Painel Abramed - O DNA do Diagnóstico - inglês

150 In 2019, the number of exams by beneficiaries was of 19.5, in the supplementary health. In 2019, the number of exams by pace of hospitalization by beneficiary beneficiaries was of 19.5, with an in- (0.18), with a growth of 6,7% in the crease of 6.5% in comparison to 2018. same basis of comparison. This increase has followed the growth Graph 9 Average quantity of complementary exams performed in the Supplementary Health by beneficiary (2015-2019) Source: ANS – Care Map of Supplementary Health 2019. Obtained in Aug. 18/2020. Designed by Abramed. Note: This considers the average number of beneficiaries of health care plans each year. It considers the number of out-patient examinations excluding those carried out during hospitalization. 25 20 19.5 15 Abramed Panel | 2020 10 3.4 5.9 5 0 Other outpatient care Complementary exams 1.5 0.2 Doctor's appointments 2015 2016 2017 2018 Therapies Hospitalizations 2019

Unified Health 151 System (SUS) In the Unified Health Sys- tem (SUS) around 3.7 bil- lion of outpatient events were performed in 2019. The events for diagnosis have to- taled nearly 981.6 million and have increased 5.0% in com- parison to 2018. Jointly, they correspond to 26.1% of the total of outpatient proce- dures performed by SUS. Table 13 Outpatient care at SUS by group of procedures (million – 2015-2019) Source: Ministry of Health – Outpatient Information System from SUS (SIA/SUS). Designed By Abramed. Note: Outpatient care – Quantity approved by year of care, according to group of procedure. Obtained in August 17/19. SUS Outpatient Production 2015 2016 2017 2018 2019 ∆ (%) 2019/2018 Total 4,116.1 3,986.1 3,978.4 3,658.0 3,760.0 1,379.7 2.8 Clinical Procedures 1,628.6 1,523.1 1,523.3 1,352.2 1,022.2 2.0 The sector of diagnostic medicine 981.6 4.8 Medication 840.2 865.6 925.9 975.3 285.2 5.0 43.6 -7.4 Procedures for diagnostic purposes 897.0 893.8 902.1 934.8 38.4 -4.9 15.6 Health promotion and prevention actions 626.4 591.4 524.0 307.9 7.5 7.2 1.8 2.0 Surgical procedures 91.9 77.1 65.1 45.8 Complementary health care actions 24.5 27.2 29.6 33.2 Orthoses, prostheses and special materials 5.7 6.1 6.6 7.0 Organ, tissue and cell transplants 1.7 1.7 1.7 1.7

152 Table 14 Outpatient care at SUS by group of diagnostic procedures (million – 2015-2019) Source: Ministry of Health – Outpatient Information System from SUS (SIA/SUS). Designed By Abramed. Note: Outpatient care – Quantity approved by year of care, according to group of procedure Obtained in August 17/19. Procedures for 2015 2016 2017 2018 2019 ∆ (%) diagnostic purposes 2019/2018 Total 897.0 893.8 902.1 934.8 981.6 5.0 Clinical laboratory 616.6 624.7 631.2 677.2 716.8 5.9 Radiology 62.2 60.8 60.8 62.6 63.8 1.9 Material collection 76.7 64.7 65.8 51.8 51.4 -0.8 Diagnostic methods in specialties 37.2 39.2 40.8 44.6 49.0 9.9 Quick test 52.9 52.3 49.1 41.9 41.2 -1.6 Ultrasound 15.4 15.9 17.0 18.2 19.4 6.7 Abramed Panel | 2020 Hemotherapy 15.9 16.0 16.4 16.4 16.6 1.8 Pathological anatomy and cytopathology 11.7 11.8 11.7 12.1 12.0 -0.6 Tomography 4.0 4.3 4.7 5.3 6.0 12.2 Endoscpy 1.8 1.8 1.9 2.0 2.1 6.8 Magnetic resonance 1.0 1.1 1.1 1.2 1.4 15.7 Epidemiological and environmental surveillance 1.0 0.7 1.1 1.1 1.3 15.5 Nuclear medicine in vivo 0.4 0.4 0.5 0.4 0.5 3.8 Interventional radiology 0.1 0.1 0.1 0.1 0.1 2.0

Analyzing the diagnostic procedures, it is possible to no- 153 tice a significant share of clinical analysis, with 716.8 million exams performed and an increase of 5.9% in comparison to 2018. These exams correspond to 73.0% of the total num- ber of events. Following that, there are the radiology exams, with 63.8 million and an increase of 1.9%. In 2019, the main imaging exams performed at SUS were radiography with 68.8 of the total number, followed by ultrasound with 20.9%, CT Scan with 6.4%, endoscopy with 2.3% and magnetic resonance with 1.5%. Graph 10 Outpatient care at SUS by group of diagnostic imaging procedures (million 2019) Source: Ministry of Health – Outpatient Information System from SUS (SIA/SUS). Designed By Abramed. Note: Outpatient care – Quantity approved by year of care, according to group of procedure. Obtained in August 17/19. 2.3% 1.5% 6.4% 20.9% 68.8% The sector of diagnostic medicine Radiology Ultrasound Tomography Endoscopy Magnetic resonance

154 Early diagnosis saves lives and reduces care expenditure T he understanding For those reasons, it is necessary that early diagnosis to propel evaluate the financial saves lives and can consequences of early diagno- considerably reduce sis in the planning of many differ- the care expenditure is already ent health areas, especially in the entrenched into health care. fight against cancer. According There is no doubt that late di- to a study requested by the Can- agnosis offers a worse survival cer Research UK, the treatment time and can result in more ex- of a variety of early stage types pensive and ineffective treat- of cancer show smaller expenses ments most of the times. and better results to the patients. Table 15 Estimate of cancer treatment expenditure (in £) and life expectancy by stage Source: Cancer Research UK. Adapted by Abramed. Abramed Panel | 2020 Type of cancer £ Stage 1 £ Stage 4 Intestine 3,400 more than 9 out of 10 survive 5 years or more 12,500 less than 1 in 10 Ovaries 5,300 almost 9 out of 10 survive 5 or more years 15,100 survives 5 years Reto 4,400 more than 9 out of 10 survive 5 years or more 11,800 Lung 8,000 more than 3 in 10 survive 5 years or more 13,100 or more

In general lines, the study suggests Court of Accounts (TCU), nearly 80% 155 that the treatment in stages 3 and 4 of the cancer patients were diagnosed cost approximately 250% more than at stages 3 and 4. Still according to the amount spend in stages 1 and 2. the report, the availability of exams in In Brazil, according to the audit report the public sector is insufficient to en- on national cancer prevention and able timely access to the diagnosis of control policy carried out by Federal the disease. Graph 11 Staging degree and ratio of detection by type of cancer in Brazil Source: Audi report on national cancer prevention and control policy in Brazil – Federal Court of Accounts. Adapted by Abramed. Note: Patients attended by SUS in 2017. 12 15 24 29 33 35 22 41 50 59 60 Proportion (%) 39 The sector of diagnostic medicine 30 29 33 38 29 25 20 20 15 23 11 7 7 56 12 14 5 4 5 5 5 9 4 3 8 5 4 Breast Cervix Prostate Colon and Stomach Oral Tracheal Thyroid retro cavity Degree of staging 0 1 2 3 4 This way, it is crucial to associate de- line of the disease. Early diagnosis bring tection actions with guaranteed access benefits to the patient and contributes to diagnostic exams in due time, and to an optimization of scarce resources with quality in all the steps of the care in the health systems.

Covid-19



Covid-19

The diagnostic 159 medicine sector has performed an important role in offering diagnostic exams for Covid-19 A t the end of 2019, a new coronavirus Covid-19 arrived ad Wuhan, province of Hubei in China, showing a clinical spectrum that varies from asymptomatic to se- vere and lethal cases. In March 11th, 2020 WHO declared a pandemic situation due to Covid-19, dis- ease caused by the virus named SARS-CoV2. Such change has happened due to the fast dissemina- tion of the virus, which spread quickly to many countries around the world. On February 3rd, Brazil has declared Public Health Emergency of National Importance (ESPIN) due to Covid-19. In February 26th, the country had its first coronavirus case in national territory and on the next day, the number of suspected cases went up to 132. On March 17th, the first death due to the disease was confirmed and three days later, the Ministry of Health ac- knowledged the occurrence of community trans- mission in the country. Since then, the virus has spread through all the Brazilian capital cities and the number of infected people and deaths was in- creasing until the first half of August, remaining rel- atively steady (but with a high number of infected people) in the following days.

160 During this pandemic, the control of the pneumonias con- diagnostic medicine sector has sequent to the infection by performed a significant role by means of imaging exams. offering Covid-119 diagnostic exams, promoting molecular Considering the serious sit- and serology exams to the Bra- uation that the public health is zilian population. Abramed’s going through because of the associates have contributed new coronavirus pandemic, with the Ministry of Health by Abramed is committed to find- keeping a permanent conver- ing solutions that enable the sation with the Health Sur- maintenance of the activities veillance Office. Nonetheless, of its associates and all other many associates act as hos- agents in the Brazilian health pital laboratories, where they market, taking into account sev- contribute with the laboratory eral factors such as logistics, monitoring of the hospitalized human resources and econom- patients, partnering with im- ic-financial aspects that are key aging clinics that perform the to the balance of the sector. Abramed Panel | 2020

The role of 161 the diagnostic medicine sector The diagnostic medicine sector has taken Considering the operational and aspects the lead when the first Covid-19 case was con- and the investment in the expansion of the firmed in Brazil. The private laboratories quickly processing capacity, the private laborato- joined forces and developed the first in-house ries have increased their domiciliary collec- exams to diagnose the disease. With the ar- tion capacity, besides establishing drive-thru rival of commercial kits, the companies started system for sample collection, both strategies to perform the molecular exams RT-PCR in a aimed at avoiding agglomeration at the ser- larger scale (Reverse Transcription Polymerase vice units. Chain Reaction), exam that was pointed out as a gold standard41, by WHO, in diagnosing Another highlight during the pandemic COVID-19. Shortly after, the sorology exams was the creation of the SARS-CoV-2 Eval- were developed and have been constantly im- uation Kit Program, a partnership between proves in order to increase their sensitivity and Abramed, the Brazilian Chamber of Lab- specificity. Since then, new exams, methods oratory Diagnosis (CBDL), the Brazilian have emerged to improve the country’s testing Journal of Clinical Analysis (SBAC) and the capacity, making them increasingly accessible Brazilian Society of Clinical Pathology and to the Brazilian population. Even facing many Laboratory Medicine (SBPC/ML). The pro- adversities such as the lack of supplies – the gram, never seen before in the world, aims reagents are all imported – and logistic issues to validate the efficacy and performance of caused by the interruption of the air network, different Covid-19 diagnostic exams regis- the laboratories remained active to expand the tered by the National Health Surveillance testing capacity in the country, including the Agency (Anvisa) and available in the Bra- development of partnerships with SUS. zilian market. 41. It is a standard exam that works as a comparison for other exams, aiming to evaluate their accuracy, maximizing the successes in order to estab- Covid-19 lish a real diagnosis.

162 Epidemiological profile According to data from WHO, by the end in a more intense way in the Americas (18.1 of the first half of October 2020, the number million cases), in Southeast Asia (8.1 million), of confirmed cases of Covid-19 reached 38.0 Europe (7.1 million), in the Mediterranean (2.6 million and the number of deaths reached 1.1 million), in Africa (1.2 million) and in the West- million. The spread of the virus has occurred ern Pacific (663.4 thousand). Graph 1 Number of registered Covid-19 cases by region, according to WHO Sources: WHO Coronavirus Disease (COVID-19) Dashboard. Obtained on October 14/2020. Adapted by Abramed. Americas Cases Deaths Southeast Asia 18,090,384 593,984 Europe 129,653 Mediterranean 8,127,106 248,498 Africa 7,108,781 67,750 Western Pacific 2,660,450 27,540 Total 1,237,088 14,430 663,834 1,083,234 38,002,699 Abramed Panel | 2020 Feb.20 Mar.20 Apr.20 May.20 Jun.20 Jul.20 Aug.20 Sep.20 Oct.20 Among the 10 countries with the biggest (52.8%). The number of cases per 100 thou- number of cases, the United States, Brazil and sand inhabitants is similar in the United States India have totaled to 20.1 million and repre- and in Brazil, as well as the number of deaths sent more than half of the total in the world and the case fatality rate.

Table 1 Countries with the biggest number of registered cases of Covid-19 (Top 10) 163 Sources: WHO Coronavirus Disease (COVID-19) Dashboard and World Bank. Obtained in October 14/2020. Designed by Abramed. Cases per Deaths per Fatality rate Cases Deaths Population 100 thousand 100 thousand inhabitants inhabitants 2.9% 2.8% World 38,002,699 1,083,234 7,673,533,970 495.2 14.1 3.0% 1.5% United States 7,728,436 213,626 328,239,520 2,354.5 65.1 1.7% 3.0% Brazil 5,103,408 150,689 211,049,530 2,418.1 71.4 2.7% 3.8% India 7,239,389 110,586 1,366,417,750 529.8 8.1 3.9% 4.1% Russia 1,326,178 22,966 144,373,540 918.6 15.9 4.6% Colombia 919,083 27,985 50,339,440 1,825.8 55.6 Argentina 903,730 24,186 44,938,710 2,011.0 53.8 Spain 861,112 32,929 47,076,780 1,829.2 69.9 Peru 851,171 33,357 32,510,450 2,618.1 102.6 Mexico 821,045 33,357 127,575,530 643.6 26.1 France 715,764 32,589 67,059,890 1,067.4 48.6 In Brazil, the first case notification hap- Regarding the number of deaths per 100 in- Covid-19 pened in February 26th, 2020 and up to Oc- habitants, the biggest rates are in the Federal tober 14th, 5.1 million cases and 151 thousand District (111.7), Rio de Janeiro (111.0) and Ror- deaths by Covid-19 were registered. The big- aima (106.2). gest number of confirmed deaths happened on July 29th, with 69 thousand cases and 1.595 Covid-19 has a bigger case fatality in Rio de deaths registered. Janeiro (6.8%), Pernambuco (5.5%) and São Paulo (3.6%). The high case fatality rates of The 10 states with the biggest number of Covid-19 are usually related to socioeconomic cases have totaled 3.3 million and concen- conditions and the offer of health services. trate 65.3% of the total number of Covid-19 People with a lower education and income, and 69.1% of deaths in the country. Consider- that live in areas densely populated and with ing the number of cases by 100 thousand in- poor infrastructure, are more likely to die due habitants, we highlight Roraima (8.308), the to being more exposed to risk factors, such as Federal District (6.532) and Amapá (5.721). hypertension and diabetes42. 42. COVID-19 fatality rates related to social inequality in Northeast Brazil: a neighborhood-level analysis.

Table 2 Number of registered Covid-19 cases by State 164 Sources: State’s Department of Health. Brazil, 2020. Obtained in October 14/2020. IBGE/Directory of Research. Coordination of Population and Social Indicators. Management of Studies and Analysis of the Demographic Dynamics. Obtained on May/2020. Designed by Abramed. Cases per Deaths per UF Population Cases Deaths 100 thousand 100 thousand Fatality rate inhabitants inhabitants 1st São Paulo 46,289,333 1,034,816 37,223 2,236 0.8 3.6% 2nd Bahia 14,930,634 324,964 7,099 2,176 0.5 2.2% 3rd Minas Gerais 21,292,666 321,140 8,061 1,508 0.4 2.5% Abramed Panel | 2020 4th Rio de Janeiro 17,366,189 283,407 19,284 1,632 1.1 6.8% 5th Ceará 9,187,103 259,764 9,130 2,827 1.0 3.5% 6th Pará 8,690,745 237,925 6,645 2,738 0.8 2.8% 7th Goiás 7,113,540 228,713 5,189 3,215 0.7 2.3% 8th Santa Catarina 7,252,502 226,614 2,908 3,125 0.4 1.3% 9th Rio Grande do Sul 11,422,973 213,782 5,135 1,872 0.4 2.4% 10th Federal District 3,055,149 199,569 3,412 6,532 1.1 1.7% 11th Paraná 11,516,840 191,135 4,755 1,660 0.4 2.5% 12th Maranhão 7,114,598 178,549 3,860 2,510 0.5 2.2% 13th Pernambuco 9,616,621 152,998 8,408 1,591 0.9 5.5% 14th Amazonas 4,207,714 147,038 4,235 3,494 1.0 2.9% 15th Espírito Santo 4,064,052 138,462 3,646 3,407 0.9 2.6% 16th Mato Grosso 3,526,220 131,548 3,602 3,731 1.0 2.7% 17th Paraíba 4,039,277 125,713 2,914 3,112 0.7 2.3% 18th Piauí 3,281,480 101,951 2,206 3,107 0.7 2.2% 19th Alagoas 3,351,543 88,790 2,132 2,649 0.6 2.4% 20th Sergipe 2,318,822 79,501 2,089 3,429 0.9 2.6% 21st Mato Grosso do Sul 2,809,394 74,567 1,425 2,654 0.5 1.9% 22nd Rio Grande do Norte 3,534,165 72,625 2,416 2,055 0.7 3.3% 23rd Tocantins 1,590,248 71,048 1,009 4,468 0.6 1.4% 24th Rondônia 1,796,460 67,812 1,396 3,775 0.8 2.1% 25th Roraima 631,181 52,440 670 8,308 1.1 1.3% 26th Amapá 861,773 49,303 725 5,721 0.8 1.5% 27th Acre 894,470 29,031 674 3,246 0.8 2.3% 211,755,692 5,083,205 150,248 2,401 0.7 3.0% Brazil

The number of cases and deaths of 6 out of 165 Covid-19 is updated daily and varies con- 10 deaths siderably according to how fast the virus are male. spread in each country and region. For that matter, estimates point out to a total number of 6.2 million of confirmed cases in Brazil by the end of February 2020 and nearly 180 thousand deaths43. In the world, the estimated numbers are 50 million of cases and between 1.8 and 3,5 million deaths. Graph 2 Estimate of confirmed cases of Covid-19 in Brazil Source: Institute for Risk and Disaster Reduction of Pernambuco. https://www.irrd.org/covid-19/projecoes/. Accessed on October 10/2020. Adapted by Abramed. 7.0 6.0 5.0 Total number of cases4.0 Covid-193.0 2.0 1.0 0 25 Feb 06 Apr 17 May 27 Jun 07 Aug 17 Sep 28 Oct 08 Dec 18 Jan Confirmed Estimated One of the characteristics of this out of 10 deaths were part of this age pandemic is related to the incidence group and approximately six out of ten of deaths in the population starting 60 deaths are from males. years old or more. Data show that seven 43. https://covid19.healthdata.org/brazil?view=social-distancing&tab=trend.

Graph 3 Ratio of Covid-19 deaths Table 3 by age group and gender 166 Source: Special epidemiological report – Health Surveillance Agency – Ministry of Health. Epidemiological Week 33 (August 8 to 15). Designed by Abramed. 90 or more 5.2% 18.7% 25.3% UF 80 to 89 7.5% 14.3% 23.4% 70 to 79 1st São Paulo 60 to 69 2nd Bahia 50 to 59 3rd Minas Gerais 40 to 49 4th Rio de Janeiro 5th Ceará 30 to 39 3.7% 6th Pará 7th Goiás 20 to 29 1.2% 8th Santa Catarina 9th Rio Grande do Sul 6 to 19 0.3% 10th Federal District 11th Paraná 1 to 5 0.1% 12th Maranhão 13th Pernambuco <0 0.2% 10.0% 15.0% 20.0% 25.0% 30.0% 14th Amazonas 0.0% 5.0% Proportion of deaths 15th Espírito Santo 16th Mato Grosso 41.8% 58.2% 17th Paraíba 18th Piauí Female 19th Alagoas Male 20th Sergipe 21st Mato Grosso do Sul Abramed Panel | 2020 Since the beginning of the pandemic and up to October 8th, 22nd Rio Grande do Norte 2020, Brazil performed nearly 15.2 million Covid-19 detection 23rd Tocantins exams. According to data from the Ministry of Health, from this 24th Rondônia total, 7.7 million were quick tests and 7.5 million were RT-qPCR. In 25th Roraima the same period, the number of exams performed by Abramed’s 26th Amapá associates totaled 6.2 million and represent 41.0% of the total. Re- 27th Acre garding the RT-qPCR, the share was of 47.5%. This result shows the significant performance of this group of companies in the Brazil fight against coronavirus since the beginning of the pandemic. 1It was not possible to calculate Abramed’s participation because no segmentation by type of serological examination is included in the data made available by the Ministry of Health. Abramed Participation

Number of laboratory exams performed by State (in 10/8/2020) Sources: Ministry of Health – Covid-19 Testing Panel. Data updated on August 8, 2020. Obtained on October 14/2020. IBGE/Directory of Research. 167 Coordination of Population and Social Indicators. Management of Studies and Analysis of the Demographic Dynamics. Obtained in may/2020. Abramed Panel. Designed by Abramed. Note: Total testing: Number of exams RT-qPCR and Quick Tests distributed until the last update. PCR: Number of laboratory diagnostic exams RT-qPCR distributed until the last update. Quick Test: Number of diagnostic exams from quick tests distributed until the last update. Cases RT-qPCR Quick Test Total (RT-qPCR + Exams by Deaths by exam Exams by thousand Quick Test) thousand cases inhabitants 1,034,816 1,180,796 1,698,520 2,879,316 2,782 1.3% 62.2 324,964 384,212 531,300 915,512 2,817 0.8% 61.3 321,140 677,256 821,120 1,498,376 4,666 0.5% 70.4 283,407 1,230,848 648,880 1,879,728 6,633 1.0% 108.2 259,764 388,464 318,600 707,064 2,722 1.3% 77.0 237,925 189,676 255,940 445,616 1,873 1.5% 51.3 228,713 116,272 237,240 353,512 1,546 1.5% 49.7 226,614 202,320 266,140 468,460 2,067 0.6% 64.6 213,782 183,584 468,300 651,884 3,049 0.8% 57.1 199,569 160,980 150,340 311,320 1,560 1.1% 101.9 191,135 948,024 427,600 1,375,624 7,197 0.3% 119.4 178,549 115,412 233,800 349,212 1,956 1.1% 49.1 152,998 227,336 335,640 562,976 3,680 1.5% 58.5 147,038 100,896 162,060 262,956 1,788 1.6% 62.5 138,462 123,128 202,300 325,428 2,350 1.1% 80.1 131,548 103,608 116,540 220,148 1,674 1.6% 62.4 125,713 102,548 154,260 256,808 2,043 1.1% 63.6 101,951 104,492 124,780 229,272 2,249 1.0% 69.9 88,790 86,884 112,920 199,804 2,250 1.1% 59.6 79,501 147,728 79,760 227,488 2,861 0.9% 98.1 74,567 103,608 116,540 220,148 2,952 0.6% 78.4 72,625 133,888 129,380 263,268 3,625 0.9% 74.5 71,048 113,396 59,200 172,596 2,429 0.6% 108.5 67,812 118,696 58,060 176,756 2,607 0.8% 98.4 52,440 82,264 17,340 99,604 1,899 0.7% 157.8 49,303 75,516 23,840 99,356 2,015 0.7% 115.3 29,031 69,724 26,560 96,284 3,317 0.7% 107.6 5,083,205 7,471,556 7,776,960 15,248,516 3,000 1.0% 72.0 PCR Serologic Total (PCR + Covid-19 Serologic) 3,548,369 2,696,330 6,244,699 47.5% n.d.1 41.0%

168 Testing the population was one of the main recommendations made by WHO to face Covid-19. Following this recommendation, Abramed’s associates intensi- fied their offer and their capacity to produce tests and process diagnostics sent to the Reference Laboratories. Graph 4 Proportion of exams performed by an Abramed associate and other labs (10/8/2020) Sources: Ministry of Health – Covid-19 Testing Panel. Data updated on August 8, 2020. Obtained on October 14/2020. IBGE/Directory of Research. Coordination of Population and Social Indicators. Management of Studies and Analysis of the Demographic Dynamics. Obtained in May/2020. Abramed Panel. Designed by Abramed. 47.5% 41.0% 52.5% 59.0% RT-PCR Total Others Abramed According to data from the Covid-19 Abramed Panel | 2020 Associated companies Report, in Supplementary Health the num- Abramed carried out ber of exams totaled 127 thousand in June more than 6.2 million 2020 – September 2020 issue of the re- laboratory tests for port. This result partially reflects the num- detection of Covid-19 ber of exams performed by a group of in the country. healthcare plans operators, which were made available on the TISS ANS Standard. Regarding the number of imaging exams, there was a substantial increase in thorax CT Scans, (TC) in comparison to February 2020. According to a study44 published by the Brazilian College of Ra- diology and Diagnostic Imaging (CBR) the CT has a high diagnostic accuracy for de- tecting Covid-19. 44. Accuracy of the chest CT Scan in diagnosing SARS-CoV-2 in- fection: initial experience at a cancer center.

Graph 5 Evolution of the number of exams for detecting Covid-19 – ANS (10/13/2020) Source: ANS Covid-19 Report – September 2020 issue. Adapted by Abramed. 169 Note: The figures given vary with each issue of the Covid-19 ANS Bulletin. 1,000,000 100,000 14,519 39,006 102,692 214,417 214,747 10,000 1,207 2,046 30,902 1,000 4,410 6,943 4,646 1,020 1,004 Quantity of exams on a logarithmic scale 100 60 Covid-19 10 3 1 April 20 May 20 June 20 July 20 March 20 SARS-CoV-2 (Coronavirus COVID-19) - RT-PCR research SARS-CoV-2 (Coronavirus COVID-19) – antibodies research IgA, IgG or IgM (each pair) Other detection exams for respiratory virus Graph 6 Monthly variation in the number of thorax imaging exams related to the month of February.2020 Source: ANS Covid-19 Report – September 2020 issue. Adapted by Abramed. Note: According to ANS, they have selected the individualized thorax imaging exams sent to ANS, as established by the TISS Standard. The percentages presented vary with each issue of the Covid-19 ANS Bulletin. 200.0% 165.1% 150.0% 133.8% 100.0% 84.0% 50.0% 36.1% 45.8% 5.5% 0.0% -50.0% -47.8% -39.9% -41.9% -57.6% -100.0% July 20 March 20 April 20 May 20 June 20 Chest x-ray Chest CT Scan

170 Covid-19 diagnosys Abramed Panel | 2020 The diagnostic exams, both laboratory and imaging, have played and will keep on playing a key role facing the Covid-19 pandemic. The ability to detect the virus has been essential to determine if a person is infected and help prescribe the most suitable clinical treat- ment, besides enabling the management of cases and determining the isolation measures necessary to avoid the a faster spread in the Society. With the relaxation of the social isolation measures, detect- ing Covid-19 and the specific antibodies capable of recognizing the virus will be even more important to evaluate the number of people infected by the virus. In this matter, many diagnosis techniques have been used to detect Covid-19.

Molecular exam – RT-PCR 171 This exam is considered gold standard by The efficacy in the results depend on the WHO due to its high sensibility and specificity. moment of collection in relation to the begin- It is the ideal exam to help contain the spread ning of the disease. According to some stud- of the pathogen, because it allows the infected ies, the specificity of most RT-PCR exams is individuals to be identified and isolated them- 100%, since the design of the primer is spe- selves. It also ensures that the people who had cific to the sequence of the Covid-19 ge- direct contact with the patient also be tested nome. Eventually, false-positives may occur and, in case they have positive results, they will due to technical failures and contamination also be isolated. The results take, on average, of the reagent. 48 hours to be available for the patient. Graph 7 Variation estimated over time in Covid-19 diagnostic exams regarding the onset of symptoms Source: Interpreting Diagnostic Tests for SARS-CoV-2. Adapted by Abramed. Notes: 1Detection occurs only if the patients were proactively followed since the moment of exposure. 2Biggest probability of registering a negative than a positive PCR result. Estimated time span and viral detection rates are based on data from many published reports. Due to the variation of the values between the studies, the estimated time span should be considered an approximation and the detection and probability of infection by Covid-19 is presented in qualitative way. Before symptom onset After symptom onset Detection unlikely1 PCR – Likely positive PCR – Likely negative2 Antibody detection SARS-CoV-2 Increasing probability of detection exposure Covid-19 Week - 2 Week - 1 Week + 1 Week + 2 Week + 3 Week + 4 Week + 5 Week + 6 Symptom onset Nasopharyngeal swab PCR Bronchoalveolar lavage/sputum PCR IgM antibody Virus isolation from respiratory tract Stool PCR IgG antibody

172 Abramed Panel | 2020 Serology environment and processed in seve- ral methodologies, such as ELISA and Unlike RT-PCR, which identifies chemiluminescence, among others. the genetic code of the virus, the These exams, unlike the others quick serologic exams detect antibodies. tests, are quantitative, that is, able Therefore, it is necessary to respect to point out the quantity of each an- the window period (time the orga- tibody in that sample, and they are nism takes to produce detectable performed by trained professio- antibodies) performing the exam at nals, in a laboratory environment least eight days after the appearance with equipment that allows scala- of symptoms (published studies bility and quality assurance. Today, show that the sensibility of these after following the particularities of exams increases after the third week COVID-19, most laboratories are offe- of infection.) ring serologic exams to detect total antibodies (IgG + IgM)), because they There are different methodolo- believe that these exams bring more gies for serologic exams. The quick assertiveness than those that detect tests that can be performed by fin- IgG and IgM alone. The quick tests ger puncture that is, by a small hole in have results delivered within minutes the patient’s fingertip, are qualitative and the serologic tests made in a la- and there is great variation in sensi- boratory usually deliver results within tivity. The serologic exams perfor- 24 hours. med in laboratory are made in venous samples collected in an appropriate

Proteomics RT-LAMP 173 The proteomics test, just like the RT-PCR, is For detection in the acute phase of the di- performed with nasopharyngeal samples that sease, the molecular exam known as RT-LAMP must be collect up to the seventh day from the methodology (reverse transcription loop-me- appearance of symptoms to detect COVID-19 in diated isothermal amplification), just like RT- its acute phase. However, the RT-PCR detects the -PCR, allows the detection of the genetic virus’ RNA in these samples, and the proteomic material of the new coronavirus, but in sam- method by mass spectrometry detects the pro- ples of patients’ saliva that must be collected tein of the new coronavirus. Because it is fully au- in the first day with symptoms. With 100% of tomated, this test is pointed out as an alternative to specificity – that is, it does not generate false RT-PCR and it is seen as an opportunity for mass positives –, the test has a sensitivity compared testing and to control the expansion of cases. to RT-PCR (low possibility of false negatives) and appears as a reinforcement so that the Considering that the protein is more stable Brazilian society can increase its testing capa- than the virus’ RNA, this method offer a better city, especially by using reagents and equip- stability, allowing samples to be transported at ment that are not scarce and generate results room temperature, which is a great characte- within an hour. ristic for a continental country like Brazil, where most of the time the samples travel thousands Imaging Exams of kilometers between being collected and pro- cessed. The results are delivered, on average, in Because the disease shows itself as a pneu- three business days. monia, the X-ray image has a key role in the diagnostic process, in the treatment and Next generation sequencing follow-up from Covid-19. Brazil has developed the first genetic test According to the Brazilian College of Ra- in the world to detect the new coronavirus in diology and Imaging Diagnosis (CBR), the a large scale, using the Next Generation Se- most indicated imaging exams for detec- quencing (NGS). With 100% of specificity, ting Covid-19 are the high resolution CT Scan the exam does not show cases of false positi- (HRCT) and the chest scan. ves and offers a 90% of sensitivity, which also drastically reduces the chance of false negati- It is important to say that the imaging ves. The test is processed by samples collec- exams are recommended to identify even- ted with swabs that get in touch with the nasal tual lung damage resulting from complica- region or the patient’s saliva on the first days tions in the pneumonia caused by the virus, after the appearance of symptoms. and should not be used as a screening on the diagnosis of the disease. Some studies show The exam is pointed out as a viable alterna- that the chest tomography has a high sensi- tive to mass diagnosis, because it allows a pro- tivity for diagnosing the disease and can be cessing volume 16 times bigger than RT-PCR considered the main current tool for detecting and, therefore, contribute to help restraining Covid-19 in epidemic areas45. the spread of the infection. This test delivers results, on average, in three business days. Covid-19 45. Correlation of chest CT and RT-PCR testing in coronavirus disease 2019 (COVID-19) in China.

174 Abramed Panel | 2020 Quick Tests technical safety requirements estab- lished by the health authorities and Anvisa has approved the pro- guarantee the patient’s safety. Accord- posal for performing temporary and ing to Anvisa, scientific studies have emergency quick tests for diagnos- shown that it is possible to detect an- ing COVID-19 in pharmacies and tibodies through quick tests from the drugstores, which got the diagnos- seventh day of symptoms in a person tic medicine sector worried. To per- with Covid-19. However, the Agency form the tests it is necessary a series of points out that the more expressive re- safety criteria and good practices pro- sults occurred in the testing after the vided by the sector rules (RDC nr. 302), tenth day. Anyway, the results must be that, usually, are not put in to use by fa- evaluated with caution and must be fol- cilities that are outside of a laboratory lowed by a health professional. environment. The measures to expand the access to diagnosis must meet the

Covid-19 175 treatment According to WHO, viral diseases will Other therapies that use corticoste- continue to appear and will represent a se- roids, antiviral agents, immunomodulators, rious health issue to public health in many serotherapy, anticoagulant and inflamma- countries. At the current moment, the ther- tion inhibitors have been used, and many apeutic strategies to face the new corona- times intensive care are required to treat virus are only supportive. The prevention the more complex forms of the disease. is aimed at reducing the community trans- Laboratory exams such as Procalcitonin mission by means of the isolation and social and D-dimer, whose incorporation to the distancing measures, helping decrease the ANS List was made on 05/29/2020, were number of cases. Currently, there is no spe- of great use to monitor hospitalized pa- cific antiviral treatment recommended for tients with Covid-19. Covid-19 and no vaccine is available. The treatment is symptomatic and oxygen ther- apy46 is the first step towards treating the airway impairment. 46. A treatment proposes to keep the blood oxygenation over 90%, which is the ideal percentage for our health. Covid-19

176 Telemedicine in the fight against Covid-19 Abramed Panel | 2020 T elemedicine is a term that With the arrival of Covid-19, there was created in the 170s was an estimate of fast and general- and can be interpreted as ized growth for medical-hospital ser- a long-distance medical vices, supplies, professionals and all treatment. The many definitions es- the components that integrate the tablish that telemedicine is a science care cycle. In addition to that, the that evolves in convergence with ad- need for social isolation and protect- vances in technology, with extreme ing the health professionals and pa- capacity for adaptation, and with the tients have contributed even more for changes and health needs in a variety the adaptations of the health services. of social and epidemiological con- By using this technology, it is possible texts. WHO recognized the telemed- to minimize the spread of Covid-19. In icine in 1990, and it has excelled in this scenario, the use of telemedicine providing health services in which the in Brazil was approved as on an ex- distance and the costs are an obsta- ceptional basis by the Federal Council cle to medical care. The use of tele- of Medicine (CFM), in addition to the medicine offers accessibility to health provisions of the Resolution CFM nr. care, allowing patient’s evaluation, di- 1,643, from August 26th, 2020, for the agnosis, treatment and follow up, es- purposes of: teleguidance, telemoni- pecially in areas less economically toring and teleconsultation during the developed and with a more vulnera- pandemic. After that, Law nr. 13.989 ble population. from April 15th, 2020 was sanctioned,

authorizing the use of telemedicine The continuity of telemedicine in 177 on an emergency basis while the cri- a large scale is still uncertain. How- sis generated by Covid-19 pandemic ever, there are some lessons for the continues. In supplementary health, future, aiming to avoid the inap- ANS has proposed actions to enable propriate use of medical services, the use of telehealth aiming to enable establishing more efficient triage and monitor the use of long-distance processes among others. Another health services to the beneficiaries of factor is associated to scientific and healthcare plans. technological advance, such as ro- botics, artificial intelligence and In other countries, the telemedi- nanotechnology; are able to provide cine was also approved to expand the medicine with a higher accuracy capacity and the access to the health and lower cost. For these reasons, system, and minimize the risk of infec- among so many others, the telemed- tion. In the United States, the pandemic icine might represent a great ad- has reduced the barriers to access the vance in healthcare services in the telemedicine and has promoted its use post-pandemic period. in the management of many types of care. In this matter, the health and ser- Telemedicine vices department has established a plays an essential group of guidelines, in accordance with role in helping the Health Insurance Portability and to tackle Accountability Act (HIPAA), to face Covid-19. the Covid-19 pandemic. Such guide- lines have pointed out the use of a vari- Covid-19 ety of free and low cost tools for video communication with people, including Apple FaceTime, Facebook Messen- ger video chat, Google Hangouts video chat and Skype. In China, the man- agement process of patients had the support of telemedicine platforms to connect patients, specialists and con- solidate clinical information. In addition to that, technology has offered preven- tion guidance, treatment and training for the medical teams that were already acting during the pandemic. The con- clusion is that the telemedicine plat- form has played a significant role in controlling dissemination and expand- ing knowledge about the disease.

Isolation and social distancing measures 178 One of the main measures facing the infected -, the faster the spread pace will be pandemic is interrupting the spread of the and the steeper curve will be. In this case, the virus by means of social isolation. The evo- demand for health services would be expo- lution of the pandemic at a slower pace al- nential. On the other hand, adopting isolation lows the public policy makers to adjust the and social distancing measures the speed of health system capacity towards infrastruc- the spread is smaller, showing that the virus ture and service. The following curves show is slowly spreading and the number of new the total number of cases in a given period. cases is decreasing and that the healthcare The faster the spread – that is, more people system is not overloaded. Graph 8 Estimate of the isolation and social distancing measures Source: CDC – Center for Disease Control and Prevention. Adapted by Abramed. Increased speed of contagion Without Reduction in Number measures contagion speed of cases control Health system capacity With control measures Time after the first case Abramed Panel | 2020 Some studies show that successful iso- pants has concluded that the combination lation and social distancing measures can of moderate physical distancing, self-isola- lead to a sharp decrease in the number of tion and contact tracking measures would cases. A study from the United Kingdom47 have a biggest probability to control the with data from more than 40,000 partici- spread of Covid-19. 47. Isolation efficacy, testing, contact tracking and physical distancing in the reduction of SARS-CoV-2 spread in different environments: a study of mathematics model.

Prevention measures 179 The main prevention measures against the virus are related to maintaining hygiene habits, isolation and so- cial distancing, as mentioned before. According to WHO, it is possible to reduce the chances of being infected with simple measures. Using masks made of fabric or other materials, Make sure that you and those who surround thus leaving the disposable surgical type you follow a proper respiratory hygiene and (N-95) for the exclusive use of the health cough etiquette. This means covering your professionals involved in fighting the disease. mouth and nose with your elbow bended of with a paper tissue when you cough or sneeze. Immediately dispose the used tissue and wash hands. Regularly and carefully cleaning hands with an Stay home and isolated yourself even with alcohol based product, or washing them with minor symptoms, such as cough, headache, soap and water. and low fever until you are recovered. Ask someone to bring supplies. If you must leave the house, use a mask to avoid infecting other people. Keep a distance of at least 1 meter from others. If you have fever, cough or difficult to breathe, Avoid places with many people. look for medical service, but call in advance and, if possible, follow all the instructions given to you by the local health officer. Avoid touching eyes, nose and mouth. Stay up to date with the most recent Covid-19 information from reliable sources, such as WHO or the local and national health authorities.

180 The role of regulating agencies Abramed Panel | 2020 In the regulatory scope, many actions were taken towards facing the developments caused by Covid-19 for the sanitary surveillance and for the supplementary health market. Within the scope of ANS, the extraordinary incorporation of exams to detect and help diagnosing Covid-19 in the List of health proce- dures and events, relaxation of Prudential rules and regulatory incentives are the highlight. ANS’s actions during the pandemic: • Mandatory coverage for Covid-19 detection exam – RT PCR (as of 03/13) • Mandatory coverage for exams that help diagnosing and treat- ing Covid-19 (as of 05/29) • Mandatory coverage for serologic exams – IgG antibodies re- search of total antibodies (as of 08/14) • Mandatory coverage for treating the disease according to healthcare plan segment • Temporary extension of maximum service terms, prioritizing Covid-19 • Guidance for conducting remote services and enabling the im- plementation of telehealth • Guidance for enabling care channels specifically for clarifica- tion and information about the disease • Extension of operators’ obligation terms • Relaxation of Prudential Rules • Temporary measures within the inspection scope • Granting regulatory incentives through counterparts (renego- tiation of contracts and payment of providers)

181 Within the sanitary sur- Resolutions published by Anvisa during the pandemic: veillance scope (Anvisa), several collegiate board • RDC 405/2020: establishes the control measures for med- resolutions were published: icines that have substances that are part of Annex 1 of this technical and informative Resolution, alone or associated, due to the Public Health notes; decrees; call notices; Emergency of International Concern (ESPIII) related to the and service orientation cov- new Coronavirus (SARS-CoV-2). ering aspects of the seg- ments with direct influence • RDC 378/2020: determines, in an extraordinary and tem- in facing coronavirus; food; porary way, about the requirements for importing, com- cosmetics and sanitizers; mercializing and donating pulmonary ventilators, vital signs medical devices; analyti- monitors, infusion pumps, used oxymetry and capnography cal laboratories; medicines; equipment – which are essential for intensive care units -, ports, airports and borders; due to the emergency situation in the international public blood, tissue, cells and or- health because of Covid-19. gans, health services, sur- veillance in all states plus • RDC 377/2020: authorizes, in in an exceptional and tempo- the Federal District; clin- rary way, the use of “quick tests” (immunochromatographic ical research and studies; assays) for Covid-19 in pharmacies and drugstores, suspend- among others. ing the effects of § 2º of art. 69 and art. 70 of RDC 44/2009, RDC 379/2020: alters the RDC Covid-19 • RDC 356/2020: determines, in an extraordinary and tem- porary way, about the requirements for producing, import- ing and acquiring medical devices identified as a priority for health services, due to the emergency situation in the inter- national public health because of SARS-CoV-2. • RDC 352/2020: determines about the prior authorization for exporting chloroquine and hydroxychloroquine, and prod- ucts subject to sanitary surveillance destined to help fac- ing Covid-19. • Call Notice no. 03/2020: calls on companies to provide the Agency with information on products subject to sanitary surveillance that might be used and essential supplies for facing Covid-19, cause by the coronavirus Sars-CoV2.

182 The role of legislature Several measures In addition to the actions taken by the reg- have been taken to ulatory agencies, the legislative has also acted minimize Covid-19’s out during the pandemic through a series of impacts on the measures. On March 20th, 2020, Brazil declared country’s economic state of public calamity. With the publication activity. of the decree, the country was exempted from meeting the fiscal target set for this year. This Abramed Panel | 2020 was one of the first measures to help facing Covid-19 in national territory. Since then, more than 50 regulations were published within the legislative scope, and we highlight the MP nr. 926, which determines the acquisition proce- dures of goods, services and supplies; the re- laxation of labor rules through MP nr. 927, which allows the suspension of labor contracts and salaries; and MP nr. 928, which suspends the deadlines for requests made via the Law on Access to Public Information (LAI). Under the economic scope, a series of measures were taken to minimize the impacts of Covid-19 on the economic activity of the country. Among which, the following ones stand out: the Bill that establishes the emer- gency aid of R$ 600,00, the Emergency Pro- gram for Maintaining Employment and income (BEm), the provisional measures that guaran- tee the complementation of salaries by the government, IOF exemption, change in the contribution to PIS/Pasep. We also highlight the measures of extension for payment of taxes and other contributions; IPI exemption for products meant to the treatment of Covid- 19; among others. According to the Ministry of Economy, this group of measures will bring an economic impact and must reach up to 46.03% of Brazil’s GDP in 2020.

Use of 183 healthcare plans The scenario of the use of healthcare tion is it possible to trace, among other services has suffered a drastic change things, the behavior of the beneficiaries with the beginning of the pandemic, es- in the use of medical-hospital services pecially after adopting the isolation and and the Evolution of the healthcare ex- social distancing measures. Since then, penditure in the period. ANS has followed and regularly released data related to the monitoring of the It is also possible to notice a decrease supplementary health market during in the number of authorizations granted the Covid-19 pandemic. That data for complementary exams and thera- shows information collected monthly pies48, showing a synchronicity with the from a significant group of heath care decrease in the number of beneficiaries plans operators. Through this informa- as of March 2020, as it follows. Graph 9 Evolution in the number of authorizations granted for exams and therapies Source: Covid-19 Report Supplementary Health – October 2020. Designed by Abramed. -2% -4% -12% -19% -16% -26% -47% -63% Feb.20 Mar.20 Apr.20 May.20 Jun.20 Jul.20 Aug.20 Sep.20 Covid-19 48. SADT – Support Service to Diagnostic and Therapy.

184 Between the months of March and June, there Considering the type of hired healthcare plans, was a decrease of 363 thousand beneficiaries of there was a decrease of 342 thousand beneficia- healthcare plans and 663 thousand of exclusively ries in the collective business plans, 54 thousand dental plans. In July, there was a slight improve- in the individual ones, while the collective plans ment in the number of beneficiaries on both care by membership had an increase of 34 thousand segments, but the sector still presents a negative new contracts. balance since the beginning of the pandemic. Graph 10 Evolution of the number of beneficiaries of healthcare plans Source: Situation Room ANS. Obtained in October 26/2020. Designed by Abramed. 47.09 47.05 47.04 47.00 47.02 47.01 47.00 47.01 Beneficiaries (million) 46.97 46.91 46.83 46.79 46.72 -363 thousand Aug.19 Sep.19 Oct.19 Nov.19 Dec.19 Jan.20 Feb.20 Mar.20 Apr.20 May.20 Jun.20 Jul.20 Aug.20 Graph 11 Evolution of the number of beneficiaries of exclusive dental plans Source: Situation Room ANS. Obtained in October 26/2020. Designed by Abramed. 25.80 25.86 25.96 25.94 25.82 25.68 Abramed Panel | 2020 Beneficiaries (million) 25.57 25.36 25.34 25.27 25.34 25.16 24.79 -663 thousand Aug.19 Sep.19 Oct.19 Nov.19 Dec.19 Jan.20 Feb.20 Mar.20 Apr.20 May.20 Jun.20 Jul.20 Aug.20

Loss ratio was From a financial perspective, the supple- 185 the lowest ever mentary health market has presented the recorded in lowest loss ratio ever recorded for health- medical-hospital care plans in the moths subsequently to the operators. beginning of the Covid-19 pandemic.49 Such fact is due to the decrease in the number of elective procedures between appointments, exams and surgeries. With the suspension of these procedures, there was a decrease of approximately 60% to 80% in hospital and diagnostic medicine activities, especially in the exams segment. Graph 12 Loss ratio (%) Source: Covid-19 Report Supplementary Health – October 2019. Designed by Abramed. Note: The monthly axis is adjusted according to the availability on the data source. 80.0% 82.0% 79.0% 81.0% 79.0% 78.0% 78.0% 78.0% 78.0% 77.0% 77.0% 77.0% 77.0% 73.0% 71.0% 66.0% 62.0% 63.0% Apr.19 May.19 Jun.19 Jul.19 Aug.19 Sep.19 Oct.19 Nov.19 Dec.19 Jan.20 Feb.20 Mar.20 Apr.20 May.20 Jun.20 Jul.20 Aug.20 Sep.20 Covid-19 49. According to ANS: “The cash loss ratio takes into account the cash flow data. It should not be confused with the accounting loss ratio, measured under the accrual basis, which follows its own methodology. The cash loss ratios were calculated by the average of the ratios of each operator individually (not by aggregated data), in order to eliminate the sample bias by the highest values.”

186 The accounting statements of the healthcare plans operators have also indi- cate a strong deceleration in the loss ratio, especially in the second quarter of 2020, period comprising the months subsequent to the adoption of the isolation measures caused by the pandemic. All the categories have showed the same pattern, with a total decrease in the supplementary health sector of R$ 7.6 billion on the health expenditure of the medical-hospital operators, while the income from consideration increased R$ 4.1 billion, on the same basis of comparison. Graph 13 Consideration income and healthcare expenditure in supplementary health – Medical-hospital operators – in R$ billion Source: DIOPS ANS – Document of periodical Information on healthcare plans operators. Designed by Abramed. 50.12 55.01 50.11 54.24 39.74 43.01 42.13 34.57 1st Quarter 2019 1st Quarter 2020 2nd Quarter 2019 2nd Quarter 2020 Consideration revenue Care expenditure Abramed Panel | 2020 Analyzing by category, it is possible to notice that in Self-management the rate went from 91.2% to 66.4%, with a decrease of 24.8 percentage points (p.p.) be- tween the second quarter of 2019 and the same period in 2020. In the Medical cooperatives, the decrease rate was of 21.5 p.p.; in Philanthropy 22.2 p.p.; in Medi- cal group, 20.0 p.p.; and in the Specialized Health Insurers, a decrease of 16.2 p.p. The same pattern can be observed when we compare the first quarter of every year. All the categories have presented a systematic decrease in the loss ratio.

Graph 14 Quarterly loss ratio (%) by medical-hospital operator’s category Source: DIOPS ANS – Document of periodical Information on healthcare plans operators. Designed by Abramed. 187 86.2% 81.9% 84.0% 91.2% 78.8% 73.4% 76.3% 81.1% 76.8% 74.6% 83.0% 78.0% 81.5% 85.9% 70.8% 69.7% 66.4% 61.5% 61.5% 55.8% 1st Quarter 2019 1st Quarter 2020 Philantropy 2nd Quarter 2019 2nd Quarter 2020 Self-management Medical Cooperative Medical Group Specialized Health Insurers Graph 15 Half-year loss ratio (%) by medical-hospital operator’s category Source: DIOPS ANS – Document of periodical Information on healthcare plans operators. Designed by Abramed. 88.7% 74.2% 77.0% 80.9% 75.9% 78.9% 83.5% 69.2% 68.1% 63.3% 1st Quarter 2019 1st Quarter 2020 Covid-19 Self-management Medical Cooperative Philantropy Medical Group Specialized Health Insurers

188 The impacts on the diagnostic medicine sector The diagnostic medicine from outpatient elective consultations, which have been inter- sector has faced structural rupted by de developments of the pandemic. and regulatory challenges since the beginning of the Therefore, a systematic decrease in the number of labora- pandemic. The sector has tories performing imaging exams was recorded in the period been facing a series of issues between March and August 2020 in comparison with the pre- regarding logistics, availabil- vious year. ity of supplies and equipment necessary to perform exams, Table 3 Variation of the number of exams performed at and maintaining the offer of Abramed’s associates (March to August 2020 in clinical analysis and imag- comparison to the same period of the previous year) ing diagnosis services. From an economic point of view, it Source: Abramed Panel. is possible to notice that the social isolation measures, de- Exams Average variation (%) spite playing a key role in con- Abramed Panel | 2020 taining the epidemic, have 1. HBsAg -34.7 negatively affected the per- 2. Hepatitis C serology -28.4 formance of the sector, which 3. HIV serology -34.6 resulted in the search for 4. Treponemal test for syphilis -34.6 credit lines. 5. VDRL -23.8 6. Glycated Hemoglobin -32.5 With the interruption of 7. PSA Total -39.5 outpatient consultation and 8. Hidden Blood -47.8 elective procedures, the di- 9. Total Cholesterol and Fractions -43.2 agnostic medicine activities 10. Pap smear -49.2 suffered a retraction of ap- 11. Mammography -46.4 proximately 60% to 80%, es- 12. Blood count -29.8 pecially in the imaging exams segment. It is important to highlight that the decrease more steep in the imaging exams clinics, which essen- tially depend on the demands

Nearly The estimate is that, due to Covid-19, nearly 165 189 165 million million diagnostic exams will not be performed in diagnostic supplementary health in 2020. In the beginning of exams will not the year, the projection was of 960 million comple- be performed mentary exams, with an increase of 4.9% in com- in 2020. parison to 2019. However, considering the decrease in the number of authorizations granted for per- forming exams until August 2020, the expectation is that approximately 795 million exams will be per- formed. It is important to emphasize that many of the exams are related to the diagnostic process for cancer and some other related to prevention mea- sures, and disease monitoring. This way, we can ex- pect future impacts on the beneficiaries’ health. Graph 16 Estimate of complementary exams in supplementary health (2020) Quantity of exams per monthSources: Covid-19 Report Supplementary Health – September 2020ANS. Care Map of Supplementary Health 2019. Estimates by Abramed. 90,000,000 80,000,000 70,000,000 60,000,000 50,000,000 40,000,000 30,000,000 20,000,000 10,000,000 January Covid-19 February March April May June July August September October November December Estimated Estimated Covid-19

190 Considering the events performed in the outpatient envi- ronment, it was possible to notice, in the public sector, a de- crease of 37.3% in the procedures with diagnostic purpose in the period between March and July 2020 in comparison to the previous year. The estimate is that nearly 154 million diagnos- tic exams are not going to be performed in this period. The de- crease of 42.8% in the surgical procedures is noteworthy. The main diagnostic methods with a steeper negative vari- ation were endoscopic, pathological anatomy and cytopathol- ogy, with a decrease of 60.3% and 50.8%, respectively. The following table shows the variation of a group of exams essen- tial to diagnosing some non-communicable chronic diseases. Graph 17 Variation of the outpatient production at SUS (March to July 2020 in comparison to the previous year) Source: Ministry of Health – Outpatient Information System from SUS (SIA/SUS). Designed by Abramed. 18.7% -2.0% Abramed Panel | 2020 -30.5% -24.9% -39.9% -37.3% -41.5% -43.7% -48.2% Health Procedures Clinical Surgical Organs, Medication Ortheses, Complementary Total promotion for diagnostic procedures procedures tissue prostheses health care and prevention purposes and cell and special actions actions transplants materials

191 Graph 18 Variation of the outpatient production at SUS by diagnostic segment (March to July 2020 in comparison to the previous year) Source: Ministry of Health – Outpatient Information System from SUS (SIA/SUS). Designed by Abramed. -6.5% -36.0% -33.9% -34.6% -36.9% -41.1% -46.2% -50.8% -60.3% Covid-19 Clinical Pathological Radiology Ultrasound Tomography Magnetic Nuclear Endoscopy Interventional laboratory and cytological resonance medicine radiology in vivo anatomy

Table 4 Variation of the outpatient production at SUS by type of selected diagnostic exam (March to July 2020 in comparison to the previous year) 192 Source: Ministry of Health – Outpatient Information System from SUS (SIA/SUS). Designed by Abramed. Exams Average variation (%) Abramed Panel | 2020 Prostate Biopsy -33.5% HDL Cholesterol Dosage -51.4% LDL Cholesterol Dosage -49.4% Total Cholesterol Dosage -51.7% Creatinine dosage -34.4% Glucose Dosage -44.3% Glycosylated Hemoglobin Dosage -45.3% Insulin Tolerance Test / Oral Hypoglycemic Drugs -36.4% Platelet Count -38.9% Complete blood count -37.8% Dosage of Specific Prostatic Antigen (Psa) -48.0% Anti-HIV-1 Antibody Research (Western Blot) -52.3% Anti-HIV-1 + HIV-2 Antibody Research (Elisa) -19.8% Fecal Occult Blood Screening -47.8% Cytopathological Breast Exam -48.5% Mammography -37.4% Chest X-ray (Apico-Lordortica) -41.1% Chest X-ray (Pa + Inspiration + Exhalation + Lateral) -29.5% Chest X-ray (Pa + Lateral + Oblique) -50.9% Chest X-ray (Pa and Profile) -32.6% Chest X-ray (Pa ILO Standard) -58.6% Chest X-ray (Pa) -34.1% Bilateral Mammography for Screening -63.4% Bilateral Breast Ultrasound -49.3% Abdominal Prostate Ultrasound -51.5% Prostate Ultrasound (Transrectal Via) -49.0% Chest CT Scan 77.9% Colonoscopy (Coloscopy) -52.5% Bronchoscopy -50.3% Electrocardiogram -44.1% Monitoring by Holter System 24 Hs (3 Channels) -47.0% Prostate Massage (Per Session) -84.1%



Abramed Panel



Abramed Panel

197 Abramed Panel highlights the main sector indicators of its associates in 2019 T he Abramed Panel consolidates and presents the set of information from a group of the main institutions that act in many different segments of the diag- nostic medicine in Brazil. In 2019, as well as in the previous years, Abramed Panel shows new indi- cators and updates the information from the last years, bringing a new importance to the sector analysis with every new issue. The sections that composse Abramed Panel show institutional, human resources, care produc- tion, service evaluation, economic-financial per- formance, and corporate governance aspects. The main goal of the Panel is to contribute to sec- torial transparency and the development of diag- nostic medicine, through an expanded view of the sector’s production and organization, which are key to understand the dynamisc and the relevance of the activities related to the diagnostic medicine in the country.

198 Institutional profile Abramed’s associates act in the – nuclear medicine, teleradiology, gra- segments of clinical analysis and ima- phic and endoscopic methods. The ac- ging diagnosis. These segments in- tivities related to imaging diagnosis are volve a series of activities related to performed by most of Abramed’s as- laboratory medicine – pathology ana- sociates50, and represented 88.5% of tomy, molecular biology, toxicology the total, while the clinical analysis ac- and genetics – and to imaging exams tivities corresponded to 69.2% in 2019. Graph 1 Participation in diagnostic medicine segments (2019) Source: Abramed Panel. 88.5% Abramed Panel | 2020 69.2% 57.7% 57.7% 53.8% 46.2% 42.3% 42.3% 34.6% 30.8% 19.2% (inclDiuadignngorsatidicoilomgayg)ing Genetics Teleradiology Telemedicine PatMhoColllieocniguiclcaalraanbinatoallooysgmisyy methods GrNaupclhiecaarlTomxmieectdoilhcoiongdsey Endoscopic 50. An associate can act in more than one segment. For that reason, the math does not add up to 100%.

199 73.1% of the From the exams performed by Abra- exams are med’s associates, 73.1% are performed processed by and processed by the associate itself, the associate 19.2% are performed by a third party, itself. and 7.7% are performed withtheir own resources and third parties. Graph 2 Proportion of services performed with their own resources and by third parties (2019) Source: Abramed Panel. 7.7% Own resource 19.2% Third parties Own resources and Painel Abramed | Institutional profile third parties 73.1%