings
    • Need: Coverage for psychotherapy, digital CBT, stress-reduction programs and ongoing chronic-disease coaching.
    • Observed Gap: Caps on psychotherapy sessions; limited reimbursement for digital mental-health apps; wellness seen as ancillary.
    • Implications: Rising depression/anxiety prevalence, productivity loss for corporate clients, higher disability claims.

  7. Value-Based Reimbursement & Quality Transparency
    • Need: Insight into provider quality metrics (infection rate, readmission) and financial incentives aligned with outcomes rather than volume.
    • Observed Gap: Fee-for-service dominant; value-based pilots cover <5 % of claims; quality dashboards unavailable to members.
    • Implications: Over-utilisation, variable clinical quality, cost escalation passed to consumers.

  8. Simplified Bureaucracy for Authorisations & Claims
    • Need: Auto-approval for low-complexity exams, digital pre-authorisation in minutes for medium-complexity procedures.
    • Observed Gap: Manual review for even routine MRI/CT; average authorisation cycle 3–5 days; physical documentation required in many cases.
    • Implications: Treatment delay, patient frustration, higher operative cost for plans.

  9. Tailored Products for Diverse Life Stages & Socio-Economic Profiles
    • Need: Flexible plan tiers, on-demand telehealth-only products, and micro-subscription models for gig-economy workers.
    • Observed Gap: Offerings still built around employer groups; individual SME workers face 20–30 % higher premiums.
    • Implications: Growing uninsured/underinsured segment, missed revenue, political pressure for subsidies.

  10. Transparent Feedback & Dispute-Resolution Channels
    • Need: In-app grievance submission, trackable ticket IDs, mediation within 72 h before escalation to ANS.
    • Observed Gap: Call-centre-centric model; average solution time >15 days; customers resort directly to ANS or courts.
    • Implications: Brand damage, regulatory fines, customer churn.

Collectively, these unmet needs constitute the roadmap for innovation and policy that can move the private system from reactive problem-solving to proactive health-management.

Key Findings

# Pain / Unmet Need Evidence Source(s) Principal Impact on Customers Strategic Importance
1 Premium affordability & cost predictability ANS premium cap data; social listening cost complaints Budget strain, plan downgrades, market exit Critical – threatens market size
2 Regional access gaps Bed-density statistics; Human-capital shortage projections Travel burden, delayed care, inequity perception High – drives regulatory scrutiny
3 Slow innovation coverage ANVISA approval backlog; judicialisation cases Therapy delay, legal costs, unmet clinical need High – affects high-severity conditions
4 Bureaucratic friction & weak digital journey ANS complaint categories; EMR fragmentation notes Time loss, duplicate exams, dissatisfaction Medium-high – solvable via tech investment
5 Insufficient clear communication Policy-holder complaints on “lack of information” Misunderstanding benefits, poor preventive care Medium – quick-win via CX design
6 Mental-health and preventive-wellness gap Plan caps on therapy sessions; rising anxiety rates Untreated mental illness, absenteeism Medium-high – growing employer demand
7 Value-based care and quality transparency deficit Fee-for-service dominance; limited VBHC pilots Quality variability, over-use, cost inflation Strategic – enables sustainable cost control
8 Product flexibility for non-traditional workers Premium differentials for individual vs group; gig economy growth Under-insurance, lost coverage continuity Emerging – new market segment
9 Fast, transparent dispute resolution Average 15-day complaint closure; litigation growth Customer frustration, legal action Medium – reputation management

References

Agência Gov. “Março de 2024: planos de assistência médica somam mais de 51 milhões de usuários.” 6 May 2024. https://agenciagov.ebc.com.br/noticias/202405

Agência Nacional de Saúde Suplementar (ANS). “ANS divulga dados de beneficiários em novembro de 2024.” 3 Jan 2025. https://www.gov.br/ans/pt-br/acesso-a-informacao/beneficiarios

CNseg. “Planos de saúde alcançam 51 milhões de beneficiários em janeiro de 2024.” 14 Mar 2024. https://cnseg.org.br/noticias/planos-51-milhoes

ISTOÉ DINHEIRO. “Planos de saúde ganham mais de 860 mil clientes em 2024.” 5 Feb 2025. https://www.istoedinheiro.com.br/planos-de-saude

Value Chain Analysis Report on the Private Health Industry in Brazil (internal analytical document, 2025).