‘Goal is to reduce processes’, says responsible for Prevent Senior’s control sector

Recently retired from the position of judge of the 1st Chamber of Private Law of the TJ-SP (São Paulo Court of Justice), Christine Santini, 59, was chosen by the health operator Prevent Senior to coordinate the external control body required by the TAC ( Term of Conduct Adjustment), signed with the Public Ministry in October last year.

The document was proposed by the Public Health Prosecutor’s Office in reaction to complaints from former doctors and patients who accused the company of distributing the Covid kit, medicines with no proven effectiveness against the coronavirus, and tampering with death certificates to influence the pandemic statistics.

According to her, the goal is to reduce the volume of lawsuits through the mediation of conflicts internally. “The judicialization of the country is absurd and there are methods for this to be corrected”, she says.

As a judge, the new coordinator of Integrity and Patient Experience at Prevent Senior claims to have had extensive experience in judging cases in the area of ​​supplementary health. “The sector has to develop a new look. Today the vision is very tight and treats these processes as if they were the sale of a vehicle, for example, and they are not. It is a situation that involves people in a situation of fragility due to a disease “, it says.

How will the Integrity and Patient Experience Coordination department be structured? This integrity sector will not replace the call center, the ombudsman or the compliance sector. The idea is to concentrate and coordinate the actions of the sectors to verify if they are really fulfilling the orders correctly.

How will it work in practice? I’m not a Prevent employee, I have a service contract. I talked to management and they came up with an even more comprehensive project than the TAC. Coordinate the sectors and make an overview of the company to check which sectors have some defect and need to be corrected and also check which ones are providing services with a quality not accepted by the beneficiaries. The idea is to have a look to the future to improve all processes in the company.

Why did you take the job? I feel the commitment of Prevent’s senior management to look to the future and improve processes. This will improve the brand, the service provided and customer satisfaction so that problems are resolved internally. One of the things that caught my attention the most is the volume of lawsuits in the courts. In 2020, we had one process for every 2.8 inhabitants. The country’s judicialization is absurd and there are methods to correct it. The consumer’s journey has to be within the company, which has to have internal bodies capable of solving the problems that arise. The Integrity Coordination is to verify that all other communication channels are working. Good communication with the person ordering solves the problem. Having a humanized communication is essential for everything to be resolved. We have a goal of dejudicialization. This has never been done in health operators.

This position is similar to the technical direction established by the ANS (National Supplementary Health Agency) in the company? I’ll even get many elements that she already has detection ready. Prevent’s vision is to improve processes to increasingly deliver a quality and humanized service. With regard to employees, provide the best possible work environment in which people truly engage with the company’s values.

What was most urgent of this contact with the technical direction of ANS? The functions are not confused. The priority will be to check what the bottlenecks are. Today it may be a matter of delay in making an appointment in a particular specialty, and in two months this may change and we will have another bottleneck. Recently, Prevent had a bottleneck in sending tickets. There was a system change and the tickets took a long time to arrive, so the number of complaints in the call center was huge.

Once the problem is detected, what is the second step? The second step is to contact the department to let them know what is happening. We will not always be able to grant everything the beneficiary asks for. Sometimes he wants to be seen by a doctor who is on vacation, for example, and cannot see him within ten days. We will be able to have an overview of what is happening in the company. This information will not be used to solve that specific problem, but also to detect flaws and strengths and verify what needs to be adapted.

How far does the department’s autonomy go to solve the bottlenecks? I have no decision-making power, I will be an external and independent body. Sometimes the competent sector is not aware of a particular failure. In the global analysis, if a recurring problem is detected, the company’s management will be communicated. If there is total inertia, within the TAC, the department will communicate other control bodies.

Will the department’s actions be public? No, in any way, to preserve the confidentiality of patient data. There is no obligation, but my idea is to make periodic and statistical reports and present them to the Public Ministry.

Did you judge any case involving Prevent Senior as a judge? I was the holder of the 1st Chamber of Private Law, which has competence to judge cases involving health plans. I judged thousands of cases from all operators, and Prevent Senior was not the one with the most cases. Often an operator that had never appeared before starts appearing in processes due to a cyclical problem. The function of the integrity coordinator is precisely to detect these cyclical problems to solve internally in the company. If this is not done, the company will not be fulfilling its role.

What is the reason for the high judicialization in the health insurance sector? It is difficult to pinpoint just one cause. Brazilians have a mentality of trying to solve problems within the Judiciary. There are many chambers and judges that resolve cases in the banking sector, major targets of judicialization. When I started my career, in 1987, I didn’t see so much judicialization in the health area. Very rarely was there a malpractice lawsuit. Mass judicialization takes place over time with greater consumer empowerment. Most cases deal with coverage failure and fraud. Denying coverage opens the door to lawsuits with the intention of fraud. There is a clash in the sector that was created in a way in which everything was taken to resolve in the Judiciary, which is not a technician in medicine. Resolving these issues before they become a process is much better because they can be analyzed by a multidisciplinary team. In court, there is expertise, but everything is slower.

Wouldn’t this need for pre-procedural mediation be up to the ANS? The agency has a very specific function and would not even be able to do this with all operators and millions of beneficiaries. There are official consumer protection agencies, but an operator-specific agency is something innovative because it brings this into the operator before reaching these defense agencies.

How will the complaints against Prevent Senior at the Covid CPI influence your work? I followed [a CPI] by television. My function does not look to the past. It is from now on for a crisis situation to be resolved before it becomes a very aggravated crisis situation. These facts that were discussed at the CPI will be dealt with by Organs competent bodies and I could not even give my opinion on that.

If this body existed at the beginning of the pandemic, would there have been complaints? It’s very difficult to say because the pandemic has changed everyone’s lives. This body could detect through complaints that a sector would need care. If the complaints reached the coordinator, a red light would light up. Going forward, if there is a situation like this, the idea is to detect it before it reaches external organs.

Did you have Covid? I didn’t have Covid, despite having had contact with several people who had. Fortunately so far I’m passing unharmed.

What will be the level of access to company documents? I will have access to complaints that arrive via the contact channel on the company’s website. These messages will only be delivered to me and people on my team.

Mrs. Will you be able to check if each claim is valid? No, I do not have the role of supervisor in the company. If there is a complaint, I will ask the relevant department for information. I will be a person with a global vision of the company. When the patient arrives at Prevent, he is sick and fragile, so he has to be treated with care. The patient is not just a body, he is an integral person and, when he is in a fragile situation, he has to be more careful.

Why does the health insurance industry generate so many complaints? My personal view is that the sector has to develop a new look. The health sector in general. Today the vision is very tight and treats these processes as if they were the sale of a vehicle, for example, and they are not. It is a situation that involves people in a situation of fragility because of a disease. You have to install a culture of care within the health sector.