Painel Abramed 2021 - O DNA do Diagnóstico - inglês

Imaging Rapid Tests Tests (immunochro- matographic RADIOLOGICAL IMAGING PLAYS A assays) FUNDAMENTAL ROLE IN THE PROCESS OF DIAGNOSIS, TREATMENT AND SHORTLY AFTER THE START OF FOLLOW-UP OF COVID-19, ESPECIALLY THE COVID-19 PANDEMIC, THE IN PEOPLE AFFECTED BY THE DISEASE NATIONAL HEALTH SURVEILLANCE AND PRESENT MORE SEVERE AGENCY (ANVISA) AUTHORIZED, ON CONDITIONS. A TEMPORARY AND EXCEPTIONAL BASIS, THE USE OF RAPID TESTS FOR The imaging examinations most indicated for DIAGNOSING COVID-19, WITHOUT the detection of covid-19 are high-resolution CONFIRMATORY DIAGNOSTIC CT scans (HRCT) and chest tomography, PURPOSES, IN PHARMACIES AND according to the Brazilian Collegiate of DRUGSTORES. Radiology and Diagnostic Imaging (CBR). This measure generated concern in the It is important to emphasize that imaging diagnostic medicine sector, since the examinations are recommended to identify execution of tests requires a series of safety eventual damage in the lungs resulting from criteria and good practices, provided for by complications of pneumonia caused by the the sector’s regulations (RDCnº302). virus and should not be used as screening or for diagnosis of the disease. Studies indicate The measures to expand access to diagnosis that chest CT has high sensitivity for disease must meet the technical safety requirements diagnosis and may be considered the main tool established by health authorities and for current covid-19 detection in epidemic ensure patient safety. According to Anvisa, areas.46 scientific studies show that it is possible to detect antibodies through rapid tests from the seventh day of the of symptoms in a person infected with Covid-19. However, the Agency stresses that the results of rapid tests are not for confirmatory diagnostic purposes and should not be used as the sole basis for treatment or other patient management decisions. 46 Correlation of chest CT and RT-PCR testing in coronavirus disease 2019 (COVID-19) in China 201COVID-19 ABRAMED PANEL

D - Dimer Procalcitonin (PCT) D-DIMER IS A BLOOD COAGULATION MARKER THAT MAY BE ELEVATED AT AN WHEN A PATIENT PRESENTS SIGNS EARLY STAGE OF THE DISEASE, WHEN OF SEVERE INFECTION, A TIMELY SYMPTOMS ARE NOT SEVERE AND DIAGNOSIS IS ESSENTIAL. THIS IS OTHER MARKERS SUCH AS PLATELET ESPECIALLY TRUE FOR PATIENTS WITH COUNT, PROTHROMBIN TIME (PT) AND SEVERE INFECTIONS SUCH AS LRTI, PARTIAL THROMBOPLASTIN TIME (PTT) COVID-19 ASSOCIATED SECONDARY REMAIN UNCHANGED. BACTERIAL INFECTION OR SEPSIS. It is indicated in the diagnosis or to rule Procalcitonin (PCT) is a biomarker that, when out the hypothesis of thrombotic diseases used in conjunction with other laboratory or conditions (production of blood clots). findings and clinical assessments, can gauge the Studies suggest a relationship between risk of bacterial infection. PCT has proven to coagulopathies and complications such as be a valuable tool during the current covid-19 acute myocardial infarction, renal failure, pandemic, serving as a prognostic indicator of pulmonary thrombosis and, in more rare disease severity. cases, clots in the cranial venous network and in the lower limbs resulting from covid-19 in The initial PCT test, combined with clinical the most severe cases of the disease. signs and symptoms, can tell whether a bacterial infection is likely or not. A decision can then In cases of covid-19 infection, D-dimer be made to start antibiotics or to consider monitoring is necessary. The higher its an alternative diagnosis. The International presence in the blood, indicates that more Federation of Clinical Chemistry and coagulative processes are taking place in the Laboratorial Medicine (IFCC) has highlighted patient’s body. the essential role of clinical laboratories in this pandemic, beyond the etiological diagnosis 202 ABRAMED PANEL COVID-19 of covid-19. The biochemical monitoring of patients with the disease by means of in vitro diagnostic tests has been critical for assessing the severity and progression of the disease, as well as monitoring therapeutic intervention.

05.4 Preventive measures ONE OF THE MAIN MEASURES USED IN THE FIGHT AGAINST THE PANDEMIC, BESIDES THE USE OF MASKS AND PROPER HAND HYGIENE, IS TO STOP THE SPREAD OF THE VIRUS THROUGH SOCIAL ISOLATION MEASURES OR QUARANTINE. The evolution of the pandemic at a slower pace combination of moderate physical distancing of contagion allows policymakers to adjust measures, self-isolation and contact tracing the capacity of the healthcare system in terms would be most likely to control the rate of of infrastructure and care capacity. In recent spread of covid-19 transmission. Even with months we have observed a relaxation of these the reduction in the number of cases and measures in line with the pace of vaccination vaccination, maintaining preventive care and the evolution of new cases of the disease. through simple measures remains essential to containing the epidemic and reducing the rate Studies indicate that successful isolation and of contagion. social distancing measures can lead to a steep decline in the number of cases. A study in the United Kingdom47 chas found that the 47 Eficácia do isolamento, teste, rastreamento de contato e distanciamento físico na redução da transmissão do SARS-CoV-2 em diferentes ambientes: um estudo de modelagem matemática. 203COVID-19 ABRAMED PANEL

Wearing facemasks made of fabric or other materials, leaving the disposable surgical masks (N-95) for the exclusive use of health professionals involved in the disease management. Clean hands regularly and thoroughly with an alcohol-based hand rub or wash them with soap and water. Keep at least 1 metre distance between you and others. Avoid crowded places. Avoid touching eyes, nose, and mouth. Make sure you and those around you follow good respiratory hygiene. This means covering your mouth and nose with a bent elbow or tissue when coughing or sneezing. Then dispose of the used tissue immediately and wash your hands. Stay home and isolate yourself even with minor symptoms such as cough, headache, low- grade fever until you recover. Ask someone to bring supplies. If you must leave home, wear a mask to avoid infecting others. If you have fever, cough and shortness of breath, seek medical attention, but call ahead if possible and follow the instructions of the local health authority. Keep up to date with the latest information from reliable sources, such as WHO or local and national health authorities. 204 ABRAMED PANEL COVID-19

05.5 Impacts on the diagnostic medicine sector THE MORE RESTRICTIVE SOCIAL ISOLATION MEASURES (LOCKDOWN) IMPLEMENTED AT THE BEGINNING OF COMMUNITY TRANSMISSION, WHILE PLAYING A KEY ROLE IN REDUCING THE RATE OF SPREAD OF THE CORONAVIRUS, NEGATIVELY IMPACTED SEVERAL ECONOMIC SECTORS, ESPECIALLY HEALTHCARE SERVICES. With the suspension of all non-essential life and With the onset health maintenance activities, a sharp retraction of the pandemic was observed in outpatient consultations, there was a admissions for elective surgeries and, especially, decrease in diagnostic tests. In the diagnostic medicine the number of segment, this reduction was more pronounced authorizations in imaging clinics, which essentially rely on issued for tests outpatient consultations, all of which were and therapies. suspended as a result of the pandemic. issued for exams and therapies. Consequently, The initial projection (pandemic-free scenario) there was a systematic reduction in the indicated the carrying out of nearly 960 million performance of supplementary exams. supplementary exams in supplementary health in 2020, with an increase of 4.9% compared 205COVID-19 ABRAMED PANEL to 2019. This estimate reflected the behavior observed between the years 2017 and 2019, when the number of exams showed an annual growth rate of 4.8% per year. However, with the pandemic’s advent, there was a decrease in the number of authorizations

GRAPH AUTHORIZATIONS EVOLUTION ISSUED FOR EXAMINATIONS AND THERAPIES IN 2020 IN COMPARISON WITH 2019 (IN %) 81 Source: Covid-19 Bulletin / ANS. Prepared by Abramed. Note: Evolution in 2020 compared to the same period last year. Sample median of 50 operators who replied to the May 2021 IR. 9,3 2,7 -4,3 -2,1 -7,2 -19,0 -12,0 -16,0 -26,0 -47,0 -63,0 FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC 2020 In the first months after the beginning of the pandemic, a new projection indicated a reductionofapproximately17.2%intheexpected number of exams in 2020, which represented about 165 million exams. However, with the worsening of the pandemic in the country and the maintenance of social isolation measures, about 177.5 million diagnostic exams would no longer be performed in 2020, considering the initial projections and the number of exams performed in 2020. In comparison with the previous year, there was a reduction of 133.5 million diagnostic exams, corresponding to 14.6%. 206 ABRAMED PANEL COVID-19

GRAPH NUMBER OF PROCEDURES IN SUPPLEMENTARY HEALTHCARE VARIANCE BY TYPE (MILLIONS – 2020 COMPARED WITH 2019) 82 Source: ANS - Assistance Map of Supplementary Healthcare 2020. Prepared by Abramed. 2019 1.606,4 Medical Consultations -69,5 Other outpatient services -27,6 Exams -133,5 Therapies -17,1 Hospitalizations -1,3 Dental procedures -28,9 2020 1.338,5 Many exams that were not performed are Among the high complexity imaging exams, associated with cancer diagnosis and others there was a 24.5% decrease in MRI scans and a connected to preventive measures and disease 3.8% decrease in CT scans. A smaller reduction monitoring. In 2020, there was a sharp in the number of CT scans is explained by reduction in the number of diagnostic tests the recommendation and use for monitoring used to assist in the diagnosis of cancer: a drop severe cases of covid-19. of 37.3% in tests for occult blood in faeces; 31.8% in colonoscopies; 28.3% in mammograms and 207COVID-19 ABRAMED PANEL 24.4% in oncotic cervico-vaginal cytopathology tests. In Brazil, according to the audit report on the national policy for cancer prevention and control conducted by the Federal Audit Court (TCU), approximately 80% of patients with cancer were diagnosed in stages 3 and 4. These numbers generate concern, since early detection and treatment can increase the likelihood of patients being cured.

GRAPH NUMBER OF CANCER SCREENING TESTS (MILLIONS – 2016/2020) 83 Source: ANS - Assistance Map of Supplementary Healthcare 2020. Prepared by Abramed. 01 2 3 4 5 67 Cervico- 4,8 (-24,4%) -vaginal oncotic cytopathology in women aged 25 to 59 years Conventional and digital mammography 3,6 (-28,3%) Colonoscopy 0,9 (-31,8%) Fecal occult blood testing in people aged 50 to 69 years 0,7 (-37,3%) 2015 2016 2017 2018 2019 2020 Among the high complexity imaging exams, there was a decline of 24.5% in MRI scans and of 3.8% in CT scans. The lower decrease in the number of CT scans is explained by the recommendation and use for monitoring severe cases of covid-19. 208 ABRAMED PANEL COVID-19

GRAPH NUMBER OF MRI AND CT SCANS PERFORMED (MILLIONS – 2016/2020) 84 Source: ANS - Assistance Map of Supplementary Healthcare 2020. Prepared by Abramed. 0 1 23 4 5 6 7 8 9 MRI (Magnetic Resonance Imaging) 6,4 (-24,5%) CT Scans (Computer Tomography) 7,4 (-3,8%) 2016 2017 2018 2019 2020 The number In SUS, the procedures with diagnostic of procedures purposes had a reduction of 24.5% between with diagnostic January and June 2020 compared to the same purposes period in 2019, considering the procedures decreased both in performed in the outpatient setting according the Unified Health to the place of residence. In absolute terms, System and in this variation corresponds to a decrease of 118.7 Supplementary million procedures. In the first six months of Healthcare. 2021, it increased 21.1% compared to the same period of 2020. Despite the positive variation, the number of procedures has not yet returned to the level of 2019. The sharpest reduction in the number of exams in the public system is related, among other factors, to the availability of resources and access to healthcare services during the pandemic. 209COVID-19 ABRAMED PANEL

GRAPH VARIANCE (%) IN OUTPATIENT PRODUCTION AT SUS (JANUARY TO JUNE - 2019/2021) 85 Source: Ministry of Health - SUS Outpatient Information System (SIA/SUS). Extracted on September 1st, 2021. Prepared by Abramed. Note: Approved volume by procedure group and year of processing. Health promotion and -30,7 prevention actions -8,3 -36,5 Procedures with 21,1 -8,6 -24,5 diagnostic purposes -3,4 Clinical -26,6 Procedures -29,1 Surgical -34,8 Procedures -50,3 -67,6 Organ, tissue and 3,8 -19,9 cell transplants -16,9 Medicinal 17,8 1,2 products 19,3 3,3 Orthoses, prosthetics and 11,2 special materials 14,8 Supplementary healtcare actions. 8,6 -22,7 -16,1 Total 3,4 -14,8 -11,9 ∆ (%) JAN/JUN 2020/2019 ∆ (%) JAN/JUN 2021/2020 ∆ (%) JAN/JUN 2021/2019 The most affected diagnostic methods by the pandemic were endoscopy, with a decline of 40.2%; material collection, 38.2%; and diagnosis by pathological anatomy and cytopathology, 33.1%, between January and June 2020 in comparison with the same period of 2019. The CT scans had a negative variation in the same period, but have the highest growth rates even in the comparison with the pre- and post- pandemic period. This variation stems from the indication of imaging exams in the clinical management of patients with covid-19. 210 ABRAMED PANEL COVID-19

GRAPH VARIANCE (%) OF OUTPATIENT PRODUCTION IN SUS BY DIAGNOSTIC SEGMENT (JANUARY TO JUNE – 2019/2021) 86 Source: Ministry of Health - SUS Outpatient Information System (SIA/SUS). Extracted on September 1st, 2021. Prepared by Abramed. Note: Approved volume by procedure group and year of processing. -38,2 Material collection 22,6 Clinical laboratories Pathological anatomy -24,3 -23,7 and cytopathology Radiology 22,7 Ultrasound 14,0 -6,3 -33,1 CT Scan 4,3 -11,8 -23,8 MRI -2,5 -27,2 in vivo nuclear medicine -24,0 -30,3 Endoscopy Interventional 26,6 radiology 36,3 -19,9 Specialty 32,9 diagnostics 26,9 1,7 Special procedures in hemotherapy 18,1 -23,9 Rapid Test -10,1 -40,2 17,9 -29,5 -22,6 18,2 -8,5 -32,7 23,5 -16,8 -11,1 6,5 -5,4 -12,3 6,6 -6,5 ∆ (%) JAN/JUN 2020/2019 ∆ (%) JAN/JUN 2021/2020 ∆ (%) JAN/JUN 2021/2019 211COVID-19 ABRAMED PANEL

05.6 The role of regulatory agencies SEVERAL REGULATORY ACTIONS HAVE BEEN ADOPTED TO FACE THE UNFOLDINGS IN FACE OF THE EMERGENCE AND SPREAD OF THE NEW CORONAVIRUS. THE HEALTH AND SOCIOECONOMIC IMPACTS CAUSED BY THE PANDEMIC REQUIRED AN IMMEDIATE ACTION OF THE REGULATORY AGENCIES IN THE SUPPLEMENTARY HEALTHCARE MARKET AND IN HEALTH SURVEILLANCE. In the scope of the National Supplementary compensations. One of the most controversial Health Agency (ANS), the extraordinary measures is related to the suspension of incorporation of exams for the detection, healthcare plan readjustments for 120 days and diagnostic support and treatment of covid-19 the definition of an adjustment index of -8.19% in the list of procedures and events in for individual or family plans, from May 2021 healthcare and the guidance for remote care to April 2022. and the feasibility of implementing telehealth are noteworthy. ANS also instituted the In the field of the National Health Surveillance flexibilization of prudential norms and the Agency (Anvisa), several resolutions were concession of regulatory incentives through published; technical and informative notes; 212 ABRAMED PANEL COVID-19

The establishment of a (negative) readjustment index of -8.19% for individual or family healthcare plans was a controversial measure in the regulatory sphere. ordinances; calls for proposals; and service To ensure the risk mitigation related to rapid guidelines covering aspects of the segments tests in pharmacies, Abramed reiterated the with direct influence on dealing with the importance and the necessity of enforcement coronavirus. The flexibility resulting from actions carried out by the National Sanitary resolution RDC 377/2020 brought enormous Surveillance System (SNVS), to combat concern to the diagnostic medicine sector. non-compliance with RDC No. 377, and the The publication of RDC 377/2020 authorized, compliance with measures to protect the health on a temporary and exceptional basis, the use and the life of the population is essential. of “rapid tests” (immunochromatographic assays) for covid-19 in pharmacies and As of June 2020, the regulatory authority drugstores, and suspended the effects of § 2 intensified the debates about the national of art. 69 and art. 70 of RDC 44/2009 and of vaccination program and authorized the first PDC 379/2020. clinical trial in Brazil to test the vaccine against covid-19, developed by the University of Oxford, Rapid tests performed outside the laboratory in the United Kingdom. In the following environment have no diagnostic purpose, month, phase III clinical trials were authorized being merely ancillary and for diagnostic to test the vaccine developed by the company support. Additionally, negative test results do Sinovac Research & Development Co., Ltd not exclude covid-19 infection, just as positive (Sinovac Biotech Co., Ltd). Also in July, a new results should not be used as absolute evidence authorization for clinical trials in Brazil to test of infection and should be interpreted by two potential vaccines developed by BioNTech healthcare professionals in association with and Pfizer (Wyeth). Since then, negotiations on clinical data and other confirmational lab the Covid-19 vaccine registration in the country tests. have taken place. 213COVID-19 ABRAMED PANEL

05.7 Usage of healthcare insurance plans SINCE THE BEGINNING OF THE PANDEMIC, ANS HAS MONITORED THE IMPACTS OF THE PANDEMIC ON THE SUPPLEMENTARY HEALTHCARE SECTOR AND THE EVOLUTION OF INDICATORS OF HEALTHCARE PLAN AND INSURANCE OPERATORS. It consists of a set of information on the The number of number of beneficiaries, assistential and beneficiaries economic-financial data, considering a sample increased of operators that covers 80% of the beneficiaries. considerably Through this information, it is possible to even during the identify a new pattern of consumption of pandemic. medical-hospital services in the supplementary healthcare market during the pandemic. Beneficiaries membership-based plans, as described in section 3 of this panel. The evolution in the number of beneficiaries of the healthcare plans followed the All types of contracts had an increase in the performance of formal jobs in the country. period between June 2020 and June 2021. The The growth rate of beneficiaries was 3.4% corporate and group membership plans grew in July 2021, in comparison with the same 4.67% and 1.18%, respectively. The individual period of the previous year. In this period, or family plans had a slight increase of 0.03%. 1.6 million beneficiaries were incorporated, going from 46.8 million to 48.4 million. This growth was driven especially by the enrollment of corporate group plans and 214 ABRAMED PANEL COVID-19

GRAPH EVOLUTION OF THE NUMBER OF BENEFICIARIES OF MEDICAL ASSISTANCE PLANS AND FORMAL EMPLOYMENT STOCK (IN MILLIONS – 2019/2021) 87 Sources: Covid-19 ANS Bulletin. Novo Caged - SEPRT/ME - July/21. Prepared by Abramed. Note: The Covid-19 ANS Bulletin presents the number of beneficiaries in the month of July 2021. For this reason the data are displayed in this section of the Abramed Panel in addition to those presented in section 3. 48,5 42 48,0 41 40 39 47,5 38 47,0 37 36 46,5 35 JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN JUL 2019 2020 2021 HEALTHCARE BENEFICIARIES FORMAL JOBS STOCK GRAPH TAXA DE VARIAÇÃO NO NÚMERO DE BENEFICIÁRIOS DE PLANOS DE ASSISTÊNCIA MÉDICA, SEGUNDO O TIPO DE CONTRATAÇÃO 88 (2019/2021 – IN %) Sources: Covid-19 ANS Bulletin. Novo Caged - SEPRT/ME - July/21. Prepared by Abramed. Note: The Covid-19 ANS Bulletin presents the number of beneficiaries in the month of July 2021. For this reason the data are displayed in this section of the Abramed Panel in addition to those presented in section 3. Individual 0,17 or Family 0,06 -0,37 Collective 0,92 membership 1,18 1,40 Corporate 3,15 Collective 4,04 4,98 VARIANCE (%) ABR.21/ABR.22 VARIANCE (%) MAI.21/MAI.20 VARIANCE (%) JUL.21/JUL.22 215COVID-19 ABRAMED PANEL

Assistencial Production The volume of authorizations issued by the in outpatient care, with consultations and operators to perform supplementary exams other healthcare services. The positive and therapies48 allows establishing the variations noted between 2021 and 2020 pattern of use of elective procedures outside have an atypical basis of comparison, due to the hospital environment as a measure of the unfolding of the pandemic. Thus, they the use of healthcare services. An increase do not assertively express the impacts of the of 17% in the volume of authorizations pandemic in this period since a period of is perceived in the most recent period recovery is being compared to a very bad compared to June 2019, the pre-pandemic period. period. This increase indicates a resumption GRAPH EVOLUTION OF THE NUMBER OF AUTHORISATIONS ISSUED FOR EXAMINATIONS AND THERAPIES (VARIANCE IN COMPARISON WITH THE SAME 89 MONTH OF THE PREVIOUS YEAR - IN %) Source: Covid-19 ANS Bulletin. Prepared by Abramed. 200 161,0 101,0 150 37,0 -8,5 49,0 23,0 2,7 9,3 12,0 -63,0 17,0 3,1 -7,2 100 -19,0 APR -0,8 -26,0 -16,0 -12,0 -2,1 50 MAR -47,0 5,6 JUL AUG SEP MAY JUN OCT NOV DEC 0,3 0 0 -50 -100 FEB 2020 2020/2019 2021/2019 2021/2020 48 SADT – Diagnostic and Therapeutic Support Services 216 ABRAMED PANEL COVID-19

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Hospitalization costs The pandemic directly influenced the average The cost of length of stay and costs of hospitalizations, hospitalization especially when comparing clinical, surgical, by Covid-19 and covid-19 hospitalizations between June increased 43%, 2020 and June 2021. In this period, the cost per from R$44 day of hospitalization by covid-19 increased by thousand to R$64 8.1% (without ICU) and 22.8% (with ICU), while thousand. the average length of stay increased, especially in ICU beds, from 11.9 days to 13.8 days. Thus, the cost of hospitalization increased 43%, from R$ 44 thousand to R$ 64 thousand. This increase is associated with high consumption of hospital materials, especially with medications, hospital supplies and use of personal protective equipment. TABLE COSTS PER HOSPITALIZATION, COST PER DAY OF HOSPITALIZATION AND LENGTH OF STAY IN DAYS (JUN.20/JUN.21) 40 Source: Covid-19 ANS Bulletin. Prepared by Abramed. COST PER DAY OF LENGTH OF STAY (DIAS) CUSTO DE STAY (R$) INTERNAÇÃO (R$) Without UTI With UTI Without UTI With UTI Without UTI With UTI Surgical 2.586 3.963 2,1 6,0 5.439 23.540 Clinical JUN/20 Covid-19 1.376 3.217 4,4 7,6 5.641 24.533 JUN/21 Surgical ∆ (%) Clinical 1.768 3.789 5,5 11,9 9.708 44.888 JUN.21/ Covid-19 JUN.20 Surgical 2.442 3.860 2,2 5,9 5.397 22.870 Clinical Covid-19 1.948 3.364 5,0 8,7 7.440 29.403 1.912 4.652 6,0 13,8 11.541 64.202 -5,6% -1,6% 4,8% -1,7% -0,8% -2,8% 41,6% 4,6% 13,6% 14,5% 31,9% 19,9% 8,1% 22,8% 9,1% 16,0% 18,9% 43,0% 218 ABRAMED PANEL COVID-19

Claim Rate In the months following the beginning of the reduction in the number of procedures, and covid-19 pandemic in the country, the claim consequently there was a faster reduction in rate49 reached the lowest level ever recorded assistential expenses. Hence, the claim rate in healthcare plans. The suspension of elective in the medical-hospital operators50 was 82% procedures, such as consultations, exams in July 2021 and remains at a lower level than and surgeries, during the most restrictive that observed before the beginning of the period of the pandemic contributed to a pandemic. GRAPH CLAIM RATE GAINS AND LOSSES INDEX (2020/2021 – IN %) 90 Source: Covid-19 ANS Bulletin. Prepared by Abramed. Note: Claim rate of cash flow. Data from the sample of vertical operators among the 100 IR responding opera- tors in DIOPS/ANS. 74 76 78 80 80 79 81 81 79 82 74 75 73 72 74 66 62 64 FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN JUL 2020 2021 49 According to ANS: “The claim rate of cash flow takes into account the cash flow data. It should not be confused with the accounting claim rate mea- sured under the accrual basis of accounting, which follows its own methodology. The claim rate of cash flow was calculated by the average of the rates of each operator individually (not by aggregated data), aiming at eliminating the sample bias by the highest values. 50 Data from the sample of vertical operators among the 100 IR responding operators in DIOPS/ANS. 219COVID-19 ABRAMED PANEL

The timeframe between the first months of the A reduction in the pandemic and the adoption of social distancing claim rate in the and quarantine measures shows a decrease in first months of the claim rate in the first quarter and in a more the pandemic. pronounced manner in the second quarter of 2020. The financial statements of the medical- hospital operators indicate a strong deceleration in the growth rate of healthcare expenses in the second quarter of 2020, compared to the same period of the previous year. However, as of the second quarter of 2021, in comparison with the same period of the previous year, the healthcare expenses increased 45%, in the medical-hospital operators. GRAPH VARIANCE OF REVENUE FROM SERVICE AND ASSISTECIAL EXPENSE IN SUPPLEMENTARY HEALTHCARE - MEDICAL-HOSPITAL OPERATORS 91 (QUARTER BEFORE THE SAME QUARTER OF THE PREVIOUS YEAR) Source: Supplementary Health Accounting Panel. Prepared by Abramed. 45,0% 11,3% 8,6% 7,3% 8,8% 7,1% 9,0% 7,1% 6,9% 2,1 2,1 -18,6% 1T19/1T18 2T19/2T18 1T20/1T19 2T20/2T19 1T21/1T20 2T21/2T20 Revenue Assistential Expenditure 220 ABRAMED PANEL COVID-19

This combination of a faster increase in assis- tance expenses and growth in counterclaims revenue resulted in a claim rate of 86.3% in the second quarter of 2021, the highest rate seen since 2018. GRAPH PAYMENT RECEIPTS, HEALTHCARE COSTS AND CLAIMS IN SUPPLEMENTARY HEALTH - MEDICAL-HOSPITAL OPERATORS (R$ BILLIONS) 92 Source: Supplementary Health Accounting Panel. Prepared by Abramed. 70 100% 60 80,9% 84,0% 84,0% 83,6% 90% 79,6% 80% 79,3% 78,2% 50 70% 40 63,7% 60% 50% 30 40% 20 30% 20% 10 10% 0 2T19 1T18 2T18 1T20 2T20 1T21 0% 1T19 2T21 Revenue Expenditure Claim Rate 221COVID-19 ABRAMED PANEL

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Abramed Panel 06 223COVID-19 ABRAMED PANEL

06 Abramed Panel THE ABRAMED PANEL PRESENTS THE CONSOLIDATION OF INFORMATION FROM A GROUP OF THE MAIN INSTITUTIONS OPERATING IN THE VARIOUS SEGMENTS OF DIAGNOSTIC MEDICINE IN BRAZIL. In 2021, as in previous years, the Abramed of services, economic-financial performance Panel presents new indicators and updates and corporate governance. The main objective information made available in the last three is to contribute to sector transparency and years, providing a new perspective of the development of the diagnostic medicine sector analysis in each edition. Especially in sector, through a broad view of the structure this edition, some data presented consider the and performance, essential for understanding results of the first semester of the year and the the dynamics and relevance of activities last twelve months ending at the end of June related to diagnostic medicine in Brazil. 2021. The sections that comprise the Abramed Panel demonstrate institutional aspects, human resources, health care production, evaluation 224 ABRAMED PANEL ABRAMED PANEL

06.1 Corporate Profile THEABRAMED´S MEMBER COMPANIES OPERATE IN THE CLINICAL ANALYSIS AND IMAGING DIAGNOSIS SEGMENTS. These segments involve various activities In 2021 there associated with laboratory medicine, clinical is an increase analysis, pathological anatomy, molecular in members biology, toxicology and genetics, in addition participation in to imaging examinations, nuclear medicine, the telemedicine telepathology, teleradiology, graphic methods and vaccine and endoscopy, among other specialties that segments. are involved in the diagnostic process. Activities associated with diagnostic imaging (including radiology) are performed by 80.8% of the Abramed members,51 while clinical analysis activities correspond to 76.9% and pathological anatomy, 69.2% in 2021. Between 2020 and 2021, there is an increase in the participation of members in the telemedicine and vaccine segments. 51 A company may operate in more than one segment. For this reason, the sum does not add up to 100%. 225ABRAMED PANEL ABRAMED PANEL

GRAPH SHARE OF ABRAMED MEMBERS IN THE DIAGNOSTIC MEDICINE SEGMENTS (IN %) 93 Source: Abramed Panel. Note: Abramed - The 2021 presented results consider the first six months of the year. Diagnostic imaging 80,8 Clinical Analysis 80,8 76,9 Pathological anatomy 76,9 Molecular biology 69,2 Toxicology 69,2 Nuclear Medicine Genetics 57,7 Graphic methods 57,7 Vaccines 53,8 53,8 Laboratory support Endoscopy methods 50,0 50,0 Teleradiology Telemedicine 42,3 Occupational medicine 42,3 42,3 42,3 38,5 34,6 34,6 34,6 34,6 34,6 30,8 30,8 23,1 15,4 3,8 3,8 2021 2020 Abramed members perform 76.9% of the It is observed that some services, especially exams internally, which means they are those related to diagnostic imaging, endoscopic collected and analyzed by the company/ methods, nuclear medicine, and telemedicine group itself. Around 15.4% are performed are mainly carried out by own means, while by third-party support laboratories, many the other segments present a portion carried of them in partnership with international out by third parties. This same proportion was research institutes. Only 7.7% are performed observed in 2020. in-house and by third parties. 226 ABRAMED PANEL ABRAMED PANEL

GRAPH SHARE OF IN-HOUSE AND OUTSOURCED SERVICES (IN %) 94 Source: Abramed Panel. Note: Abramed - The 2021 presented results consider the first six months of the year. In-House and Outsourced 7,7 Outsourced 7,7 In-House 15,4 19,2 76,9 73,1 2021 2020 GRAPH SHARE OF IN-HOUSE AND OUTSOURCED SERVICES ACCORDING TO DIAGNOSTIC SEGMENT (IN % – 2021) 95 Source: Abramed Panel. Note: Abramed - The 2021 presented results consider the first six months of the year. Clinical Analysis 50,0 32,4 17,6 Diagnostic imaging (including 43,8 43,8 12,5 77,3 Radiology) 92,3 50,0 13,6 9,1 Pathological anatomy 77,8 41,7 7,7 88,9 (Pathology) 35,7 53,8 11,1 11,1 Teleradiology 50,0 11,1 Endoscopic methods 46,2 33,3 86,7 14,3 Graphic methods 80,0 8,3 55,6 Genetics 75,0 13,3 Molecular biology 75,0 20,0 Toxicology 11,1 25,0 Nuclear Medicine 25,0 Telemedicine Laboratory support Vaccines Occupational medicine In-House Outsourced In-House & Outsourced 227ABRAMED PANEL ABRAMED PANEL

The main types of clients served by Abramed Intense activity in member companies in the B2B (business-to- the B2B segment business) segment are represented by private especially in for-profit and non-profit hospitals, which providing services corresponds to 80.8%, i.e. eight out of every ten to private member companies provide diagnostic services hospitals. to private hospitals and 61.5% provide support services to other laboratories. GRAPH SERVICING THE B2B SEGMENT (IN % – BUSINESS-TO-BUSINESS) 96 Source: Abramed Panel. Note: Abramed - The 2021 presented results consider the first six months of the year. Private Hospitals 80,8 76,9 (FOR OR NON PROFIT) 61,5 Outher laboratories 57,7 (SUPPORT SERVICES) 46,2 38,5 Public Hospitals 23,1 Public health points 19,2 Dental segment 19,2 19,2 2021 2020 Regarding direct patient care B2C (business- Diagnostic services are available mainly in the to-customer), 96.2% of the member companies state capitals and the countryside, or only in the work with beneficiaries of private healthcare state capitals. The offer of services exclusively in plans and insurance, 84.6% serve patients the countryside occurs to a lesser extent because through direct payment and 57.7% serve the member companies have service units in patients in the public sector. It is noteworthy various municipalities. that some companies do not offer services directly to the public since they act as support laboratories. 228 ABRAMED PANEL ABRAMED PANEL

GRAPH SERVICING THE B2C SEGMENT (IN % – BUSINESS-TO-CUSTOMER) 97 Source: Abramed Panel. Note: Abramed - The 2021 presented results consider the first six months of the year.A member company may operate in more than one segment. Healthcare plan patients 96,2 88,5 (PAYMENT THROUGH HEALTHCARE PLAN OPERATORS) 84,6 Private practice 84,6 (DIRECT PAYMENT AT THE LABORATORY COUNTER) 57,7 53,8 Public sector patients 2021 2020 GRAPH SHARE OF SERVICES PERFORMED IN STATE CAPITAL OR IN THE COUNTRYSIDE BY DIAGNOSTICS SEGMENT (IN % – 2021) 98 Source: Abramed Panel. Note: Abramed - The 2021 presented results consider the first six months of the year. Clinical Analysis 23,1 15,4 61,5 Pathological anatomy 25,0 16,7 58,3 41,7 (PATHOLOGY) 25,0 8,3 50,0 71,4 75,0 Diagnostic Imaging 30,0 Teleradiology 41,7 28,6 38,5 10,0 60,0 Endoscopic methods 27,3 Graphic Methods 75,0 16,7 41,7 Genetics 33,3 15,4 46,2 Molecular Biology 11,1 11,1 18,2 54,5 Toxicology 50,0 Nuclear Medicine 25,0 Telemedicine 66,7 77,8 Laboratory support Vaccines 12,5 37,5 State Capital Countryside State Capitals & Countryside 229ABRAMED PANEL ABRAMED PANEL

The services provided by the group of The scientific production recorded by companiesassociatedwithAbramedhavetheir Abramed members was boosted in the year quality assured through various accreditation 2021 due to the effects of covid-19 in the and certification processes. The main population and the importance of exams for accreditations observed in 2021 were: ONA3 the management of the pandemic caused by (National Accreditation Organization), thecoronavirus.Thisproductionisrepresented PALC-SBPC/ML (Accreditation Program for through the participation in several national or Clinical Laboratories of the Brazilian Society international events, besides the participation of Clinical Pathology/Laboratory Medicine) in the elaboration of book chapters and and ISO 9000/9001. scientific articles. There were 163 publications in journals and periodicals and 146 papers It is noteworthy that the members have an presented in international congresses. The average of four certifications or accreditations scientific papers presented in the country per company. The following graph illustrates totaled 38, and the number of chapters in the main certifications or accreditations most books with the participation of associates was used in the sector. 20. We highlight an expressive participation of scientific production specifically related to the study on covid-19. GRAPH PARTICIPATION BY TYPE OF CERTIFICATION OR ACCREDITATION (IN % – 2021) 99 Source: Abramed Panel. Note: Abramed - The 2021 presented results consider the first six months of the year. ONA 3 57,7 PALC SBPC/ML 53,8 ISO 9000/9001 Joint Commission 42,3 DICQ 34,6 ISO 14.001 30,8 30,8 ONA 2 30,8 CAP Accredited 26,9 23,1 ONA 1 23,1 PADI (CBR) 19,2 SELOS (CBR) 19,2 Others 11,5 ISO/IEC 17.025 7,7 Canadian Accreditation 230 ABRAMED PANEL ABRAMED PANEL

GRAPH SCIENTIFIC PRODUCTION OF ABRAMED MEMBER COMPANIES 100 Source: Abramed Panel. Note: Abramed - The 2021 presented results consider the first six months of the year. Authorship of books and/or chapters in 20 national or international books 35 24 Papers presented at international congresses 163 (INCLUDING ORAL PRESENTATIONS SUCH AS LECTURES, TALKS AND 296 PRINTED OR ELECTRONIC POSTERS) 146 162 486 Papers presented at national congresses (INCLUDING 194 ORAL PRESENTATIONS SUCH AS LECTURES, TALKS AND PRINTED OR ELECTRONIC POSTERS) Indexed publications in journals and periodicals 38 55 393 2021 2020 2019 Even in the midst of the crisis caused by the models, among which the following stand out: new coronavirus, Abramed’s members invested expansion of home care, vaccine supply, digital in the development of new business models, health platforms and care coordination, tests especially in the vaccine segment. It is noted to detect covid-19, hospital support and Home that 64.4% of the companies invested in new Care. GRAPH PARTICIPATION IN NEW BUSINESS MODELS (IN %) 101 Source: Abramed Panel. 34,6 No 42,3 Yes 65,4 57,7 2021 2020 231ABRAMED PANEL ABRAMED PANEL

Each year the member companies invest in the development of applications for smartphones in order to offer greater comfort and convenience to patients. Additionally, the increased access of patients and doctors to test results contributes to significantly reduce waste in the sector. In 2021, 69.2% of the member companies developed apps, mainly for scheduling appointments due to the pandemic. GRAPH APPS FOR PATIENTS (IN %) 102 Source: Abramed Panel. 30,8 69,2 No 61,5 38,5 Yes 2021 2020 Abramed’s members invest continuously to promote solutions capable of delivering more value to patients. By means of advanced management software and systems, it is possible to analyze laboratory and image exams in an increasingly faster and more efficient manner, in addition to enabling more assertive clinical conducts. An increasing number of Abramed´s members have adapted to these technologies, especially the use of Business Intelligence (BI) software, used by 96.2% of the associates. 232 ABRAMED PANEL ABRAMED PANEL

There is a growing trend for companies to invest in integrating data from various segments of patient care, in order to provide better agility, improve decision-making and achieve greater efficiency gains in the healthcare system. GRAPH SOFTWARES & MANAGEMENT SYSTEMS (IN %) 103 Source: Abramed Panel. Note: Abramed - The 2021 presented results consider the first six months of the year. BI (BUSINESS INTELIGENCE) 88,5 96,2 Service systems 84,6 PACS - Picture Archiving 92,3 and Communication System 84,6 RIS - Radiology Information System 88,5 LIS - Laboratorial Information 73,1 System 73,1 ERP - 57,7 69,2 Enterprise Resource Planning 69,2 LIS or RIS integrated with HIS 69,2 69,2 (HOSPITAL INFORMATION SYSTEM) 69,2 2021 2020 In terms of structure, the number of service Image centers totaled 469 units at the end units (collection points) totaled 1,696 in of June 2021. This number increased slightly December 2020 and maintains the growth compared to the previous year, especially trajectory in comparison with the previous in the Southeast and Centre-West regions, year, even in the face of the unfolding of the remaining practically stable in the other pandemic in the diagnostic medicine sector, regions. This was also observed in relation with the exception of the Centre-West and to the number of laboratory units providing Northeast regions. By 2021, they will have services in hospitals, which totaled 275 units reached a partial total of approximately 1,754. in 2021. The laboratory execution centres totaled 83 units, and continue on a stable trajectory. 233ABRAMED PANEL ABRAMED PANEL

GRAPH COLLECTION POINTS 104 Source: Abramed Panel. Note: Abramed - The 2021 presented results consider the first six months of the year. 1.754 1.696 1.643 877 921 950 313 292 293 239 235 240 189 218 239 25 30 32 Centre-West Northeast North South Southeast Total 2021 2020 2019 GRAPH LABORATORY EXECUTION CENTRES 105 Source: Abramed Panel. Note: Abramed - The 2021 presented results consider the first six months of the year. 78 83 83 42 46 44 13 15 15 767 5 34 11 13 13 Centre-West Northeast North South Southeast Total 2021 2020 2019 234 ABRAMED PANEL ABRAMED PANEL

GRAPH IMAGING CENTERS 106 Source: Abramed Panel. Note: Abramed - The 2021 presented results consider the first six months of the year. 472 472469 392 394393 12 13 16 43 39 37 11 11 11 14 15 12 Southeast Centre-West Northeast North South Total 2021 2020 2019 GRAPH LABORATORIES PROVIDING SERVICES IN HOSPITALS 107 Source: Abramed Panel. Note: Abramed - The 2021 presented results consider the first six months of the year. 253 267275 178 187 190 14 17 18 30 31 33 0 00 South 31 32 34 Total Centre-West Northeast North Southeast 2021 2020 2019 235ABRAMED PANEL ABRAMED PANEL

The member companies are in step with the New diagnostic technological evolution of diagnostic imaging technologies equipment and seek to tailor this tendency to enable the reality of the diagnostic medicine sector. increasingly These new technologies enable increasingly accurate and less accurate and less invasive exams to be carried invasive tests. out. Ultrasound equipment is the most prevalent in the diagnostic imaging medicine sector, totaling 2,013 units in 2021, considering all the Abramed member companies. The MRI and CT Scan equipments totaled 151 and 86 units, respectively. GRAPH NUMBER OF EQUIPMENTS 108 Source: Abramed Panel. Note: Abramed - The 2021 presented results consider the first six months of the year. Ultrasound 1.914 1.987 2.013 MRI 149 CT Scan 146 Mammography 151 Bone Densitometry 84 PET/CT 84 Electrocardiograph 86 Analog X-Ray 101 Digital X-Ray 102 Camara gamma 107 75 75 76 15 14 14 200 210 214 51 40 34 84 78 79 40 41 41 2021 2020 2019 236 ABRAMED PANEL ABRAMED PANEL

06.2 Human resources THE DIAGNOSTIC MEDICINE SECTOR EMPLOYED MORE THAN 275,700 WORKERS IN THE VARIOUS ACTIVITIES INVOLVING THE DIAGNOSTIC PROCESS, ESPECIALLY IN CLINICAL LABORATORIES, WHICH ACCOUNTED FOR ALMOST HALF OF ALL JOBS IN THE SECTOR. This is a multidisciplinary and labor-intensive pandemic, but still resulted in a positive sector, comprising professionals with various balance of 1.6 thousand direct jobs. In 2021, medical and technical specialties. In 2021, there was an increase in the number of hirings the members of Abramed employed over and a reduction in the number of dismissals, 84,400 workers through formal employment resulting in a positive balance of 1.8 thousand contracts (CLT) and legal entities. In 2020, jobs. the hiring pace was less intense due to the GRAPH NUMBER OF HIRINGS, DISMISSALS AND BALANCE 109 Source: Abramed Panel. Note: Abramed - The 2021 presented results consider the first six months of the year. 15.000 + + + 10.000 2,9 1,6 1,8 thousand thousand thousand 5.000 0 2020 2021 2019 Hirings Dismissals 237ABRAMED PANEL ABRAMED PANEL

The professionals working in the technical areas of the Abramed member companies represent the largest contingent of employees, in general, corresponding to 41.8% of the total, in 2021. A higher proportion of employees is observed in activities related to corporate administration. Among the other activities, there is a high proportion of nurses, nursing technicians, biomedical and pathology technicians. The composition and distribution of employees varies according to the segment in which the associate company operates in the diagnostic medicine sector. GRAPH SHARE OF EMPLOYEES BY AREA OF OPERATION (IN %) 110 Source: Abramed Panel. Note: Abramed - The 2021 presented results consider the first six months of the year. 40,8 41,9 41,8 37,1 33,9 33,5 22,1 24,2 24,7 Administrative Technical Operational 2019 2020 2021 238 ABRAMED PANEL ABRAMED PANEL

GRAPH SHARE OF EMPLOYEES BY TYPE OF ACTIVITY (IN %) 111 Source: Abramed Panel. Note: Abramed - The 2021 presented results consider the first six months of the year. Administrative 37 38 Physicians 39 Nurses 3 12 Nurses (technicians) 3 13 3 13 Imaging Technicians 3 11 Biomedical imaging 5 11 examiner 5 9 Biomedical, biologist 2 8 or pharmacist 2 9 2 10 working at the NTO 10 Clinical pathology 1 10 technicians 1 10 1 Hospitality 1 Pharmacists 2 2 2019 2020 2021 The diagnostic medicine sector requires technical qualification and appropriate training to develop its activities. It is noted that 55.2% of the employees have technical and higher education. 239ABRAMED PANEL ABRAMED PANEL

GRAPH SHARE OF EMPLOYEES BY EDUCATION LEVEL (IN % – 2021) 112 Source: Abramed Panel. Note: Abramed - The 2021 presented results consider the first six months of the year. Fundamental 2,3 42,5 High School 31,5 Technical 14,6 Bachelor’s Degree 8,0 Post-graduation/MBA 0,8 0,3 Masters Doctorate The salary model is the main one used Although the fixed model is present in to pay medical professionals in the most of the Abramed members, we observe diagnostics segments by Abramed members. a distribution of compensation mainly Approximately 92% of the companies through the fixed+variable model, that is, associated with Abramed use the fixed model, for each R$100.00 used for remuneration of 53.8 use the variable by performance and 69.2% physicians, R$42.5 are allocated for this type of use the fixed + variable model. Companies may compensation. use one or more remuneration models. GRAPH COMPENSATION MODEL (IN % – 2021) 113 Source: Abramed Panel. Note: Abramed - The 2021 presented results consider the first six months of the year. Fixed 92,3 Variable (performance) 53,8 Fixed-Variable (performance) 69,2 240 ABRAMED PANEL ABRAMED PANEL

GRAPH SHARE OF PAYMENTS BY COMPENSATION MODEL (IN %) 114 Source: Abramed Panel. Note: Abramed - The 2021 presented results consider the first six months of the year. Fixed 28,5 Variable (performance) 28,9 Fixed-Variable (performance) 28,9 28,7 29,0 28,7 42,8 42,1 42,5 2019 2020 2021 The most common hiring system among physicians is through legal entities, with a 90.1% share in 2021. Regarding technicians, hiring through CLT predominates, with 98.8%. Among biomedical doctors, 100% of hirings are through CLT. GRAPH DISTRIBUTION OF PHYSICIANS BY CONTRACT REGIME (2021) 115 Source: Abramed Panel. Note: Abramed - The 2021 presented results consider the first six months of the year. 7,4% 90,1% CLT Legal Entity 2,6% Cooperatives 241ABRAMED PANEL ABRAMED PANEL

GRAPH DISTRIBUTION OF TECHNICIANS BY CONTRACT REGIME (2021) 116 Source: Abramed Panel. Note: Abramed - The 2021 presented results consider the first six months of the year. 1,2 % 98,8 % Cooperative CLT The percentage of physicians with specialty distributed among the areas of radiology and degrees reached 96.2% in 2021. This result diagnostic imaging (7,080); clinical analysis reflects the concern of the members with (310); endoscopy and colonoscopy (340); and medical training and with quality in the pathological anatomy (228). In total there was provision of diagnostic medicine services. a 1.3% reduction in the number of doctors between 2020 and 2021. Abramed members employed 7,959 physicians at the end of the first half of 2021, GRAPH DOCTORS WITH SPECIALTY TITLES (IN %) 117 Source: Abramed Panel. Note: Abramed - The 2021 presented results consider the first six months of the year. 95,9 96,2 90,7 2020 2021 2019 242 ABRAMED PANEL ABRAMED PANEL

GRAPH NUMBER OF DOCTORS PER SPECIALITY 118 Source: Abramed Panel. Note: Abramed - The 2021 presented results consider the first six months of the year. Diagnostic imaging 7.209 7.113 7.040 Clinical Analysis 316 Endoscopy & colonoscopy 315 304 Pathological anatomy 347 361 341 214 229 228 TOTAL 8.086 8.017 7.913 2019 2020 2021 GRAPH NUMBER OF X-RAY TECHNICIANS 119 Source: Abramed Panel. Note: Abramed - The 2021 presented results consider the first six months of the year. 2.323 2.289 2.233 2020 2021 2019 243ABRAMED PANEL ABRAMED PANEL

06.3 Assistential production THE ABRAMED MEMBERS CARRIED OUT MORE THAN 532.8 MILLION DIAGNOSTIC EXAMS IN THE LAST 12 MONTHS (ENDING IN JUNE 2021), AN INCREASE OF 15.4% COMPARED WITH THE 12 MONTHS IMMEDIATELY BEFORE. In 2020, about 461.6 million exams were supplementary health care. This significant performed, with a reduction of 10.7%, due to the share is related to the quality of the exams unfolding of the new coronavirus pandemic. performed by the members in the diagnostic The most performed exams are concentrated process. The exams offered by the members in the clinical analysis segment, with 509.2 provide a set of information used to diagnose million exams, while imaging exams totaled or rule out specific health problems of a patient. 17.6 million. By using exams rationally and according to clinical guidelines and protocols, patients The exams performed by the member and physicians will have the best information companies of Abramed correspond to available that can help in the decision making approximately 60% of the total performed in process to indicate or manage treatments. 244 ABRAMED PANEL ABRAMED PANEL

GRAPH NUMBER OF CONDUCTED TESTS BY SPECIALITY (PER THOUSAND) 120 Source: Abramed Panel. Note: Logarithmic scale - base 10 graph. The 2021 presented results consider the first six months of the year. Supplementary healthcare estimates for 2021 1 10 100 1.000 10.000 100.000 1.000.000 Total 592 532.844 Clinical Analysis 577 461.572 749 488 516.975 466 509.227 534 439.872 311 490.342 317 Diagnostic 434 17.584 imaging 106 16.469 103 19.942 Pathological 139 anatomy 4.534 3.760 Graphic 4.375 methods Genetics Endoscopic methods Nuclear Medicine Toxicology 4 3 Molecular 2 Biology 1 2021 2020 2019 245ABRAMED PANEL ABRAMED PANEL

GRAPH NUMBER OF EXAMS PERFORMED IN SUPPLEMENTARY HEALTHCARE AND ABRAMED MEMBERS (PER THOUSAND), AND MARKET SHARE (%) 121 Source: Abramed Panel. Note: Abramed - The 2021 presented results consider the first six months of the year. Supplementary healthcare estimates for 2021. 916,5 783,0 58,9 900,5 461,6 59,2 56,4 532,8 516,8 2019 2020 2021 (ESTIMATE) Supplementary Health Care Abramed Market Share With regard to the proportion of the number The exams of imaging exams performed, it is noted performed by that ultrasonography and radiography the companies represent 40.7% and 19.4%, respectively, of the associated total number of diagnostic imaging exams with Abramed performed in 2021. correspond to nearly 60.0% The no-show rate of patients with previously of the total scheduled imaging exams was 16.9% in 2021 performed in and 17.32% in 2020. This percentage may vary supplementary according to the type of exam and indicates healthcare. that, on average, for every 100 exams scheduled to take place in a given location and period, 17 fail to be performed due to patient absence, most often unjustified. 246 ABRAMED PANEL ABRAMED PANEL

GRAPH SHARE OF SELECTED IMAGING EXAMINATIONS (IN % – 2021) 122 Source: Abramed Panel. Note: Abramed - The 2021 presented results consider the first six months of the year. Ultrasonography 40,7 X-Ray 19,4 MRI 10,9 CT Scan 10,6 Mammography 6,5 Echocardiogram 4,6 Densitometry 3,3 Other 2,9 Fetal medicine 1,0 247ABRAMED PANEL ABRAMED PANEL

GRAPH AVERAGE NUMBER OF EXAMS PER SERVICE BY DIAGNOSIS SPECIALTY 123 Source: Abramed Panel. Note: Abramed - The 2021 presented results consider the first six months of the year. Clinical Analysis 10,1 Pathological anatomy 10,1 Diagnostic imaging 11,0 (INCLUDING RADIOLOGY) 1,9 1,4 Endoscopic methods 1,4 Graphic methods Genetics 1,6 Molecular Biology 1,7 Toxicology 1,8 Nuclear Medicine 1,3 Vaccines 1,3 1,3 1,1 1,1 1,1 3,0 3,3 3,3 1,4 1,4 1,4 1,0 1,1 1,0 1,3 1,3 1,3 1,2 1,5 1,2 2019 2020 2021 GRAPH NO SHOW – RATE FOR DIAGNOSTIC IMAGING EXAMINATIONS 124 Source: Abramed Panel. Note: Abramed - The 2021 presented results consider the first six months of the year. 18% 17,32 16,29 17% 2020 2021 16% 15,90 15% 2019 248 ABRAMED PANEL ABRAMED PANEL

Therefore, the physical and human resources performed in 2021. The growth of electronic planned for these services are not properly access is an industry trend as new data sharing used, representing another form of waste technologies become available, facilitating and making it impossible for more patients access by patients or physicians. In this sense, to access the exams indicated to clarify their many exams are only accessed by the physician clinical situation. As a result, the costs of the or team responsible for patient follow-up exams may increase significantly as these and can be considered as non-accessed. It is resources become idle. The participation of the estimated that this number is even higher patient in the cycle of care is essential to avoid and its more precise and exact measurement the increase of expenses and waste in the health is hindered by the lack of interoperability of sector. some systems. The number of reports electronically accessed totaled approximately 94.1 million and corresponds to 17.8% of the total number of tests GRAPH NO SHOW – RATE IN DIAGNOSTIC EXAMS BY TYPE OF EXAM (IN %) 125 Source: Abramed Panel. Note: Abramed - The 2021 presented results consider the first six months of the year. CT Scan 16,3 26,6 X-Ray 16,9 25,8 17,9 24,3 Echocardiogram 18,8 Densitometry 20,6 Mammography 20,2 Ultrassonography 16,4 18,0 MRI 16,0 19,0 16,7 19,2 15,2 15,7 15,8 14,1 14,9 15,4 2021 2020 2019 249ABRAMED PANEL ABRAMED PANEL

GRAPH NUMBER OF REPORTS ACCESSED THROUGH THE INTERNET (PER 1,000) 126 Source: Abramed Panel. Note: Abramed - The 2021 presented results consider the first six months of the year. Total 91.303 74.328 Clinical Analysis 94.076 88.266 72.771 91.977 Diagnostic imaging 2.619 1.271 1.724 Pathological 231 anatomy 152 217 Graphic methods 143 104 120 Endoscopic methods 29 21 Nuclear Medicine 26 11 8 10 Genetics 3 1 2 2019 2020 2021 The number of reports neither retrieved nor Clinical analysis and diagnostic imaging tests accessed totaled approximately 21.8 million are usually more frequent from the age of 15 and represents 4.1% of the total, considering in women, especially during adolescence and the set of clinical analysis and imaging tests at reproductive age. Among men, an increase is Abramed member companies in 2021. Despite observed from the age of 24 and around the age the nominal increase, the share of these exams of 60. over the total performed remains at the same average level of 4%. 250 ABRAMED PANEL ABRAMED PANEL