Strategic circumvention of regulations: the judicialization of the Brazilian private health system

Abstract The article aims to advance the understanding of the successive circumvention of regulations by organizations, to determine whether it is possible to characterize them as purposeful actions, while the institutional literature analyzes decoupling and circumvention as sporadic activities. It analyzes the responses adopted by health plan companies to favor their interests, responses that often fail to comply with the rules of the institutional context, and which boosted the phenomenon known as ‘judicialization’. The study analyzed 158 lawsuits collected from the electronic archives of the Court of Justice of São Paulo, where beneficiaries sue health plan companies because of treatment coverage denial. Using correspondence and thematic analysis, some associations between denials and allegations showed to be significant, suggesting companies’ strategic patterns. It was possible to identify different strategic practices adopted by companies to avoid complying with institutional guidelines, and to observe that certain regulatory features can contribute to non-compliance strategies. The article contributes to the institutional literature by identifying organizational practices meant to successively circumvent and confront institutional prescriptions, indicating that health plan companies apparently design specific strategies to respond to beneficiaries’ demands.摘要 本研究旨在深化对组织持续规避监管行为的认知，判断此类行为是否可被界定为有目的的行动——而现有制度主义文献多将脱耦（decoupling）与规避行为视作零星开展的活动。本研究聚焦健康保险计划公司（health plan companies）为维护自身利益所采取的应对举措，此类举措往往不符合制度语境下的规则，并助推了被称为"司法化"的现象。研究分析了从圣保罗州法院电子档案中调取的158起诉讼案件，案件均为参保人因治疗保障被拒而起诉健康保险计划公司。通过对应分析与主题分析，研究发现拒付行为与诉讼主张间存在若干显著关联，这暗示了企业所采用的战略模式。研究得以识别出企业为规避遵守制度准则所采用的多种战略实践，并观察到特定的监管特征可能会助长不合规战略的实施。本研究为制度主义文献作出了贡献：通过识别出组织持续规避与对抗制度规定的行为实践，表明健康保险计划公司似乎会设计针对性战略以应对参保人的诉求。