“Telemedicine is an opportunity to truly transform health into a social right. And I’ve been trying to lend my credibility to prevent this discussion from turning into a corporatist and market-restriction debate.” The speech is from Claudio Lottenberg, an ophthalmologist in activity and who for over 20 years has also worked as a manager in the sector.
At 60, he is chairman of the board of directors of Hospital Israelita Albert Einstein since 2017, after 16 years as CEO. He was the São Paulo health secretary and president of the Amil UnitedHealth Group for three years. In addition, he is an avid writer of management books in the sector, entrepreneur and passionate about health innovation – in times without a pandemic, he makes four to five trips a year to research and follow news around the world. The list of predicates to define Lottenberg goes far.
Now, however, he is concerned about the future of telemedicine, a segment he fell in love with and started to bring innovations to Brazil. First for Einstein himself, since he came into contact with the modality in 2010, on a trip to Israel, and more recently as an entrepreneur. He owns, for example, a business of self-service medical booths that can be spread around the city. “There’s a test run at Parque do Povo. Prevent Senior will adopt 20 and the city of Anápolis, too.”
The adoption of telemedicine was temporarily authorized in Brazil since April last year through Law 13.989/20, but only during the covid-19 pandemic. The idea now is to discuss a permanent regulation in Congress.
Although Lottenberg does not directly cite the Federal Council of Medicine (CFM), he openly speaks of the medical sector’s own resistance to the novelty.
The budget of the Union foreseen for the health sector in 2021 is of BRL 126 billion, compared to the R$ 161 billion invested in 2020, the year in which the covid-19 pandemic arrived in Brazil. The sector is also experiencing great movement in the private sector. Large companies have listed shares on the stock exchange and there is a strong movement of consolidation and investment in technology underway. Any setback in the adoption of telemedicine in the country is absolutely off the radar of any of these big players, who include Rede D’Or, Hapvida, NotreDame Intermedical Group, Dasa, to name only the biggest. Together, all companies linked to the healthcare sector at B3 have a market valuation of over R$ 350 billion — that is, they concentrate almost 7% of the value of all Brazilian publicly-held companies.
Check out the main excerpts from the interview with Lottenberg below. The doctor, executive and entrepreneur granted the interview to the EXAME IN in his office inside the Einstein, while attending to several patients.
What have you seen in the debate on the regulation of telemedicine in Brazil that worries you?
These are issues that I can only call, even if I don’t like the name, corporatist and attempts to restrict the market. They are wanting to adopt rules such as geographic limitation for care — with requirements such as that it can only be practiced by doctors close to the patient — and preventing the use of remote solutions for the first consultation, which violates the legislation on medical autonomy. All of this is a nonsense that hinders the innovation and advancement that telemedicine itself represents.
What should regulation be concerned with then?
Legislation should be very free. Ensure data privacy, with the General Data Protection Law (LGPD). Make it very clear that the medical record belongs to the patient, but provide a reliable database that can be accessed with authorization from people. Telemedicine serves to democratize access, not to stifle it. Regulation is necessary, first, so that the market is not too voracious and becomes excessively mercantilist. And secondly, to preserve patient safety. It is necessary to provide for the accountability of the physician and the definition of a remuneration structure that does not harm, but helps the system. That’s all. Everything else is unnecessary. It is necessary to stop inventing things that will only narrow and reduce access.
Do you believe that the adoption of telemedicine will reduce the demand for doctors?
The dynamics of our profession are changing. Changing a culture is very complex. But there will be no subtraction of functions. On the contrary. In medicine, it is already proven that with each adoption of new technologies, instead of decreasing, it increases the demands of the sector. The more evaluations you do, the more doctors you need. But it frees up functions. For example, before, surgical questions can now be asked by an interventional radiologist, who makes guided accesses to the body, for biopsies, drainages, catheter insertions. It’s a function that didn’t exist before. Therefore, the idea that the demand for doctors is falling is false. I wonder if whoever is representing the medical community in the debate really knows medicine. He really understands the challenges in this sector.
But are you talking about public or private management efficiency here?
Of everything. Of course, more money is needed in healthcare. But I have been saying for some time that it is also necessary to make better use of the existing budget. Of everything that moves in health today, 1/3 is waste with redundancy, inefficiencies, excesses. In public management, for example, just to get out of the efficiency of patient management: do you know how much it costs to examine a person who is in prison? It costs R$ 40 thousand. And if you’re a maximum security prisoner, even more so. This person must be transported by specialized car and with multiple escorts. Or even a worker on a Petrobras platform who needed to be rescued by helicopter even for simpler questions.
But are there gains for patients as well?
Clear. Did you know that 40% of patients with chronic diseases, such as high blood pressure, stop taking their medication after about 50 to 60 days after the last medical appointment? Imagine what we couldn’t do to prevent strokes, the biggest cause of death in Brazil. Think of a dermatologist’s line in public health. Hives and melanoma, which can be a lethal cancer, go into this funnel together. Try to predict if there was a system to separate this. Other information: did you know that about 90% of emergency care could be solved in a primary care clinic? Often, the Emergency Room is the place where people go to alleviate their anguish. I thought about this a lot when I was secretary. There, people are sure there will be a doctor. And a person with a headache, a stab wound, and a heart attack enter the same line.
What was your first contact with telemedicine?
It was 10 years ago, in Israel, when visiting a medical emergency room I noticed that there were almost no children and I asked if there was a pediatric area. The answer is that yes, there was, but most issues were resolved over the phone. Who invented telemedicine, therefore, was the [Alexander] Graham Bell.
Will regulating telemedicine expand Brazilian medical access?
I am convinced that it will. Because the rich today already use telemedicine. My patients talk to me when they travel or when I travel. There are places in the United States where if you want an assessment for a highly complex problem, a second opinion, you enter the site, which gives you guidance on which exams to send, register and, presto, you make a remote consultation. So, it is necessary to create a mechanic that remunerates professionals adequately for this. I’m not talking about me, of course. After so many years working in health, it is clear to me that it is a social right. It is inconceivable to imagine a thriving society in which security, health, education and housing are not available.
What is the problem of not adopting telemedicine in the best way?
It feeds an onerous structure, where the degree of satisfaction is not good. At your side is someone having a heart attack, someone with a knife. It does not have a structure focused on need. Telemedicine is a great element that matches the digital moment of health. All of this brings us the opportunity, when working on a platform, to automate information, improve data security, reduce the need for labor, guide flows and improve processes. We cannot miss this chance.
But what about the risks of errors and the reduction in the humanization of care that are so talked about?
They speak of risks as if a doctor could not make a mistake in a face-to-face diagnosis. The risk is the same. But, for this reason, the medical accountability must be clear in the regulation. About dehumanization, this debate existed even when the stethoscope was created, and doctors stopped putting their ear to the chest of patients, or when urine tests went to the laboratory and no one else needed to assess the smell of the material. . Einstein performed between 4 million and 5 million telemedicine consultations for the SUS during the pandemic. If you compare the NPS [a nota de satisfação atribuída pelas pessoas] from those who go to an emergency room with those who use telemedicine, they will notice that those who received care from a distance are more satisfied. Of the people who go through teleservice, around 60% return within 45 days. People need to talk, I need feedback. So it’s such an obvious scenario that it’s a good thing and it was so helpful during the pandemic that I can’t accept that the regulatory environment is being set up without taking into account the positive aspects.
And what needs to be done to get the debate to the right place?
I think the population will have to press for progress. And that’s why I’ve been dedicated to speaking, to pointing out the subject in my lectures and presentations. So that people understand the advantages and can demand it from the government.
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