Healthcare telemonitoring and business dynamics: challenges and opportunities for SUS

ABSTRACT OBJECTIVE To point out challenges and opportunities for the Brazilian Unified Health System (SUS) with the use of telemonitoring to face the increasing costs of non-communicable chronic diseases, based on its general panorama in Brazil, business dynamics and reapplication of data from American studies. METHODS Quali-quantitative approach with exploratory research. The field work focused on the analysis of the national market from private companies, since no experiences or studies related to this theme were identified in the SUS. To analyze the panorama and market dynamics, we investigated the offer of this technology based on the products and services available and their demand by reference hospitals the ten largest private health plan companies. To support the central discussion, we analyzed the reduction of costs with hospital admissions by the SUS due to chronic non-communicable diseases sensitive to telemonitoring (HCDST), using data from Datasus and some American studies from the MEDLINE/PubMed database. RESULTS Although in the embryonic phase, business agents search for new business opportunities, whereas public initiatives for the use of telemonitoring in collective health seem inexistent. The reapplication of U.S. data would reduce spending on HCDST and provide benefits, such as the reduction in emergency room care, acute hospitalizations, readmissions and home care time, among others, which point to even greater economic gains. CONCLUSIONS The development of a major project to reduce HCDST using this technology has the potential to advance in a comprehensive network of primary care, contribute to a greater dynamism of the national productive and innovative base and induce innovations along the chain of this emerging industry.


INTRODUCTION
Telemonitoring is one of the most important applications of telemedicine, characterized by telemonitoring of health data of a patient by a specialized center for monitoring, interpretation and analysis. Dehospitalization, preventive health, early diagnosis, increased life expectancy, better comfort and increased worked hours are among the benefits of this technology. It has been considered important to address the growth in the costs of chronic non-communicable diseases (CNCD) by the national health systems, one of the main problems in the provision of health services worldwide [1][2][3] .
CNCD are a global concern, impacting the goals established in the Millennium Development Goals, as they are responsible for the main causes of death in the world, with repercussions on the loss of quality of life and limitation of work and leisure, as well as on the economic impacts for families and health systems. Therefore, the United Nations (UN) has instructed countries to develop action plans for their prevention and control 4,5 .
Primary health care plays an important role in their prevention and control, since some CNCD are preventable by conditions sensitive to primary care 6,7 . Therefore, countries seek different approaches, among which telemonitoring has stood out as an important alternative.
Brazil faces significant challenges in the construction of the Unified Health System (SUS) due to the country's continental dimensions and population of more than 200 million people, which hinders the compliance with the constitutional precept of health universalization. Moreover, the complex demographic and epidemiological transitions imply greater efforts that impact the health budget. The increase in CNCD accounts for 75% of SUS expenses and 72% of deaths, of which 31.3% are due to diseases of the circulatory system, 16.3% of cancer, 5.2% of diabetes and 5.8% of respiratory diseases, being the four most representative groups 4,8 .
Despite the experiences and important studies from the Telehealth Network Program (Telehealth), the scientific production in the specific field of telemonitoring that seeks to demonstrate the benefits arising from its use is insufficient, which includes the analysis of costs, given its undeniable importance for public and private health systems 7,[9][10][11] . One example is a recent study conducted in Brazil with older adults in chronic condition, which pointed out a positive relationship between the use of telemonitoring and adherence to drug treatment 12 .
However, we observed a development and offer of solutions for the Brazilian market, which shows the interest and expectation of business agents in the growth of demand, whereas public policies, in turn, are scarce in this area. This fact points to the need for greater participation of the State, given the risk of the opportunities opened by telemonitoring being appropriated exclusively by business strategies.
Thus, the objective of this article is to identify the challenges and opportunities for the SUS due to the use of telemonitoring, based on business and institutional dynamics and economic benefits.

METHODS
Our study fits into the qualitative-quantitative approach with exploratory research. A literature review allowed a qualitative analysis with developments in the quantitative approach to estimate the cost reduction with the use of telemonitoring by the SUS 13 .
Within the Scope of the SUS, no experiences or studies related to this theme were identified in the search in the SciELO, Capes and Google Scholar databases, as well as in the analysis of projects between 2009 and 2020 of the SUS Institutional Development Support Program (Proadi) 14 . Therefore, the fieldwork focused on the analysis of the national market from private companies.
Regarding the offer, a survey was conducted to identify companies that sell specialized services and telemonitoring products in the Brazilian market, based on searches in the Google search with the descriptors "remote health monitoring," "health management," "homecare" and "health teleassistance," while suppliers of products were identified among the exhibiting companies in the largest fair of hospital equipment in Brazil in 2017 15 .
Regarding the demand, we opted for the reference hospitals recognized by the Brazilian Ministry of Health (MS) in the triennium of 2018-2020, i.e., the Health Entities of Recognized Excellence (HERE), and the ten largest private health plan companies were selected, which establish a competitive modus operandi 16,17 .
To support the central discussion, we analyzed the reduction of costs with hospital admissions by the SUS due to CNCD most impacted by telemonitoring (cardiovascular and respiratory diseases, and diabetes), hereinafter "hospitalizations for chronic diseases sensitive to telemonitoring (HCDST)," a subgroup of hospitalizations due to CNCD (HCNCD), a category already existing and monitored by the MS 1,4,18 . Datasus and some studies from the MEDLINE/PubMed database, identified by the descriptors "telemedicine," "telehealth" and "ehealth" associated with the terms "economic benefit monitoring" and "remote patient monitoring" were also used. Finally, the calculations of cost reduction with HCDST were obtained from the replicability of the most conservative data from these studies.

RESULTS
We present a framework of telemonitoring in Brazil with data from the main policy initiatives, regulatory issues and the national market, as well as some estimates of economic benefits for the SUS with the use of telemonitoring.

Telemonitoring Framework in Brazil
There are few actions to expand its use in Brazil, especially by the SUS, despite the immense benefits pointed out by specialists and the evolution of telemedicine in the country in recent years, resulting from incentives of research promotion agencies and important government actions that resulted in the formation of infrastructure, teams and research centers in several academic institutions in the country. Regarding public policies, it can be said that in Brazil there were some initiatives that culminated essentially in the projects University Telemedicine Network (Rute) and Telehealth, both with a focus on telemedicine to support and improve the quality of Primary Health Care 9,10 .
Currently, Telehealth is implemented in all states of the country and is an important instrument of innovation for the Family Health Program (FHP). Despite the emphasis given in some states, such as the remote electrocardiogram service developed in the state of Minas Gerais, teleradiography (TeleRX) in Rio de Janeiro, telediagnosis for chronic respiratory diseases and obstetric ultrasounds in Rio Grande do Sul and teleducation in São Paulo, among others, national actions in the field of telemonitoring are not identified.
However, although the Strategic Action Plan for Coping with CNCD in the MS provides for the use of telemonitoring, and studies point to its benefits, there are no initiatives in the field of public health policies in Brazil, as well as formal studies of the Ministry of Health for an analysis of its cost-benefit, although several other countries, such as members of the European Union (EU), have this application as one of the main focuses in the strategy to combat the problems arising from this group of diseases 4,19 .
Regarding regulatory aspects, there is a wide variety in the positioning of federal councils regarding the use of telemedicine by professionals and service providers. Some councils have a liberal position, but no regulations for the provision of distance services, such as those of physical education and social services; there are others with significant flexibility, such as those of psychology and nursing; and some others are still very reactive, such as the councils of physiotherapy, nutrition and medicine [20][21][22][23][24][25][26] . Unlike other applications of telemedicine, Telemonitoring has no explicit regulatory restriction in different health specializations.
The case of the Federal Council of Medicine (FCM) deserves a more detailed analysis. With resolution no. 2,227 of 2018 published in February 2019, the FCM expanded the attributions of telemedicine, enabling distance medical services vis-à-vis, that is, teleconsultation. However, the FCM opted to postpone its entry into force due to the numerous criticisms from physicians, representative entities and regional councils, especially regarding the insufficient participation in the drafting of this resolution, the early release by some private companies of new services based on teleconsultation, prohibited until then by resolution No. 1,643 of 2002.
Although this discussion has as its central element the teleconsultation, it is reflected in telemonitoring regarding private initiative, for its responsiveness, based on the perspective of occupation of this market with the offer of integrated service packages. This point was illustrated the anticipation of announcement of teleconsultation by the hospital Albert Einstein in early February 2019. In the field of public health, in turn, regulatory decisions that do not involve all stakeholders with extensive discussions and reflections on their impacts may distort comprehensive care projects and further weaken the SUS.
Specialized services and products are offered for the national market, as well as a wide variety of devices, which indicates a potential for the commercialization of this technology in the country. Chart 1 shows companies in Brazil that offer specialized services and products within the scope of telemonitoring, the federative unit in which they are located, their application and customers 4,11 .
There is diversity regarding the modality of providing specialized services, such as homecare, health management and telemonitoring service providers for older adults. As for the technologies used, the use of telephone, wearables or smart clothing such as electronic bracelets, as well as the application of artificial intelligence and big data for predictive analysis and health management.
Regarding the products, we observed, in the market, an offer of solutions aligned with the main strategies pointed out by the literature for their use by patients with CNCD: education or self-care, telecare and management or monitoring. However, the main consumer market is retail, which indicates that service providers have not yet adopted telemonitoring as a tool. On the other hand, it is a sign that their acceptance by the end user grows. These first movements of the private sector signal prospects for market growth, in which new business opportunities, service expansion and increased health costs due to CNCD, among other factors, help explain the growing interest in this emerging industry. Despite the dissemination of studies in other countries that point to positive impacts of its use regarding the improvement in quality of life and cost reduction in the provision of health services to patients with CNCD, some initiatives of private companies in this area focus mainly on telemonitoring without the use of innovative technologies that would allow remote telemonitoring in real time.
Chart 2 shows the most important private health service providers in the country, which have developed initiatives for health prevention and management in their businesses, with the perspective of improving the quality of life and self-care of patients, especially of chronic patients, albeit with different objectives. Hospitals bet on the development of a new market, preventive medicine, for which they built structures with multidisciplinary teams and Chart 1. Companies providing specialized services and telemonitoring products: field survey. for new business opportunities, whereas initiatives for use by the SUS in collective health are apparently inexistent. This dichotomy can segment the provision of this service, leaving a significant part of the population at the mercy of the private payment logic.

Challenges and Opportunities for SUS
Despite the enormous benefits of telemonitoring, few studies seek to relate its use to an improvement of the sustainability of health systems.
Based on the replicability of the most conservative data available in MEDLINE/PubMed database studies, our research resulted in an estimate of HCDST costs by SUS. Thus, Figure shows the rates of hospitalization for chronic diseases in Brazil between 2000 and 2009, which support the estimation of HCDST and respective expenses for the year 2017.

Cost Calculation for Telemonitoring Sensitive Hospitalizations in 2017
Based on Figure, we can determine the total rate of HCNCD (Tx HCNCD) per 100,000 inhabitants: Tx HCNCD = cardiovascular diseases + cancer + diabetes + respiratory diseases = 600 + 300 + 180 + 70 = 1,150 In our study, considering that the HCDST are equal to the HCNCDT minus the hospitalizations for cancer, we can estimate the total rate of HCDST (Tx HCDST)   That is, the potential for cost reduction only with the use of telemonitoring for HCDST in 2017 is around R$ 2.0 billion if aligned with a comprehensive primary care strategy in the SUS 29 . Since our study seeks not only the potential for cost reduction, but also an estimate of the economic benefits with the adoption for HCDST by the SUS, we show some MEDLINE/PubMed study results and analyze its replicability for the Brazilian situation.
One of the pioneers in these studies is the Veteran Health Administration ( In two recent studies coordinated by the Maryland Health Care Commission (MHCC) involving telemonitoring, some data corroborate those found by VHA. The first analyzed the acute hospitalizations (in intensive care units) of 22 patients with CNCD at a cost of US$ 66,000.00 for the entire program. The results showed a reduction of 66% in acute hospitalizations and from 15.7% to 4.5% in the rate of readmissions. Considering the cost of US$ 10,352.00 of each hospitalization of the U.S. program Medicare, the estimated savings were US$ 372,672.00, much higher than the cost to implement the entire program 1 . The second lasted 180 days and only analyzed the readmissions of 57 patients with CNCD at a cost of US$ 60,000.00. The final report pointed to a reduction of 44 readmissions in the first 30 days of the program alone and an estimated savings of US$ 308,000, considering the cost of US$ 7,000 per hospitalization 2 .
Therefore, the potential for reduction was around R$ 2.0 billion in HCDST due to telemonitoring for 2017 and the variation in the rate of reduction of HCDST among the three studies above (minimum of 25% in VHA and maximum of 66% in MHCC). Hence, we estimated that costs with HCDST in the SUS could be reduced between R$ 500 million and R$ 1.3 billion per year with the replication of these experiences, without considering other benefits such as reductions in emergency room care, acute hospitalizations, readmissions and home care time, among others, which would point to an even greater economic gains.

DISCUSSION
The MEDLINE/PubMed studies presented in our article are in consistence and point to a significant reduction in HCDST costs when compared with the costs to implement and manage telemonitoring systems. The economic benefits estimated in our research consider only the reduction of costs of HCDST for SUS. However, other important benefits can be provided by the use of telemonitoring if associated with a structure that enables a comprehensive primary care network, such as reduction in the demand for consultations and emergencies, logistics costs, costs for inactive workers, etc., as well as other qualitative benefits, such as time to respond to disorders, comfort and transportation of patients.
Retail companies are the main consumer market of specialized telemonitoring products and services, an indication that its acceptance and use by the end user grows, a result of behavioral changes in which people increasingly seek to monitor their health conditions preventively. These factors stimulate the use of telemonitoring by service providers as a powerful tool for health promotion, disease prevention, improvement of the quality of services and, especially, cost reduction. The use of this technology by large operators of private health plans, similar to global trends, will also be a major inducer for the growth of this market in the country.
Within the scope of business dynamics, solutions for the Brazilian market have been developed and offered, which demonstrates that business agents see interest and expect demand growth for these products. The interest of these business agents in this emerging market is reflected in the recent discussion on the expansion of the use of telemedicine promoted by the Federal Council of Medicine. The early launch of service packages over the private network signals both the game of interests involved and the strong pressures for greater regulatory flexibility. It also shows the tension between the private sphere, concerned with the opening of new markets, and the public sphere regarding patient safety, patient information security, doctor-patient relationship, quality or accuracy of diagnosis, among other ethical and legal aspects relevant to the practice of telemedicine. These aspects reinforce the need for a further discussion with broad participation and that contemplate the strengthening of public health in Brazil.
The country is lagging behind in telemedicine, especially in telemonitoring. Learning from other countries' experiences, obtaining up-to-date and georeferenced data on bed use (quantity, costs and occupancy rate by type of use) and analyzing regulatory restrictions and legal aspects, safety issues and technologies most appropriate to the Brazilian reality, as well as developing contingency plans, are examples of issues that must be further studied.
Within the Scope of the SUS, we observed caution regarding new advances. Considering that the main technologies that support telemonitoring solutions also form the structural basis of other telemedicine applications, the development of a major project to reduce HCDST has the potential to progress in the construction of a comprehensive primary care network, contribute to a greater dynamism of the national productive and innovative base and induce innovations throughout the chain of this emerging industry.
Our article shows the potential of this technology, with perspectives of significant cost reduction in the SUS only considering the HCDST. However, scientific production in the specific field of telemonitoring is still insufficient. Therefore, the challenges for government agencies, service providers, industry, educational and research institutions, among others, require joining forces for the development of new studies and customized solutions to the characteristics of a country of such a continental extension; solutions oriented simultaneously to the improvement of the sustainability of the SUS, advance in the provision of health services and development of the national industry and the economic-industrial complex of health, including regarding the services already offered by Telehealth, from the perspective of the political economy of the health.