“In our SAMS we suffer fewer restrictions than Portuguese people who have health insurance”

Paulo Gonçalves Marcos is the president of the National Union of Banking Staff and Technicians (SNQTB), the entity that manages SNQTB Saúde, a medical-social assistance system for the banking sector. In an interview with ECOseguros, he talks about the functioning of the so-called SAMS, the mutualist model that contrasts with private health insurance and currently covers around 200,000 people.

He advocates a solidarity system, with a single price, without exclusions due to illness or age, and criticizes more patrimonialist models that, in his view, limit freedom of choice . During the conversation, he also addresses the impact of inflation on health costs, the concentration of the private sector, the challenges of management and the relationship with the NHS: “We are not substitutes, we are complementary”, he says.

How does SAMS work?

The acronym SAMS is the abbreviation for Medical-Social Assistance Service. These are mutualist systems where no one is excluded on the grounds of race, sex or anything else and where assistance and coverage continues until death .

It is not because someone falls ill that the insurance premium – because it is not insurance – increases. It is characterized by having a single price that, in some way, the healthier pay for the less healthy . Unlike insurance, which is of a commercial nature and in the event of illness, the premium increases and ultimately the coverage ends, here we do not have this mechanism . Therefore, no one is expelled because of their health condition. I think this is a very important creation in Portugal.

Between active professionals, retired professionals and their families, there are around 200,000 people who benefit from SNQTB Saúde or the two or three SAMS that exist from other smaller unions.

Our competitors who are more patrimonialist, that is, who own hospitals and clinics, may be prevented from contracting or making agreements with other competitors, particularly in the provision of health care.

How does subsystem financing work?

The various banking subsystems are rivals among themselves. Therefore, there is freedom of union choice. Bank employees are free to choose whether or not to be union members. Once unionized, they can have access to the subsystem.

This health system is paid for by the employer and the employee in varying proportions. The construction of the financing mechanism is identical across all banking subsystems. But we have different philosophies.

Our SAMS is called SNQTB Saúde. Our rivals are called SAMS Mais Sindicato. There is one in the center called SAMS Centro, another in the north called SAMS Norte and there is SAMS SIB.

What makes you different?

Management. The way we manage the system.

So are healthcare provider networks different?

It is different because of the way we manage it. This union does not have its own units. It hires and negotiates with service providers throughout the country.

There are other competitors of ours that are more patrimonialist, that is, they own hospitals and clinics, which perhaps inhibits contracting or making agreements with other competitors, namely in the provision of health care.

Typically, the north does not go down to the south, the south does not go to the north and therefore ours has national coverage, which is relatively unique. Furthermore, as we are not sellers of health services, we have much less constraints to negotiate . If I had, hypothetically, a hospital next door, which some people do, I would obviously be interested in filling my hospital with my partners and if there was anything left over (which there probably wouldn't be), I would try to negotiate with third parties (CUF, Lusíadas, etc.).

Our construction is different. There is an almost Soviet model and there is a model of more free choice. I don't think it is necessary to say which one is ours. The participation is always the same . We have no interest in taking people to specific places.

Do all workers have to pay the same rate?

Yes. That's the same everywhere.

As with insurance, is there a co-payment here too?

There may also be a copayment here. I would say it is lower than in the insurance market. There is less concern about it being an important part of the financing. It is like the moderation fees, if I remember correctly it was not so much for filling prescriptions but rather to avoid overconsumption. That is, those who really did not need to go to the emergency room but went for whatever reason.

This is a mutualist system. Its management is regulated by collective regulation between unions and banking employers. The financing mechanism is the same. What sets us apart is our philosophy. Some have professional management, while others have non-professional management. Some have their own entities and a bias in that direction. Others have freedom of choice.

When bank employees leave the profession and change sectors, one of the reasons for their resistance to change and even to making career changes is that they value this type of mutualist system too much.

Is it similar to the ADSE system?

Very similar. In fact, SNQTB Saúde and ADSE are very similar because we neither own service provision infrastructures. They and we negotiate and seek the best agreements with service providers in the national territory.

Who manages the network?

It's us. We are independent. We don't have any dogma about it, but the management is ours .

To what extent do health insurance policies compete with insurance?

I would say that they are different models that can be competitive or complementary. This mutualist construction means that the price that people pay and that employers pay is independent of age, clinical pathologies, pre-existing conditions, professional status, or number of children. Therefore, they are completely different markets. It seems that this model of a single price, inter-operational solidarity and solidarity between pathologies makes sense.

This is a solidarity model. These are different markets and in other countries in Central Europe they coexist with each other. I would say that when bank employees leave the profession and change sectors, one of the reasons they resist change and even make career changes is because they value this type of mutualist system so much , especially ours.

Have your partners' prices increased in line with or above inflation?

In general, above inflation, but it depends a little on the region and the intensity of capitalism. For about 16 years now, we have been seeing an increase in the level of sophistication of supply and technological intensity on the part of providers. In almost all areas, it competes head-to-head with the NHS on a technological level, with different response times and different levels of service that are important.

In emerging industries there is then a phenomenon of concentration or consolidation and in the last ten to fifteen years the private sector has become more sophisticated. Today there are five groups that dominate the market for complementary diagnostic and therapeutic means and five groups that dominate the hospital market – with market shares above 80% and in some cases close to 90%.

Every time one of these groups buys a smaller independent unit or when it expands its geographic presence as has been happening in recent years, it is common for prices to tend to rise more than inflation.

If, for example, I promote a set of important exams for 50-year-old men, I am preventing them from having complications that are much more expensive to treat and potentially untreatable in 5, 10 and 15 years.

Without necessarily corresponding to the sophistication of the offer that justifies it?

We can have a bit of both. When we have, for example, a more sophisticated entity, with better clinical staff, more advanced equipment and a better image, and expands to the Alentejo, where this type of offer did not exist, it is normal for prices to be higher.

What we know is that, generally speaking, prices that had been stable, then rose during the inflationary movement caused by Covid-19 and tended to be above inflation.

But there are several phenomena here. We have the phenomenon of aging and, strange as it may seem, the increase in minimum wages has a not insignificant impact on the provision of health care. Since there will be a high percentage of hospital staff who are on minimum wage.

There is also greater sophistication, the entry of units with larger brands, an increase in supply, some market power, an increase in cost bases, particularly in terms of labor. I think this has led to an increase in costs in Portugal.

How do you manage to ensure that SAMS costs do not become unsustainable for members?

With professionalism and great dedication. Negotiating, negotiating and negotiating. We are the payer, we have the clients, the users. It is a process of ongoing negotiation.

However, it is not just the price component that needs to be addressed. There is also the service component, preventive medicine, for example, so that if our members adopt certain behaviors they are less likely to develop illnesses later on.

But such prevention wouldn't affect the price that person pays, would it?

No, the price is independent. But if I work with my partners on behaviors that are not prone to modern diseases caused by a sedentary lifestyle, smoking, for example, I am probably below the increase in health care costs. If I promote, for example, a set of important exams for men aged 50, I am preventing them from having complications that are much more expensive to treat and potentially untreatable in 5, 10 and 15 years.

Management has many components other than just negotiations.

Do members have a preference between the SNS and the SAMS network?

Banking subsystems are complementary to the NHS . Therefore, we all have an obligation to use the NHS within the scope of our civic duty. As the NHS has parts where it is perhaps less effective, our complementary nature is to cover this lack .

For example, four years ago there were few dentists in the entire NHS. Our complementary nature led us to specialise in providing services, negotiating and concluding agreements with dentists, stomatologists and dental clinics, precisely because there is a gap here in the NHS.

We have a little bit of all areas. This nature is not a substitute, it is complementary. For example, when the pandemic hit, this was a risk that not even a well-managed and solid mutual society could cover alone. Therefore, it is a risk that is assumed by the whole of society and no subsystem can replace it. No one has the capacity, not even ADSE, to assume this risk alone.

In certain areas where the NHS response times are high, our complementary role is obviously called upon more than in those where there are no problems. There may be a perception that we are substitutes, but we are not. Neither the financing model, nor the construction, nor the archetype, nor the collective agreement foresee that it could be otherwise and in this sense. Basically, the offer is the same. It is normal that they are used more when the public response is lower.

Who are your partners?

Over 90% of healthcare providers in Portugal are our partners.

How do you manage demand to speed up service to members so they don't end up on waiting lists?

The answer is the secret of the business. We suffer fewer restrictions than the majority of Portuguese people who have health insurance. There are not enough doctors to meet the needs. Even so , we manage to ensure that our members have access to private healthcare, disproportionately . On average, we have fewer access restrictions than perhaps other private operators, but we do have some restrictions.

The Portuguese became aware that the social system, the private system and the public system can coexist with each other.

What do you think is behind the increase of around one million people in Portugal who, from 2019 to 2024, now have health insurance?

I think the Portuguese have become aware that the social system, the private system and the public system can coexist. It makes sense to have a private response in case the NHS is having more difficulty responding.

Although half of the Portuguese population has health insurance, this represents a very small percentage of the overall response in Portugal. Therefore, the regulator is now trying to have a typology to certify health insurance that complies with a set of rules on transparency, capital coverage, etc., because although there is coverage, it does not cover what it should.

There is a way forward, but people will not achieve decent coverage with insurance at 20 euros per year . There are many proposals for things at this price level that cannot guarantee anything.

The systems should coexist and, perhaps, the management of the SNS could have elements and experiences taken from the mutualist and private systems because there may be interesting practices here that can be replicated.

Are there plans to transform SNQTB Saúde into a mutual insurance company?

Our ambition is to provide excellent service to our members. We are growing the number of members and benefits, and have been growing by almost 50% for the past nine years. This organic growth is a huge challenge, but I think it is going really well. We are happy to see initiatives that are emerging that are very much modeled and inspired by what we do, and that is enough for us.