2011 Survey of Health Care Consumers in Brazil Key Findings, Strategic Implications

Produced by the Deloitte Center for Health Solutions

Contents
Foreword Introduction Survey highlights Zone One: Wellness and healthy living Zone Two: Information resources Zone Three: Traditional health services Zone Four: Alternative health services Zone Five: Health insurance Zone Six: Health policy Major findings Stakeholder implications Closing thoughts Contacts 3 4 6 8 9 11 16 17 19 21 22 23 24

Foreword

This as an important time for Brazil to be part of the 2011 Survey of Health Care Consumers since Deloitte Brazil has just consolidated Brazils Life Sciences & Health Care platform within a team of specialists (physicians, veterinarians, dentists, pharmacists, and economists, among others). This platform was developed to meet the industrys needs across all of its segments: Pharmaceutical Industry, Biotechnology Industry, Medical Devices, Animal Health, Health Plan Payors, Health Care Supply Chain, Hospitals, Laboratories, Image Services, Dentistry, Home Care, and Public Health. Brazils health care system comprises eight percent of the countrys gross domestic product (GDP). It is responsible for transactions totaling US$100 billion a year, has been designated the sixth-largest private health care market in the world by the World Health Organization (WHO), and is responsible for two million direct jobs and five million indirect jobs. The Brazilian health care market has been facing growing challenges for more than a decade. For example, the number of health plan operators has been decreasing year after year; key issues include high cost of services, high levels of claim rates, and questions regarding old coverage contracts. Hospitals, clinics, and physicians are also facing challenges, such as assisting patients under agreements that do not adequately cover their costs. Pharmaceutical and biotech industries must deal with patent expirations, threatened price controls by the government, and an influx of imports, which exposes these companies to USD exchange rate variations and the consequences of worldwide economic instability. The 2011 Survey of Health Care Consumers in Brazil, conducted by the Deloitte Center for Health Solutions, studies for the first time Brazilian consumers attitudes, behaviors, and unmet needs. It offers health care industry leaders and policy makers a timely look at how health care consumerism is evolving, as well as a comprehensive perspective on how Brazilians approach their health, health care, and health insurance. Enrico De Vettori Partner Deloitte & Touche Sao Paulo

In health care, the role that individuals play in choosing doctors and hospitals, treatment options, and insurance coverage is becoming increasingly important. In many of the worlds health care systems, that role to date has been minimal; however, it is clear that engaging individuals to become more active increases the likelihood of better care and lower costs. This survey of Brazilian health care consumers offers a glimpse of current opinions and activities as a baseline for future trend analysis. Concurrently, Deloitte conducted surveys in 11 other countries to compare consumer attitudes and behaviors in varied circumstances and systems of care. In most systems, consumers role in managing their health has been secondary; physicians and hospitals have made most of the decisions on their behalf. Looking forward, though, it is apparent that the emergence of technologies that assist consumers in decision-making, and anticipated limits on funding for health care systems, will require new approaches to population health management. Equipping consumers to be more active, engaged, and accountable for their care and the associated costs may be an important new dimension for health care system improvement. Paul H. Keckley, PhD Executive Director Deloitte Center for Health Solutions Washington, D.C.

2011 Survey of Health Care Consumers: Brazil

Introduction

How do health care systems perform from the viewpoint of the citizens they serve? Do individuals understand their treatment options and respond accordingly? Are choices of physicians and hospitals made based on objective information about quality, service, and cost? Are prescription drugs and alternative courses of care thoughtfully considered by consumers when recommended? Are mechanisms to mitigate financial risk via insurance or personal spending managed effectively, or are costs for health care forcing compromises for families? These questions are at the center of a global discussion about how health care systems whether governmentrun or private relate to their end users, consumers. In 2011, the Deloitte Center for Health Solutions surveyed adults in 12 countries to gauge opinions and expectations about their health care systems. Across these countries there are many differences in health care systems structures and operations as well as in the political and economic thrusts of national health care reforms. Citizens in each of these countries differ widely in their social, cultural, economic, and generational viewpoints; however, they are all end users of health care and hold strong views on the performance of their respective systems and what they expect to receive from health care. In this report, we offer a baseline analysis about health care consumerism in Brazil.

Health care consumerism: Conceptual framework for this study Conducted annually since 2008, Deloittes longitudinal study of heath care consumers seeks to provide a comprehensive view of health care consumerism, a view that goes beyond the conventional boundaries of what health and health care are commonly thought to encompass. In addition to the traditional services that doctors and hospitals provide, the studys framework takes into account the expanding spectrum of treatment alternatives, delivery settings, information sources, and programs that are coming into existence to promote wellness and self-care, address health needs, and finance health care. Now in its fourth year, and the first year for Brazil, the 2011 survey continues to build on previous years surveys by exploring consumers behaviors, attitudes, and unmet needs in six areas (Figure 1): Wellness and healthy living Information resources Traditional health services Alternative health services Health insurance Health policy

Figure 1: Zones of health care consumer activity

2. Information resources

1. Wellness and healthy living

Health care consumerism

3. Traditional health services

6. Health policy

4. Alternative health services

5. Health insurance

Copyright 2011 Deloitte Development LLC. All rights reserved.

This year, Deloitte surveyed health care consumers in Belgium, Brazil, Canada, China, France, Germany, Luxembourg, Mexico, Portugal, Switzerland, the United Kingdom, and the United States (Figure 2). Highlights of Brazils results are included in this summary. A global report, which contrasts findings from the 12 countries, and separate country reports can be found at www.deloitte.com/us/2011consumerism. Survey methodology A nationally representative sample of 1,000 Brazilian adults, aged 18 and older, was surveyed in April 2011 using a web-based questionnaire. The sample was representative of the nations population with respect to age and gender. The margin of error is +/- 3.0% at the .95 confidence level. The survey consisted of 56 questions, with 29 potential follow-up questions. It was administered in Portuguese. Participants were asked about behaviors before attitudes within each topic area to reduce response bias. Background: Brazils health care system Brazil has a national health care system in which the government provides free services to all Brazilian citizens. Seventy-five percent of the population uses the public system exclusively to access health care. Funding is financed by public resources and contributions from beneficiaries. Brazil also has a private supplementary system comprised of health plans and insurance companies. Twenty-six percent of the population has private insurance coverage. The private system is financed by employers and/or individuals. There are over 6,800 hospitals, 27,800 specialized diagnostic clinics, and 15,800 diagnostic centers as well as many other types of health care organizations in Brazil. Also, hospitals are 41 percent public, 34 percent private, and 25 percent philanthropic owned.

Figure 2: 2011 surveyed countries

Canada Europe U.S. Mexico China

Brazil Belgium France Germany Luxembourg Portugal Switzerland UK Copyright 2011 Deloitte Development LLC. All rights reserved.

2011 Survey of Health Care Consumers: Brazil

Survey highlights

Consumer perceptions of Brazilian health care system performance Brazilian consumers are dissatisfied and believe that the system is not performing well. Slightly fewer than 1% of consumers give the Brazilian health care systems performance a grade of A (excellent); 8% grade it B (very good). In contrast, 57% give the system a grade of D or F (31% of consumers grade it as F or failing; 26% give it a D) and 35% give it a C (Figure 3). 4 in 10 (40%) respondents are dissatisfied with the performance of the Brazilian health care system, with more Generation X (those born 1965 to 1981) (44%) and Boomers (those born 1946 to 1964) (42%) being dissatisfied than Generation Y (those born 1982 to 1993) (34%). Consumers are dissatisfied with wait times for services (81%), access to services (57%), and a lack of focus on patient-centered care (57%). 32% feel that they have a good understanding of how the Brazilian health care system works; 9% feel that they do not. Most consumers are aware of changes being made in the health care system (11% are very aware and 69% somewhat aware). 30% believe that the system is performing better now than five years prior; 48% believe that it is performing similarly, and 19% believe that it is worse (Figure 4). Few (6%) consumers believe the Brazilian health care system works better than other comparable systems in the world particularly with respect to quality of care (4%) and being technologically advanced (16%). 43% of survey respondents report an increase in their health care spending in the last year. Of the 25% who delay or forgo treatment recommended by their doctor, 27% do not go because the cost is too high and they cannot afford it. Consumers say they received good value for out-ofpocket spending in the past year on prescription drugs (50%), physicians (47%), over-the-counter products (41%), hospital care (39%), rehabilitation services (34%), and insurance premiums (25%).

Figure 3: Report card grades of overall health care system performance Using a typical report card scale with grades of A, B, C, D, and F, how would you grade the overall performance of Brazil's health care system?
100%

80% 8% 60% 57%

40%

35% 26%

31%

20% 8% 0% 1% A Favorable grade B C D Unfavorable grade F

Note: Bars may not sum precisely to the totals above due to rounding. 2011 Brazil Copyright 2011 Deloitte Development LLC. All rights reserved.

Figure 4: Health care system performance compared to previous years How do you think the public health care system in Brazil is performing now compared to what it was like ve years ago?
100%

80%

60% 48% 40% 30% 20% 19%

4% 0% Better 2011 Brazil Copyright 2011 Deloitte Development LLC. All rights reserved. Much the same Worse I dont know

Many Brazilians are responsible for the care of others. 44% of consumers report providing care for another individual. Of consumers who report caring for other individuals, 36% care for individuals under age 18, 17% care for individuals between ages 18 and 25, 28% care for individuals between ages 26 and 45, 32% care for individuals between ages 45 and 64, and 22% care for individuals 65+.35% care for individuals in more than one age group. Care is provided primarily by the recipients spouse (38%), parent (26%), son or daughter (26%), extended family members (8%), paid for out-of-pocket (4%) or paid for by the government (1%). Duration of care ranged from less than six months (24%), between six and 12 months (9%), between 12 and 24 months (12%), and over two years (32%). 23% are unsure of the duration of care. 88% of family caregivers report some impact on their income-generating capacity; for one-quarter (25%), this represents a major limitation on their ability to earn an income.

2011 Survey of Health Care Consumers: Brazil

Zone One: Wellness and healthy living

Most Brazilians report they are in good health. Almost half say they have at least one chronic condition. 13% of consumers rate their physical health as excellent and 41% rate it as very good (Figure 5). More men (57%) than women (49%) rate their physical health as excellent or very good. Almost half (46%) of individuals report having a chronic condition (Figure 5). 28% have one chronic condition, 13% have two, and 5% have three or more chronic conditions. Healthy living programs are used by 1 in 4 whereas few use personal trainers to improve health. About 1 in 4 (23%) reports participating in a health living/wellness program in the past year (Figure 6). Those with supplemental health insurance (25%) are more likely than those without (16%) to participate. Those with excellent or very good health (26%) are more likely to participate in a healthy living/wellness program than those with fair or poor health (13%). 12% of survey participants report they used personal trainers to improve their health (Figure 6). Vitamins and food with health benefits are popular. In the past year, around half of consumers (49%) say they took vitamins, minerals, or herbal supplements and half (48%) deliberately chose particular foods for their health benefits (Figure 6). To improve their health or to treat a health condition, 29% of Brazilian consumers take vitamins on a regular basis, 31% use nutritional foods, and 15% take overthe-counter medications. More men (34%) than women (24%) report taking vitamins or minerals. Many have regular check-ups and screenings. 2 in 3 (67%) consumers say they visited a doctor/ medical professional in the past year for a routine check-up (Figure 6). More women (70%) say they did so than men (63%). Half of consumers report they had an imaging exam or test (50%) and 40% of consumers say they had a flu shot in the past year (Figure 6).
Got a u shot 40%

Figure 5: Self-reported health status and chronic conditions In general, how would you rate your overall health? Have you been diagnosed by a doctor or other medical professional as having one or more chronic conditions?
100%

80%

60% 46% 41% 40% 35%

20%

13%

10% 2%

0%

Excellent

Very Good

Good

Fair

Poor

Self-reported health status 2011 Brazil Copyright 2011 Deloitte Development LLC. All rights reserved.

One or more chronic conditions

Figure 6: Wellness and preventive behaviors Which of the following have you done in the last 12 months?
Visited a doctor for a routine check-up Had an imaging exam or test 67%

50%

Took vitamins, minerals, or herbal supplements Chose a food for its health benet

49%

48%

Participated in a healthy living/wellness program Consulted a personal trainer 0% 2011 Brazil 12% 20%

23%

40%

60%

80%

100%

Copyright 2011 Deloitte Development LLC. All rights reserved.

Zone Two: Information resources

Consumers trust medical providers for information about treatments, safety, and costs. For information on the most effective and safe treatments for a certain health condition, consumers trust medical associations/societies (47%) and academic medical centers/teaching hospitals (47%) (Figure 7). Employers are the least-trusted source for quality/safety information (13%) (Figure 7) and for information on cost (19%). 1 in 5 says they trust the Internet (21%) and independent health-related websites (17%) for treatment and safety information (Figure 7). More than 1 in 4 trusts the Internet (27%) and independent health-related websites (27%) for cost information. Trust in Internet sources and websites does not vary by generation. Use of social networking sites for health care information, management, and monitoring is low. 70% respondents do not use social networking sites to learn more about prescription drugs, communicate with their physician or insurance company, or comment about health experiences. More Boomers (80%) than Generation Y (63%) and Generation X (70%) say they do not use social networking for the above healthrelated communications. One in five (20%) consumers reports using social networking sites to comment about their experiences using the health care system. Other uses include learning more about prescription drugs (16%), communicating with their insurance company (7%), and communicating with their physician (5%). Figure 7: Trust in information sources If you wanted information about the most effective and safe treatment(s) for a certain health condition, how much trust would you have in the following third-party sources to provide reliable information?
Academic medical centers/teaching hospitals Medical associations/societies State Departments of Health and Human Services Ministry of Health Community hospitals Health insurance companies/health plans Internet search engines/sites (e.g., Google, Wikipedia) Pharmacies Pharmaceutical/biotech/ medical device manufacturers Independent health-related websites (e.g., Web MD) Employers 0% 29% 25% 24% 23% 21% 18% 18% 17% 13% 20% 40% 60% 80% 100% 47% 47%

Chart shows % who trust the source (i.e., gave a rating of 8, 9, or 10 on a 10-point scale, where 1 = no trust and 10 = complete trust) 2011 Brazil Copyright 2011 Deloitte Development LLC. All rights reserved.

2011 Survey of Health Care Consumers: Brazil

Brazilians are interested in self-monitoring technologies and smart phones for their health management. Interest in using smart phones to monitor health and medical records is high: 43% say they are very likely and 44% are somewhat likely to use the technology if available (Figure 8). Boomers (18%) are more likely to say they are not interested than Generation X and Generation Y (11% each). 69% of respondents say they are interested in remote monitoring tools (Figure 8). 4% of consumers do not show interest in using a medical device that would enable them to check a condition and send information to their doctor electronically through a computer or cell phone via the Internet. More Boomers (78%) are interested than Generation Y (64%) and Generation X (69%) in remote monitoring tools. Personal health records are not widely used by most Brazilians. 4 in 10 (41%) respondents are concerned about privacy and security in maintaining a personal health record (PHR). 16% currently maintain a PHR. Utilization does not vary by health status or generation. 4% of consumers say they switched physicians in the past 12 months because they wanted a doctor who used the Internet and electronic medical records. 36% of individuals say they are very likely and 50% are somewhat likely to switch doctors if they could get access to their medical records through an Internet connection with the physician.

Figure 8: Interest in medical devices and cell phones for health-monitoring purposes If you have or were to develop a health condition that needs to be checked regularly, how interested would you be in using a self-monitoring device? If your medical records were available to you on your smart phone, and you were able to download information about your medical condition and treatments, how likely would you be to use your smart phone to monitor your health?
100% 80% 60% 43% 40% 20% 0% Interested in using a medical device that would enable you to check your condition and send information to your doctor electronically 2011 Brazil Copyright 2011 Deloitte Development LLC. All rights reserved. Very likely Somewhat likely Not at all likely 13%

69% 44%

Likelihood of using a smart phone (or PDA) to monitor health

Use of online resources for health care is low compared to use for banking, shopping, and travel. In the past year, 86% of consumers say they used the Internet to purchase merchandise, 67% to conduct online banking, and 45% to make travel reservations. Fewer (41%) say they looked online for information about health care treatment options. 1 in 3 consumers (33%) reports searching online for information about the quality of care provided by a specific physician or specialist; more women (38%) say they do this than men (28%). Survey respondents report using the Internet to find information about the costs of physician services (31%) and for information on treatment options or a particular treatment (41%). 1 in 5 (21%) says they used a blog in the preceding year to share or comment on a health experience; more 25-44 year-olds (25%) than 18-24 (21%), and 45-64 year-olds (13%) use blogs.

10

Zone Three: Traditional health services

Physicians Less than half of Brazilian consumers report having a primary care relationship. Less than half (45%) of survey respondents have a primary care provider (PCP). 49% have visited a doctor/medical professional for injury or illness in the past 12 months. Switching physicians is somewhat common: 33% of consumers report switching doctor/medical professionals in the past year. More women (38%) switch physicians than men (29%) do. Reasons for switching physicians include dissatisfaction with the care received from their doctor (49%), needing a different type of specialist (26%), dissatisfaction with the service provided by the staff in the doctors office (26%), the doctor no longer accepting a particular type of insurance (15%), and a preference for doctors who charge a lower fee (8%). Of the 86% who report they paid out-of-pocket for physician services in the past 12 months, nearly half (47%) feel that they received good value for their money; one quarter (26%) feel the opposite. One in five (20%) individuals says they decided not to see a doctor when sick or injured. This is due primarily to a belief that the problem would go away without medical attention (65%). Others report they did not seek care due to time pressures or inconvenient appointment times (38%), cost (20%), or lack of insurance coverage (9%) (Figure 9). In the past year, 25% delayed or decided not to seek treatment recommended by a medical professional. The main reason for delaying or forgoing treatment is concern over potential side effects (31%) and cost (27%). Of those who have a PCP, most (76%) are satisfied with the quality of care received from their PCP (Figure 10). Figure 9: Reasons consumers did not see a doctor when they were sick or injured Why did you decide not to see a doctor/medical professional when you were sick or hurt?
Thought the problem would go away Appointment times were inconvenient/I did not have time/took too long Wanted to use an alternative approach/natural therapy rst or instead Cost was too high Insurance did not cover the service or treatment I needed Difcult to nd a doctor who would accept a new patient Other 0% 2011 Brazil Copyright 2011 Deloitte Development LLC. All rights reserved. 20% 29% 65%

38%

9%

8%

7% 20% 40% 60% 80% 100%

2011 Survey of Health Care Consumers: Brazil

11

Hospitals Perceived specialization, ease of access, and reputation are factors Brazilian consumers consider in differentiating hospitals. 61% of consumers say they used a hospital service in the previous 12 months, primarily for emergency room (ER) care (44%) and outpatient treatment (29%). 14% report they stayed overnight. 57% of consumers are satisfied with the quality of care received from the hospital they used most recently (Figure 10). Women (61%) are more satisfied than men (53%). Consumers base hospital selection primarily on insurance coverage (61%), specialization (61%), fast access (61%), and reputation (60%). Medical school affiliation (21%) and religious affiliation (10%) are the least important factors (Figure 11). Retail medicine Brazilian consumers are receptive to retail/ ambulatory options for non-urgent care. 1 in 5 (21%) says they used a walk-in clinic such as a pharmacy or grocery store in the past 12 months for a non-urgent health problem. Many are willing to use a walk-in retail clinic for a minor condition if it meant they would be seen immediately (43%). Younger individuals express more interest than older individuals: 18-24 (49%) vs. 45-64 (38%). 1 in 3 (32%) is willing to use a walk-in retail clinic for a minor condition if it cost 50% less than visiting a doctor in a doctors office. Many consumers are willing to pay for care for a minor condition if it meant that they would receive care more quickly (41%).

Figure 10: Satisfaction with primary care providers and hospitals Overall, how satised are you with the quality of care you receive from your primary care provider/received from the hospital you used most recently?
100%

80%

60%

1%/6%

76%/57%

40% 23% 21% 23% 18%

32%

20% 0% 4% 1% 0% 2 Not satised 0% 2% 3 1% 4% 4 5% 7% 5 9% 3% 6

17% 13%

16%

0%

9 Satised

10

Primary care provider

Hospital care

Copyright 2011 Deloitte Development LLC. All rights reserved.

Figure 11: Factors important to hospital choice How important were the following factors to you in choosing the hospital you used most recently?
Fast access/no waiting times Insurance coverage Specialization Reputation Quality/satisfaction ratings or consumer reports Doctor recommendation/referral Amenities Distance from home Close to public transportation Cost of services Afliation with a medical school Afliation with a religious organization 0% 10% 20% 40% 60% 80% 100% 21% 41% 41% 53% 53% 51% 50% 61% 61% 61% 60%

Chart shows % who gave the factor a rating of 8, 9, or 10 on a 10-point scale (1 = not at all important and 10 = extremely important) among consumers who used hospital services in the last 12 months 2011 Brazil Copyright 2011 Deloitte Development LLC. All rights reserved.

12

Traveling for care Traveling for care outside Brazil is not common; however, many are willing to consider that option if it is recommended by their doctor. 15% of consumers report they traveled outside their local area in the preceding year, and 2% traveled outside Brazil, to consult with a doctor, undergo a medical test or procedure, or receive treatment. Many consumers say they would consider traveling outside Brazil if they needed a necessary hospital procedure like joint replacement or heart surgery (18% definitely and 41% maybe) or chose to undertake an elective procedure (13% definitely and 34% maybe) (Figure 12). Consumers say they would be willing to travel outside Brazil for necessary care based on the following: availability of the specific treatment needed (75%), an expectation of superior quality medical care and treatment (72%), more up-to-date technologies and facilities (70%), and lack of waiting times (59%). Many are open to travelling outside their local area for treatment if recommended to do so by their physician (49%). If necessary care (such as joint replacement or heart surgery) was available faster or of a better quality, then consumers would: Seek care at a hospital not the nearest to their home (66% definitely and 28% maybe). Seek care in a hospital located in a town or nearby city (53% definitely and 37% maybe) (Figure 12). If elective procedures (such as cosmetic surgery or dental treatments) was available faster or of a better quality, then consumers would: Seek care at a hospital not the nearest to their home (56% definitely and 36% maybe). Seek care in a hospital located in a town or nearby city (37% definitely and 48% maybe) (Figure 12). The decision to travel outside Brazil for elective procedures is based on criteria such as superior quality of medical care and treatment (70%), up-to-date technologies and facilities (67%), availability of specific treatments (66%), cost (61%), and no waiting times (61%).

Figure 12: Willingness to travel for hospital care How likely would you be to travel for necessary or elective hospital care?
Necessary 100% 6% 28% 36% 60% 37% 48% Elective 7% Necessary 9% Elective 16% 41% 53% Necessary Elective

80%

40% 66% 20% 56% 53% 37%

41% 34%

18% 0% Go to a hospital that is not the one nearest to your home because it offers better care or faster access to services Highly unlikely Maybe Denitely Travel to a hospital outside your town or city (e.g. in a major or different city) which is known to provide better care or faster access to services

13%

Travel outside Brazil to have the procedure

Copyright 2011 Deloitte Development LLC. All rights reserved.

2011 Survey of Health Care Consumers: Brazil

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Prescription medication use 4 in 10 (40%) take prescription medications and 15% use over-the-counter therapies. 40% say they take prescription medications on a regular basis. Of those who take prescriptions regularly, half (51%) take one daily, 27% take two daily, and 20% take three or more daily. 3 in 4 (76%) are highly confident in the effectiveness of their prescription medications. 15% take over-the-counter medications on a regular basis. 19% of those who are taking one or more prescription medications discontinued taking it before the supply was finished, and 1 in 10 (14%) modified the dosage or frequency of prescribed medication without asking their doctor (Figure 13). 6% of those who are taking one or more prescription medications switched medications in the past year (Figure 13). Prescription medication users looked online for information about treatment options (46%), compared treatment options for a particular health condition (24%), and sought advice at the pharmacy about a prescription medication prescribed by a doctor (24%) (Figure 13). Of the 6% of consumers who say they switched prescription medications in the past 12 months, most switched to a generic brand to save money (59%). Other reasons included the particular medication being no longer being available (30%), medication not working (28%), preference for an easier to take medication (24%), side-effects (22%), and switching to another brand because their insurance did not pay for the one prescribed (7%).

Figure 13: Seeking and using information about treatment options Which of the following have you done in the last 12 months?
Looked online for information about treatment options Asked a pharmacists opinion about a medication that was prescribed by a doctor Compared available treatment options for a particular health condition/problem Discontinued taking a prescribed medication before it was nished Modied the dosage or frequency of prescribed medication without asking or telling your doctor Asked doctor to prescribe particular drug by name or brand or asked whether it would be a better choice Switched prescription medications 6% 46%

24%

24%

19%

14%

13%

0% Chart shows % of prescription medication users 2011 Brazil

20%

40%

60%

80%

100%

Copyright 2011 Deloitte Development LLC. All rights reserved.

14

 Of those taking one or more prescription medications, 44% of consumers report they asked their doctor to prescribe a generic drug due to cost considerations (Figure 14). Consumers who are taking one or more prescription medications are willing to use non-traditional methods of acquiring those medications: 21% say they purchased prescription medications via mail order or online and 3% purchased prescriptions outside Brazil (Figure 14). Of the consumers who take one or more prescription medications, 1 in 3 (30%) says they purchased an over-the-counter product instead of filling a prescription (Figure 14). 15% of consumers report they were treated, or are aware of someone who was treated, in the last year with a personalized medication, which is described as a medicine that is tailored to an individuals needs and condition (e.g., using genetic testing to develop a specialized medication that specifically targets the individual with a particular disease).

Figure 14: Which of the following have you done in the last 12 months? Which of the following have you done in the last 12 months?
Asked doctor to prescribe a generic drug rather than the brand drug due to cost Purchased a generic drug instead of a prescription drug because of price or advice received at the pharmacy counter Purchased an over-the-counter product from a store instead of lling a prescription Purchased prescription medications from a mail order or online pharmacy Asked doctor to prescribe a generic or different drug because prescribed drug was not in insurance plan formulary Purchased a drug using a coupon provided by the pharmaceutical company Purchased prescription medications from a source outside the country 0% Chart shows % of prescription medication users 2011 Brazil Copyright 2011 Deloitte Development LLC. All rights reserved.

44%

42%

30%

21%

14%

12%

3%

20%

40%

60%

80%

100%

2011 Survey of Health Care Consumers: Brazil

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Zone Four: Alternative health services

11% of Brazilian respondents use alternative/ natural therapies. 11% of respondents say they consulted an herbalist, homeopath, chiropractor, or other alternative health care practitioner or advisor in the past year, and 23% treated a health problem with alternative/natural therapies (Figure 15). More women (28%) than men (19%) utilized alternative and natural treatments. Individuals who are taking one or more prescription medications report using an alternative treatment approach or natural therapy in addition (25%) to a prescribed medication and as a substitution (15%) to an alternative treatment for a prescribed medication. Of the 33% who report switching doctors in the preceding year, 11% switched to a health care practitioner who offered alternative/natural therapies. Of those who decided in the past year not to see a doctor when they were sick or hurt, 29% say they did so as they preferred to try an alternative treatment approach first or instead; of those who delayed or decided not to follow physician recommendations, 17% say they did so because they wished to use an alternative treatment or natural therapy first or instead. Figure 15: Use of alternative treatment approaches and natural therapies Which of the following have you done in the last 12 months?
Used an alternative approach/ natural therapy in addition to a prescribed medication (% of medication users)

25%

Treated a health problem with an alternative approach/natural therapy

23%

Substituted an alternative approach/natural therapy for a prescribed medication (% of prescription medication users) Consulted an herbalist, homeopath, chiropractor, or other alternative health care practitioner or advisor

15%

11%

0% 2011 Brazil Copyright 2011 Deloitte Development LLC. All rights reserved.

20%

40%

60%

16

Zone Five: Health insurance

3 in 4 (75%) consumers who responded have supplemental insurance; 6 in 10 (60%) believe they are adequately insured. 75% of all respondents are covered by some kind of supplemental health insurance, health plan, or health care program. Few people have PBM (Pharmacy Benefit Management or Programa de Benefcio de Medicamentos) (2%) and about 1 in 3 (36%) has dental. Of those who have supplemental insurance, the types of insurance held include: Insurance (51%) Cooperative (29%) Group medicine (22%) Self-managed (10%) Philanthropy (2%) Reasons for not having supplemental health insurance include too expensive (58%), having lost supplemental insurance after changing employment (20%), believing it was not necessary due to good health status (7%), preferring to pay out-of-pocket (6%), and other reasons (9%). Health insurance is obtained primarily through employers (52%). 38% of consumers say they purchased insurance directly. 12% are insured through other sources. 23% feel well-insured across their public and private plans, 61% feel that they are adequately insured, and 15% feel they are under-insured (Figure 16). Switching insurance plans is not common. 4% of consumers report they switched to a different health plan offered by the same insurance company and 5% switched to a different health plan offered by a different insurance company. Of those who switched, most say they wanted to get better coverage (46%) and pay less (39%). Figure 16: Adequacy of insurance coverage Thinking about the amount and types of health insurance coverage you have, how adequately insured do you consider yourself to be?
100%

80% 61% 60%

40% 23% 20% 15% 1% 0% Well-insured Adequately insured Under-insured Not sure

2011 Brazil (n = 750 who said they have supplemental insurance) Copyright 2011 Deloitte Development LLC. All rights reserved.

2011 Survey of Health Care Consumers: Brazil

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Brazilians with insurance value benefits that enhance care coordination and active health management. Most consumers say they would be very (40%) or somewhat (56%) interested in a plan that offered an incentive to PCPs to coordinate care and manage health. Interest does not vary by chronic condition prevalence, health status, or generation. 8 in 10 consumers say they limit spending for household essentials because of health care expenses. Those who feel adequately insured feel better prepared to deal with future health care obligations. 83% of survey participants are limited in their ability to spend money on essential household items (housing, groceries, fuel, and education) due to monthly health care expenses. 1 in 5 (22%) consumers reports being financially prepared to handle future health care costs; 1 in 4 (24%) is not financially prepared (Figure 17). Wellinsured (42%) consumers are more financially prepared for future health care costs than under-insured (11%), and adequately insured (22%). More men (25%) than women (18%) feel secure.

Figure 17: Financial preparation for future health care costs To what extent do you feel your household is nancially prepared to handle future health care costs?
100%

80%

60%

24%

22%

40%

20% 9% 0% 1 2 Not prepared 3 7% 9%

16% 11%

13%

13%

13% 5% 4% 10

9 Prepared

Note: Bars may not sum precisely to the totals above due to rounding. 2011 Brazil Copyright 2011 Deloitte Development LLC. All rights reserved.

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Zone Six: Health policy

Consumers are critical of Brazils health care system and desire improvements. Consumers are critical of the health care system. Few are positive about the system (e.g., believing that it is better than many other comparable systems [6%], is of high quality [4%], and is technologically advanced [16%]). Opinions vary concerning privatization, with around 1 in 5 (22%) believing that privatization would improve performance, and one-third (30%) not believing. 4% of consumers agree with the statement that the government does a good job balancing priorities in the system. Consumers are optimistic (56% agree) about the possibility of improving quality and reducing costs simultaneously in the current system of care. Opinions held by generations about the performance of the Brazilian health care system are remarkably consistent (Figure 18).

Figure 18: Consumer insights about the Brazilian health care system by generation Boomers (1946-1964) and Seniors (1900-1945)
Agree 5% 3% 22% 5% 23% 65% Disagree 64% 71% 38% 65% 32% 5%

Generation Y (1982-1993) System Insights Our system works better than most systems in the world. The quality of care in our system is comparable to the best in the world. Physicians and hospitals in our system have access to latest technologies and treatments. The government does a good job balancing priorities in our system. Increased privatization in our system would improve its performance. It is possible to improve quality and reduce costs simultaneously in our current system of care.
Agree = ratings of 8, 9, or 10 on a 10-point scale Disagree = ratings of 1, 2, or 3 on a 10-point scale

Generation X (1965-1981) Agree 6% 4% 15% 4% 25% 55% Disagree 62% 76% 42% 71% 26% 9%

Agree 7% 5% 15% 4% 19% 51%

Disagree 56% 68% 39% 61% 32% 10%

2011 Survey of Health Care Consumers: Brazil

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 Components of the Brazilian health care system that consumers feel favorably about include medical innovation (34%) and up-to-date technology (28%) (Figure 19). More women (38%) than men (31%) grade their system well for medical innovation.

Figure 19: Report card grades for specic elements of the health care system How would you grade the public health system in Brazil on the following dimensions (using a typical report card scale of A, B, C, D, F)?
Medical innovation (new treatments or services) 34% 29% 28% 35% 18% 46% 13% 51% 13% 57% 13% 57% 7% 81% 0% Favorable grade (A or B) 20% 40% 60% 80% 100%

Up-to-date technology

Up-to-date buildings and equipment Focus on wellness rather than illness

Patient-/consumer-centered

Access to services (availability and convenience)

Wait times for service

Unfavorable grade (D or F)

Copyright 2011 Deloitte Development LLC. All rights reserved.

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Major findings

#1: Consumers say the Brazilian health care system performs poorly and does not compare well with other systems around the world. Many consumers are dissatisfied with performance but recognize opportunities for improvement. 90% of Brazilian respondents believe that their health care system performs sub-optimally and 4 in 10 are dissatisfied with how the system functions. Few believe that the system works better than other comparable systems in the world, and the majority is dissatisfied with aspects of the system. Major areas for improvement are enhanced access to services, shorter wait times, better technology, and improved quality of care. Over half of Brazilians are optimistic about the possibility of improving quality and reducing costs simultaneously. #2: Access to primary care is relatively low, but satisfaction for those with access is high. The majority of Brazilian consumers do not participate in formal health lifestyle programs; however, vitamins and nutritional foods are commonly used to improve health. Satisfaction with care is high among consumers who have a PCP. Although less than half have a PCP, many consumers seek care for routine and sick visits along with preventive measures such as imaging exams and flu immunizations. Of the 23% participating in health lifestyle programs, 26% indicated that they are in excellent or very good health whereas 13% are in fair or poor health. Increasing participation by those in fair or poor health is an opportunity for improvement. Half of consumers use vitamins and nutritional foods as a preventive measure.

#3: Use of health care information technologies for self-monitoring and care management and use of online resources are low. 87% of consumers are interested in medical record access via smart phones and 50% indicate willingness to switch doctors to gain access to their medical records via an Internet connection. Privacy and security of personal information in PHRs is an issue but not one of overwhelming concern to consumers; less than half (41%) say they are concerned. #4: Brazilian consumers are concerned about health costs and see the role insurance programs play in assuring financial security. 83% of consumers say health care costs have limited their spending on other essential household items. 1 in 4 consumers does not feel financially prepared to handle future health care costs. 3 in 4 consumers have supplemental insurance, and most consumers feel either adequately insured (61%) or well-insured (23%) by all types of coverage. 96% of survey participants are interested in insurance plans offering an incentive to PCPs to coordinate care and actively manage health. #5: Policy changes that support improved access to primary health care services, improved service, and innovation that reduces costs are popular among Brazilians. Brazilians want their health care system to improve and are highly receptive to innovation in the sector. From a consumer perspective, much can be done that focuses on improving care systems, technology, reducing wait times, and developing a stronger consumer focus.

2011 Survey of Health Care Consumers: Brazil

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Stakeholder implications

Stakeholders in the Brazilian health care system should consider these questions and issues: How should providers doctors and hospitals improve their value proposition to consumers to achieve seamless continuity of care; enhance access and service delivery; reduce consumer out-of-pocket costs; and reduce non-evidence-based tests, surgery, and diagnostics? Value, evidence-based care, and attention to quality and service are all critical at a time when there is considerable market activity via acquisition and investment and a growing demand for hospitals in Brazil to become internationally accredited. Efforts to upgrade the quality of Brazilian hospitals, including collaboration with private sponsors, are appropriate given the publics appetite for innovative technologies and specialization. Consumers are clearly interested in technology. There is opportunity for stakeholders to take advantage of the growing amount of information available to consumers through online sources, social media, smart phones, and medical devices for monitoring health. Consumers are increasingly wired and information systems that educate and equip individuals to act accountably and appropriately can have great impact, as can clinical information systems and integrated systems for consolidating personal health care information.

How can companies that manufacture medical devices, pharmaceuticals, and over-the-counter solutions best reach consumers? How can consumers be engaged in understanding the impact and implications of emerging regulatory requirements such as policies to track and trace pharmaceuticals? Science presents a multitude of opportunities for consumers as well as limitations and challenges in achieving the optimal solution for their needs. Explicit efforts to educate Brazilians about the efficacy of prescription drugs and policy initiatives to improve oversight of the therapeutics industry are widely viewed as improvements. This is an important moment for health care in Brazil, with new national health care policies emerging that have the potential to stimulate the production of higheradded-value products, spur a generation of technical innovation, and improve international partnerships. How will policy directions translate into a transparent health care system offering quality service and a full range of diagnostic, analytic, health information technology, and therapeutic products to the consumer? Finally, what levers are necessary to engage consumers more meaningfully in decisions that affect their health care and, thus, the spending associated with that care?

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Closing thoughts

There are no easy answers to the challenges that face Brazils health care system; however, this study offers insights to guide development of possible solutions. Consumers participating in this survey have shared their thoughts and feelings; they have told us that high-quality, readily accessible and understandable health care is incredibly important to them. We agree. This ongoing study by Deloitte is a major milestone in capturing what consumers want from their respective health care systems and provides valuable guidance to stakeholders planning the industrys future.

2011 Survey of Health Care Consumers: Brazil

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Contacts

Authors Paul H. Keckley, PhD Executive Director Deloitte Center for Health Solutions Deloitte LLP pkeckley@deloitte.com Sheryl Coughlin, PhD, MHA Head of Research Deloitte Center for Health Solutions Deloitte LLP scoughlin@deloitte.com Leslie Korenda, MPH Research Manager Deloitte Center for Health Solutions Deloitte LLP lkorenda@deloitte.com Enrico De Vettori Partner Deloitte & Touche enricovettori@deloitte.com Aline Silva Ranieri Senior Consultant Deloitte & Touche aranieri@deloitte.com Verena Pinto Consultant Deloitte & Touche vepinto@deloitte.com

Acknowledgements We wish to thank Laura Eselius and all those who contributed their ideas and insights during the design, analysis, and reporting stages of the project. We would also like to thank Jennifer Bohn, Anna Brewster, and Kerry Iseman in the Deloitte Center for Health Solutions as well as Patsy Bolduc and Terry Koch from Deloitte Global Life Sciences and Health Care for their contributions. Contact information To learn more about the Deloitte Center for Health Solutions, its projects and events, please visit: www.deloitte.com/centerforhealthsolutions. Deloitte Center for Health Solutions 555 12th Street N.W. Washington, DC 20004 Phone 202-220-2177 Fax 202-220-2178 Toll free 888-233-6169 Email healthsolutions@deloitte.com Web http://www.deloitte.com/centerforhealthsolutions

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2011 Survey of Health Care Consumers: Brazil

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