Analysis of network dynamics of Market concentration in healthcare companies in Brazil

Abstract

The promulgation of Law No. 13,097 / 15 extended the possibility of the participation of foreign companies in the health area in Brazil, until then accessible to some sectors, such as supplementary health. In this context, this paper seeks to characterize the dynamics of the networks of operations of economic concentration acts in hospitals and health plans in Brazil. For such purpose, data were collected from the processes available on the website of the Administrative Council for Economic Defense (CADE), organized from the corporate structure, originated by investors (foreign or national) and analyzed using network analysis software. In data analysis, 93 acts of economic concentration were identified from 2009 to 2017, the participation of 12 foreign companies with predominant origin from the United States of America. These acts of concentration evidenced the formation of a robust network composed of three economic groups with predominantly foreign corporate control and a latent need to establish policies to analyze the risks and benefits of this new reality to the Brazilian health market. In another scenario, potential reflexes in the Brazilian health system will be fortunate.

Keywords:
Health; Concentration Acts; Network

Resumo

A promulgação da Lei nº 13.097/15 estendeu a possibilidade da participação de empresas estrangeiras na área da saúde no Brasil, até então acessível a apenas alguns setores, como o da saúde suplementar. Nesse contexto, o objetivo, no presente trabalho, foi caracterizar a dinâmica das redes de operações de atos de concentração econômica em hospitais e em planos de saúde no Brasil. Para isso, foram coletados dados nos processos disponibilizados no sítio do Conselho Administrativo de Defesa Econômica (Cade), organizados a partir da estrutura societária e da origem dos investidores (estrangeira ou nacional) e analisados com a utilização de software para análise de redes. Por meio da análise dos dados, foi identificada a realização de 93 atos de concentração econômica no período de 2009 a 2017 e a participação de 12 empresas estrangeiras com origem predominante nos Estados Unidos da América. Esses atos de concentração evidenciaram a formação de uma robusta rede composta por três grupos econômicos com controle societário predominantemente estrangeiro, bem como uma latente necessidade de que sejam estabelecidas políticas para analisar os riscos e os benefícios dessa nova realidade ao mercado da saúde brasileiro. Caso contrário, colocar-se-á à sorte os potenciais reflexos no sistema de saúde brasileiro.

Palavras-chave:
Saúde; Atos de Concentração; Rede

Introduction

Financing and provision of health goods and services are carried out by public and private sectors in Brazil’s healthcare system, characterizing it as a mixed system (Andrade et al. 2015).

This public-private relationship that provides healthcare services to Brazilian citizens is defined in article 197 of the 1988 Constitution (Brasil, 1988), even though this same Constitution defines health as a public, free and universal right, expanding the complexity of the system. In this context, given the private sector participation in healthcare services and due to this duality, over the last few years a relationship initially based on a “right” has become increasingly conflicting, and the right has turned into a “product.” One of the main issues of this complex industrial organization with peculiar characteristics, compared to other markets, is how financing takes pace.

In general terms, public policies related to healthcare financing are established, at times, for the benefit of the public sector and, at others, for the benefit of the private sector or, even, covered by reciprocal benefits, under the allegation that public and private services are precarious (Brasil, 2014). Faced with a precarious public healthcare system, which is unable to provide comprehensive and universal quality care, a favorable space is opened for a number of possibilities for the expansion of the private sector (Zocratto, 2014). Specifically regarding how the healthcare sector financing takes place, two examples of public policies can be highlighted. The first is related to the supplementary health insurance market, and the second refers to the hospital market in general, and both have participation of foreign capital in common.

Soon after the structuring of the supplementary health insurance market, in 1998, by Law No. 9.656 (Brasil, 1998), a little more than 10 years after the promulgation of the Constitution, Provisional Measure No. 1.908-18/99 (Brasil, 1999) introduced the possibility of foreign companies investing in health insurance providers. The 1988 Constitution (Brasil, 1988), in its article 199, established the need for specific legislation for this case, which was, therefore, defined by the aforementioned Provisional Measure and later solidified in Provisional Measure No 2.177-44/01 (Brasil, 2001). The definition of this policy generated an anomaly in the healthcare sector, since, although there was specific legislation via provisional measure, there was also an express prohibition on the foreign investors’ participation in this sector, as established in article 23 of Law No. 8.080, of 1990 (Brazil, 1990).

In this context, as clarified by document No. 002 of the Federal Attorney General’s Office, of 2008, (PGF, 2008), it would be possible, for example, the existence of a foreign investor in a supplementary health insurance provider, which, in turn, could own a hospital in its own network, but there could be no hospitals that had the direct participation of foreign investment. This nonsense was maintained until 2015, when the aforementioned article 23 of Law No. 8.080 was amended by Law No. 13.097 (Brasil, 2015), allowing the unrestricted action of foreign investors in the Brazilian healthcare market.

This scenario of market opening to foreign investors and the growth of interest in the healthcare market on a global scale boosted operations involving economic concentration acts in health insurance providers and hospitals in the country, as evidenced by Andrade et al. (2015) and Menezes (2019). Through economic concentration acts, private healthcare companies can organize themselves in a network in order to explore market opportunities, reduce costs, facilitate the allocation of resources and expand their boundaries of operation. On the other hand, they can build anti-competitive structures that harm the market. Aiming at characterizing the dynamics of the networks of economic concentration acts in hospitals and health insurance providers in Brazil, this work was based on the following question: what are the characteristics of the dynamics of the network of concentration acts occurred from 2009 to 2017 in the health insurance sector and the hospital sector in Brazil?

For this purpose, data from 2009 to 2017 were collected in the processes available on the Administrative Council for Economic Defense (Cade) website, organized based on the investors’ corporate structure and origin (foreign or national) and analyzed using software for network analysis, specifically Ucinet and NetDraw. Based on this analysis, it was possible to present an evolutionary map of the operations carried out over these years, determining the predominant economic groups, their origin and the peculiar characteristics of each of the transactions.

Material and Methods

This is a descriptive study, with a quantitative approach, using secondary data collected based on volumes of processes available on Cade’s website. The data and information on concentration acts and companies involved were extracted from the volumes of processes systematically obtained as follows: on Cade’s website, in the section Pesquisa Processual [Procedural Research], one searched for the terms “hospital” and “health,” establishing the period from January 1, 2009 to December 31, 2017, and with the following items selected: processes; generated documents and external documents; if the process was primary; and summary concentration act (simplified decision process) and ordinary concentration act (decision process with detailed analysis).

Summary concentration acts present the greatest offensive potential to competitors, given the simplicity of the operations; in turn, ordinary acts are the most offensive to competition and with a greater degree of operation complexity (Cade, 2012). “Concentration acts are justified, from a business point of view, by the prospect of exploring economic and financial synergies between companies and by the expectation of greater surpluses for applicants after the transaction” (Cade, 2016, p. 45).

The data collected were organized in spreadsheets and the analysis of the network dynamics was performed using Ucinet software package and the NetDraw network visualization tool. For the analysis of Network Dynamics, the database was formed by 211 companies and three individuals that performed economic concentration acts in Brazil from 2009 to 2017 involving hospitals and/or health insurance providers. Although it was not the scope of this work to address aspects related to the Decision Units Theory, proposed by Hermann and Hermann (1989), the actors were initially treated as operational units, and later the decision units were identified through nodes, which in turn control the operating units in their link. For network characterization, the indicators were calculated for density, average distance, degree centrality and betweenness centrality, described by Alejandro and Norman (2005), as shown in Chart 1.

Chart 1
Indicators for network characterization

Indicator	Description
Density	It shows us the value, in percentage, of the Network Density, that is, the high or low connectivity of the Network. It is a measure expressed as a percentage of the quotient between the number of existing relationships and possible relationships.
Average distance	It is the smallest number of ties needed to connect, directly or indirectly, one actor to another in the network.
Degree centrality	It is the number of actors to which an actor is directly related.
Betweenness centrality	This is the possibility that an actor has to mediate communications between two other nodes. These actors are also known as “bridges.”

• Source: Alejandro and Norman (2005).

For the indicator calculation on Ucinet and generation of charts on NetDraw, binary relational matrices were created in spreadsheets. The construction of these relational matrices is exemplified as follows: in cell A3, if company X (column) had performed an economic concentration act with company Y (row), cell A3 was indicated with the number 1. Otherwise, the number zero was indicated.

By analyzing the dynamics of networks of 211 companies and three individuals, it was possible to define the main actors involved in the operations and their connections, with a network having two main elements, the “nodes” (or actors) and the link. Nodes/actors are people or groups of people that come together with a common goal. The link is the ties that exist between two or more nodes/actors, which are represented by lines (Ghiradini, 2015).

In this research, the “nodes” are the companies and the links are the concentration acts that occurred between hospitals and/or health insurance providers from 2009 to 2017, whose operations were submitted to Cade’s assessment. Companies that are part of the same economic group are also characterized as a link. In this way, a line between two actors (companies) shows that they participated in the same concentration act or are part of the same economic group. For example, in Figure 1, there was an economic concentration act between Bradesco Dental and Odontoprev, which established a link between these companies; in turn, Amil and Amico have a connection, since Amico is part of Amil.

Figure 1
Network of companies that performed operations, 2009

With regard to the colors adopted on the maps, black indicates “buying” companies, that is, those that acquired a shareholding/portfolio in other companies or carried out the request for the operation with Cade, configuring themselves as the most interested in performing the operation; white indicates “selling” companies, that is, those that were selling shares, portfolio or issuing debentures, and called “object of the operation” by Cade in the volumes of the processes; finally, black, in Figure 11, indicates foreign companies. After the initial clarifications, results and discussions are presented below.

Figure 2
Network of companies that performed operations, 2010

Figure 3
Network of companies that performed operations, 2011

Figure 4
Network of companies that performed operations, 2012

Figure 5
Network of companies that performed operations, 2013

Figure 6
Network of companies that performed operations, 2014

Figure 7
Network of companies that performed operations, 2015

Figure 8
Network of companies that performed operations, 2016

Figure 9
Network of companies that performed operations, 2017

Figure 10
Network of companies that performed operations, 2009 to 2017

Figure 11
Network of companies that performed operations - foreign capital, 2009 to 2017

Results and discussions

One hundred economic concentration acts were identified in hospitals and health insurance providers in Brazil from 2009 to 2017; those with no consummation by the companies and those rejected and not recognized by Cade have been removed, with a total of 93 acts being reached. The highest number of operations occurred in 2010, 2012 and 2015. In 2009, the lowest number of operations was registered - five -, as shown in Table 1.

Table 1
Economic concentration acts in hospitals and health insurance providers, by year

Year	Number of operations	Ordinary operations	Summary operations	Number of Companies
2009	5	2	3	11
2010	13	4	9	29
2011	12	0	12	31
2012	15	4	11	42
2013	10	3	7	20
2014	6	0	6	18
2015	13	1	12	37
2016	9	6	3	30
2017	10	3	7	32
Total	93	23	70	250

It was found that most operations performed from 2009 to 2017, 79 (85%), were approved by Cade without restrictions, and 14 (15%) approved with restrictions, a factor that can favor increased economic concentration in the health sector. Economic concentration acts strengthen a company, as these operations bring advantages, such as cost reduction, infrastructure expansion and increased profits (Hitt; Ireland; Harrison, 2001).

When verifying the origin of the companies involved in the operations, most were concentrated in the state of São Paulo (49%), followed by Rio de Janeiro (22%), and Pernambuco (10%). Based on this information, it can be seen that the companies that most participated in economic concentration acts in the period studied were located in the Southeast region (72%).

In 2009, there were five economic concentration acts, four approved without restrictions by Cade, and one with restrictions. Two were classified as ordinary and three as summary. As for the type of operation, there were three shareholding acquisitions, one portfolio acquisition and one merger, which involved 11 companies, as shown in Figure 1.

One operation stood out in 2009, when Amil Assistência Médica Internacional, a health and dental insurance provider, acquired shareholdings in two companies, Medial Participações and Medial Saúde, which also operated as health and dental insurance providers.

When analyzing the year 2010, it was noticed that the number of economic concentration acts more than doubled when compared to 2009, jumping from five to 13. There were 10 operations approved without restrictions by Cade, and three approved with restrictions, four classified as ordinary and nine as summary, and all operations were shareholding acquisitions. In Figure 2, it is possible to verify that 29 companies were involved.

FMG Empreendimentos Hospitalares was involved in five economic concentration acts with 12 companies in 2010, as shown in Figure 2. Also in 2010, it is possible to note that there were foreign investments in the country, when The Carlyle Group, a globally active US asset management holding company, acquired a shareholding in Qualicorp Participações, which operates as a collective health insurance provider.

Amil Assistência Médica Internacional was the only company to carry out economic concentration acts in 2009 and 2010, expanding its operation to five companies, namely: ASL Assistência à Saúde, Ceame - Centro Especializado de Atendimento Médico, Excelsior Med, Medial Saúde and Medial Participações. From these acquisitions, Amil Assistência Médica Internacional expanded its operation in the states of Pernambuco, Rio Grande do Norte and São Paulo.

There were 12 economic concentration acts in 2011, eight approved without restrictions by Cade, and four with restrictions. All were classified as summary operations, with 10 shareholding acquisitions and two assignments of rights, involving 31 companies, as shown in Figure 3.

Qualicorp, Qualicorp Corretora de Seguros and Qualicorp Administratora de Benefícios were part of the Grupo Qualicorp - acquired in 2010 by The Carlyle Group -, and carried out three operations in 2011 involving seven companies, expanding its operation in health insurance activities in the states of Rio de Janeiro and São Paulo.

Also in 2011, Rede D’Or São Luiz, a group of companies that provide hospital services, carried out three operations involving five companies; Oncotech Oncologia, one of those companies, also performed an operation with six companies in hospital activities, expanding activities in the states of Rio de Janeiro and Rondônia. Two companies that already belonged to Grupo Rede D’Or São Luiz, namely, Hospital Norte D’Or de Cascadura and Centro de Tratamento em Oncologia, performed two operations. Hospital Norte D’Or de Cascadura acquired a shareholding in Unimed-Rio Participações e Investimentos, which is part of Rede de Cooperativas Unimed.

In 2012, 15 operations were registered, six approved without restrictions by Cade, and nine with restrictions. As for classification, four operations were classified as ordinary and 11 as summary. As for the type, there were two portfolio acquisitions, 11 shareholding acquisitions, one assignment of rights and one issuance of debentures, involving 42 companies as shown in Figure 4.

During the period analyzed, the health insurance providers and hospitals carried out economic concentration acts with companies performing several activities, expanding the portfolio of services and products, which indicates search for a greater vertical integration.

Also in 2012, the companies previously controlled by Edson de Godoy Bueno, LAF - - Empresa de Serviços Hospitalares; Carpevie - Centro de Medicina Integrada; EGB 01 Empreendimentos e Participações, and ESHO - Empresa de Serviços Hospitalares, performed three operations.

It is worth noting that, in 2012, foreign investments were made through an operation in which Oncoclínicas do Brasil Serviços Médicos issued debentures to the Canadian VSAP 21 Fundo de Investimento em Participações - which operates acquiring shares, debentures, subscription bonuses and other securities in other companies, in accordance with the interest of their shareholders - and is part of Victoria Capital Partners Group.

In 2013, there were 10 operations, all approved without restrictions by Cade, with three classified as ordinary and seven as summary. As for the type, there were four portfolio acquisitions, four shareholding acquisitions and two mergers, which involved 20 companies, as shown in Figure 5.

In 2013, Rede de Cooperativas Unimed stood out for being involved in 50% of the operations. It made four portfolio acquisitions and one merger. Unimed Odonto carried out two operations, acquiring Unimed Vitória’s and Unimed Recife’s dental insurance portfolios. Even after the operation, Unimed Vitória and Unimed Recife continued to exist in the health insurance market, except for dental insurance.

The UnitedHealth Group, from the United States, which operates in health insurance and provision of medical and hospital services, acquired control of Amil Assistência Médica Internacional in 2012; however, this operation was not part of the scope of this work, since it was not submitted for evaluation by Cade for not having met the legal notification requirements. Even so, this is important information for the health market in Brazil, considering that Amil Assistência Médica Internacional was a group with a large activity, with more than 26 companies in the health area and that was directly linked to Grupo EB, which also has several companies in this market, both controlled, until then, by Edson de Godoy Bueno.

Also in 2013, another foreign company invested in the healthcare market in Brazil. Swiss Re Direct Investments Company, from Switzerland, which belonged to the Swiss Re Group and operates worldwide as reinsurance, insurance and other forms of insurance-based risk transfer provider, acquired a shareholding in SulAmérica, which offers several products and services, including insurance, pension plans, asset management, health insurance and health care services.

In 2014 there were further reductions in the number of operations, going from 10 in 2013 to only six in 2014. All operations in 2014 were approved without restrictions by Cade, all classified as summary acts, with five shareholding acquisitions and one merger, involving 18 companies as shown in Figure 6.

From Figure 6, it can be seen that only four companies performed operations in 2014: Caixa Seguros Holding, Qualicorp, Rede D’Or São Luiz and Bain Capital Brazil Participações.

Bain Capital Partners, a US global private investment company that manages several capital investments, including private equity, venture capital, public investment, credit products and absolute return investments, acquired shareholdings through Bain Capital Brazil Participações in the country, in Intermédica Sistema de Saúde, Interodonto - Sistema de Saúde Odontológica, and Notre Dame Seguradora, which were part of Grupo Notre Dame Intermédica, a private healthcare provider that offered health insurance in Brazil, with a focus on corporate packages for small, medium and large customers.

In 2015, 13 operations were carried out, all approved without restriction by Cade, one classified as an ordinary act, and 12 as a summary act. As for the type, there were 12 shareholding acquisitions and one portfolio acquisition, involving 37 companies as shown in Figure 7.

In 2015, the greatest volume of foreign investments was made in Brazil’s health market, with four operations being carried out, as described below.

Broad Street Principal Investments, from the United States, a Goldman Sachs Group’s company, acquired a shareholding in Grupo Oncoclínicas’ Oncoclínicas do Brasil Serviços Médicos.

AXA Group’s AXA Corporate Solutions Brasil e América Latina Resseguros, from France, acquired a shareholding in Grupo Sulasa’s SulAmérica Companhia Nacional de Seguros.

Pacific RDSL Participações, from Singapore, managed by GIC Ventures Group, acquired a shareholding in Rede D’Or São Luiz.

In the fourth operation, Carlyle Hill South America Buyout Fund, America Hill do Sul Investimentos, SA Partners Hill, Brazil Hill Buyout Coinvestment and Fundo Brasil de Internacionalização de Empresas - FIP 11, from the United States, The Carlyle Group’s investment funds, acquired a shareholding in Tempo Participações, which belonged to Grupo Tempo.

In 2016, nine operations were carried out, all approved without restrictions by Cade, in addition to six ordinary acts and three summary acts, seven shareholding acquisitions and two assignments of rights, involving 30 companies as shown in Figure 8.

There was a reduction in operations in 2016, concentrated in three groups: Rede D’Or São Luiz, GIF V Fundo de Investimento em Participações and the group of companies controlled by Amil, which is part of Fundo de Investimentos em Participações Genoma I, Esho - Empresa de Serviços Hospitalares, Amil Assistência Médica Internacional and Hospital Alvorada Taguatinga.

Ten operations were identified in 2017; all were approved without restrictions by Cade, three classified as ordinary and seven as summary. As for the type, nine shareholding acquisitions and one portfolio acquisition were carried out, involving 32 companies as presented in Figure 9.

In 2017, Rede D’Or São Luiz and Notre Dame Intermédica Saúde stood out, which participated in three operations each. Grupo Cyrela’s Abaporu Participações and Fundo de Investimento em Participação Abaporu participated in two operations.

During the research period (2009 to 2017), 93 economic concentration acts were carried out, involving 211 companies and three individuals. In Figure 10, it can be seen that, during the period studied, three groups were consolidated in Brazil’s hospitals and health insurance market, namely Rede D’Or São Luiz, Amil Assistência Médica Internacional and Qualicorp.

In addition to finding horizontal operations of hospitals and health insurance providers, vertical operations between hospitals and/or health insurance providers with companies in other healthcare services were identified. Moreover, there were conglomerate operations, that is, those carried out with unrelated markets (Angeli; Maarse, 2012; Ross; Westerfield; Jordan, 2016).

Analyzing the average distance between the actors, it appears that, on average, an actor is 6.23 actors from another actor in the network. This means that the distance between any actor in the network is 6.23 actors, and the smaller this value, the closer the actors in a network. The Network Density was 0.011, that is, there are 1.1% of connections out of the number of possible connections in the network, or even, of all possible connections in the network, there are 1.1% of connections. The larger this result, the denser a network.

The degree centrality consists of the number of actors to which an actor is directly linked, demonstrating the influence and power of an actor over others (Ghiradini, 2015). The 10 companies with the highest degree centrality established connections with 36% of the companies in the network. Rede D’Or São Luiz had the highest degree centrality (54), that is, it has a direct influence on 13% of the actors in the network. Table 2 lists the 10 companies that registered the highest degree centrality in the network that was formed from the concentration acts from 2009 to 2017, which involved hospitals and health insurance providers.

Table 2
Degree centrality

Company	Degree centrality	%
Rede D’Or São Luiz	54	13%
Amil Assistência Médica Internacional	20	5%
Qualicorp	16	4%
ESHO - Empresa de Serviços Hospitalares	14	3%
Notre Dame Intermédica Saúde	14	3%
Tempo Participações	8	2%
Oncotech Oncologia	7	2%
Athena Saúde Holding	7	2%
Brazilian Private Equity V	7	2%
Rede UNIMED	6	1%

The betweenness centrality considers the importance of each actor in the connections that are established in the network; it is the distance between actors, the possibility that an actor has to mediate communications between two other actors (Ghiradini, 2015). Table 3 presents the 10 companies with the highest betweenness centrality.

Table 3
Betweenness centrality of Actors

Company	Betweenness centrality	%
Rede D’Or São Luiz S.A	4,929,000	22%
UNIMED - Rio Participações	2,744,000	12%
Hospital Norte D’Or de Cascadura	2,590,000	11%
Rede UNIMED	2,489,000	11%
Notre Dame Intermédica Saúde	1,656,000	7%
UNIMED do ABC	1,602,000	7%
Amil Assistência Médica Internacional	876,000	4%
Oncotech Oncologia	621,000	3%
Intermédica Sistema de Saúde	415,000	2%
ESHO - Empresa de Serviços Hospitalares	320,00	1%

Rede D’Or São Luiz presented the highest betweenness centrality (22%), followed by Unimed - Rio Participações (12%); Hospital Norte D’Or de Cascadura, and Rede Unimed (11%). In this way, these companies are characterized as “bridges” between the companies.

Rede D’Or São Luiz has the highest betweenness centrality, as it is directly and/or indirectly linked to several companies in the network; it participated directly in concentration acts with 54 companies, and indirectly in six operations, through its Group’s companies. As an example, in 2017, Hospital Esperança (belonging to Rede D’Or) acquired shareholdings in three companies of Grupo UDI, namely UDI Cárdio, UDI Imagem and UDI Hospital.

Hospital Norte D’Or de Cascadura ranked second, with 12% of betweenness centrality, and was the “bridge” between Rede D’Or São Luiz and Rede Unimed. In 2012, Hospital Norte D’Or de Cascadura (belonging to Rede D’Or) acquired a shareholding in Unimed - Rio Participações.

Analyzing foreign capital participation, based on Figure 11, it is observed that the main groups in the network receive foreign investment and that practically the entire network presents a direct or indirect influence of foreign capital.

Pacific RDSL Participações, from Singapore, managed by GIC Ventures Group, was one of the main international actors, since, in 2015, it acquired a shareholding in the largest group in the network, Rede D’Or São Luiz. The Carlyle Group also stands out, as it acquired two other prominent groups in the network, Qualicorp, in 2010 and Tempo Participações, in 2015. Although it has not been analyzed by Cade, it was also possible to identify the entry of the UnitedHealth Group, having acquired control of Amil Assistência Médica Internacional, in 2012.

Generally speaking, with regard to foreign capital participation in the health area, the results are similar to those of Outreville (2007) and Angeli and Maarse (2012), since it was also possible to identify predominance of cross-border operations carried out by companies from the United States, a country that also leads, on a global scale, the number of operations of mergers and acquisitions, according to Unctad (2017).

Based on the data presented in Figure 11, it is possible to verify formation of a network with 214 actors, grouped into three main groups, Rede D’Or São Luiz, Amil Assistência Médica Internacional and Qualicorp. Rede D’Or São Luiz presented the highest degree centrality and betweenness centrality, that is, it was the actor with the greatest influence, power and importance, exerting direct influence on 13% of the actors in the network.

The companies that moved the most to carry out concentration acts in the hospital and health insurance market were Rede D’Or São Luiz, Amil Assistência Médica Internacional and Qualicorp, all with the foreign investors’ participation.

It was found that these groups concentrated investments in the country’s most populous regions, with higher income and greater coverage of health insurance. Through network analysis, it is clear that these companies have expanded and diversified their performance in the market, which can increase their influence and, specifically, their power, the latter stressed even by Cade (2018).

This strong presence of foreign investors in healthcare can pose risks and benefits. As benefits, the considerations of Smith (2004) can be highlighted, which present foreign investment as a cost-free source, representing additional resources - provided that they are regulated - for the improvement of the service quality and efficiency, freeing up public resources for other health segments, even though this improvement is conditioned to an increase in the current productive capacity.

In terms of risks, the aforementioned author emphasizes the fact that large corporations, with better financial flow, create a shift of health professionals from the public sector to the private sector, making it an even more polarized system, which will allocate more resources to the rich at the expense of the poor and even forcing the reallocation of large public spending to equalize public sector inequalities due to the strong presence of private capital (Smith, 2004).

Accordingly, Scheffer (2015) points out that the increase in foreign investment and the enhancement of the private health sector promote unfair competition with the public sector, opening space for the formation of a “segmented system, incapable of ensuring access to all levels of care, in all regions, including in sanitation voids and for vulnerable and neglected populations” (Scheffer, 2015, p. 664), as these are places the private sector is not interested in, since they offer less financial return.

In this sense, the considerations of Outreville (2007) are also consistent with the fact that the capacity of this type of investment strengthens or weakens the health system, and it is likely to strongly contribute to market segmentation, concentrating it on higher-income segments.

That being said, given the changes in public health policy, regarding the permissibility of foreign investments, both in supplementary health and in the health market as a whole, it is urgent that policies be established to analyze these risks and benefits for the country.

Final considerations

The general objective of this work was to characterize the dynamics of the networks of operation of economic concentration acts in hospitals and health insurance providers in Brazil. Ninety-three economic concentration acts were identified that involved hospitals and/or health insurance providers from 2009 to 2017.

It was observed participation of 211 companies and three individuals in those economic concentration acts. Nine companies participated in 66% of the operations carried out, with Rede D’Or São Luiz, in an individual analysis, being responsible for 22% of these operations, and which became controlled by the foreign GIC Ventures Group, from Singapore. It was found that most of the operations performed were approved by Cade without restrictions, a factor that may be favorable to increased economic concentration in the health sector.

As for the dynamics of networks, based on the database, there was a network with three large groups, in which Rede D’Or São Luiz, Amil Assistência Médica Internacional and Qualicorp, which are controlled by foreign groups, present the highest degree centrality, that is, the companies that have the highest number of connections in the network.

In this sense, it is possible to understand the consequences of the opening of the Brazilian healthcare market to foreign investors, the predominance of operations of acquisitions of companies by these groups and the latent need to establish policies to analyze the risks and benefits of this new reality for the Brazilian health market, so that any effects on the health system are foreseen. Although the impact of these operations on Brazilians’ health has not yet been measured by the scientific community, the notes by Filippon (2015) and Hiratuka, Rocha and Sarti (2016) show the importance of discussions about this adopted economic policy and the challenges it represents.

In this research, the analysis was limited to mapping acts of concentration in the health area, specifically health insurance providers and hospitals, from 2009 to 2017, with analysis of the public version of the processes made available on Cade’s database; contracts entered into between the interested parties were not analyzed. Also as a limitation, non-verification of the value of the operations is mentioned, as it is confidential information in most of the processes made available by Cade.

Also, it is highlighted that future research can be conducted aimed at verifying impacts on this industrial organization, its structure, conduct and performance, as well as reflections on the prices and quality of services offered by companies subject to an economic concentration act.

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Appendix I - List of economic concentration acts in hospitals and/or health insurance providers from 2009 to 2017

Process Year Stakeholder Sector of the main stakeholder (s) 08012.007443/2009-41 2009 1 - São Francisco Saúde Sociedade Empresária LTDA Health Insurance 2 - Amico Saúde LTDA 08012.009906/2009-17 2009 1 - Amil Assistência Médica Internacional LTDA Health Insurance 2- Medial Participações S.A 3 - Medial Saúde S.A 08012.002248/2009-24 2009 1- Intermédica Sistema de Saúde S.A Hospital and Health Insurance 2 - Medicamp Assistência Médica LTDA 08012.008325/2009-50 2009 1 - Tempo Participações S.A Health Insurance 2 - Unibanco Saúde Seguradora S.A 08012.008989/2009-19 2009 1 - Bradesco Dental S.A Health Insurance 2 - Odontoprev S.A 08012.003389/2010-06 2010 1 - AMIL Assistência Médica Internacional LTDA Health Insurance 2 - ASL Assistência a Saúde LTDA. 3 - CEAME Centro Especializado de Atendimento Médico LTDA. 08012.004902/2010-78 2010 1 - ESHO - Empresa de Serviços Hospitalares LTDA Hospital 2 - Hospital Pró-Cardíaco S.A 08012.006190/2010-21 2010 1 - Sul América Seguro Saúde S.A Health Insurance 2 - BB Seguros Participações S.A 08012.010274/2010-60 2010 1 - FMG Empreendimentos Hospitalares S.A Hospital 2 - São Luiz Operadora Hospitalar S.A 08012.000917/2010-67 2010 1 - UNIMED Porto Alegre Sociedade Cooperativa de Trabalho Médico LTDA. Health Insurance 2 - UNIMED Centro Sul, Sociedade Cooperativa de Trabalho Médico LTDA. 08012.004756/2010-81 2010 1 - FMG Empreendimentos Hospitalares S.A Hospital 2 - Hospital e Maternidade Brasil S.A 08012.010675/2010-10 2010 1 - FMG Empreendimentos Hospitalares S.A Hospital 2 - Hospital e Maternidade Assunção S.A 3 - Assunção Imagem S.A 4 - Ressonância Assunção S.A. 08012.010734/2010-50 2010 1 - Amil Assistência Médica Internacional LTDA Health Insurance 2 - Excelsior Med LTDA 08012.011280/2010-34 2010 1 - FMG Empreendimentos Hospitalares S.A Hospital 2 - Casa de Saúde e Maternidade Rio de Janeiro S.A 3 - Casa de Saúde e Maternidade Joari S.A 4 - JMJB Diagnósticos e Serviços Hospitalares S.A 5 - LE Participações Societárias S.A 6 - Medise Medicina Diagnóstico e Serviços S.A 7 - Hospital Realcordis S.A 08012.012150/2010-19 2010 1 - FMG Empreendimentos Hospitalares S.A Hospital 2 - Prontolinda S.A 08012.013181/2010-97 2010 1 - Sul América Companhia de Seguro Saúde Health Insurance 2 - Dental Plan Ltda 08012.013200/2010-85 2010 1 - Hospital das Clínicas de Niterói Hospital 2 - Clínica Médico-Cirúrgica Botafogo S.A 08012.008112/2010-61 2010 1 - The Carlyle Group Health Insurance 2 - Qualicorp Participações S.A 08012.000596/2011-81 2011 1 - Hospital Norte D’Or de Cascadura S.A Hospital and Health Insurance 2 - Unimed-Rio Participações e Investimentos S.A 08012.002872/2011-46 2011 1 - Medgrupo Participações S/A Hospital 2 - Hospital Renascer Ltda 08012.004596/2011-51 2011 1 - Hospital e Maternidade São Luiz S.A Hospital 2 - Oncotech Oncologia Ltda 3 - Cotefil Hospital Geral Ltda 08012.006525/2011-92 2011 1 - Centro de Tratamento em Oncologia S.A Hospital 2 - Oncologistas Associados Serviços Médicos Ltda 3 - Instituto Oncológico de Pernambuco Ltda 08012.006542/2011-20 2011 1 - AMIL Assistência Médica Internacional S.A Health Insurance 2 - LINCX Sistemas de Saúde LTDA 08012.009232/2011-67 2011 1- Qualicorp S.A Health Insurance 2 - Medlink Conectividade em Saúde Ltda 08012.009582/2011-23 2011 1 - Centro de Tratamento em Oncologia S.A Hospital 2 - Instituto Oncológico de Pernambuco Ltda 08012.011059/2011-67 2011 1 - Rede D’Or São Luiz S.A Hospital 2 - Vivaile Serviços de Saúde Ltda 08012.011421/2011-08 2011 1 - Oncotech Oncologia Ltda Hospital 2 - Centro Radioterápico da Gávea Ltda. 3 - Serviços de Radioterapia São Peregrino Ltda. 4 - CORAL - Centro de Oncologia e Radioterapia Ltda 5 - LFC Serviços Médicos Ltda 6 - Scanmed - Aluguel de Máquinas e Equipamentos Ltda 08012.011602/2011-26 2011 1 - Rede D’Or Hospital 2 - MAIS - Multi Assistência Incorporada à Saúde Ltda 3 - Centro Hospitalar São Marcos S.A 08012.004653/2011-00 2011 1 - Qualicorp Administradora de Benefícios S.A. Health Insurance 2 - Qualicorp Corretora de Seguros S.A. 3 - Divicom Administradora de Benefícios Ltda. 4 - Divicom Gestão de Benefícios Ltda. 5 - Divicom Corretora de Seguros S.S 6 - Divicom Assessoria e Negócios S.S. 08012.009575/2011-21 2011 1 - Qualicorp Administradora de Benefícios S.A Health Insurance 2 - Qualicorp Corretora de Seguros S.A 3 - Adplan Administração e Planejamento de Benefícios Ltda 4 - Destak Corretora de Seguros Ltda 08012.002189/2012-90 2012 1 - Central Médica de Prevenção LTDA Health Insurance 2 - UNIMED Porto Alegre Sociedade Cooperativa de Trabalho Médico LTDA 08012.005776/2012-31 2012 1 - Pio Sodalicio das Damas de Caridade de Caxias do Sul Health Insurance 2 - UNIMED Nordeste RS Sociedade Cooperativa de Serviços Médicos LTDA 08012.000309/2012-14 2012 1 - Qualicorp Administradora de Benefícios S.A Health Insurance 2 - Qualicorp Corretora de Seguros S.A. 3 - Afinidade Administradora de Benefícios Ltda 4 - Equilibrar Corretora de Seguros Ltda 08012.002520/2012-71 2012 1 - Rede D’Or São Luiz S.A Hospital 2 - Sinisgalli Administração e Participações S.A 3 - Hospital e Maternidade Nossa Senhora de Lourdes S.A 4 - Instituto de Especialidades Pediátricas de São Paulo S.A 5 - Angiodinâmica S.A 6 - Lithocenter S.A 7 - Centro Diagnóstico NSL S.A 08012.002680/2012-11 2012 1 - Carpevie — Centro de Medicina Integrada Ltda Hospital 2 - LAF — Empresa de Serviços Hospitalares Ltda 3 - Mariliz Lima — Ginecologia e Obstetrícia e Erickson ÉIun — Cirurgia do Aparelho Digestivo Ltda 08012.002866/2012-70 2012 1 - Carpevie — Centro de Medicina Integrada Ltda Hospital 2 - EGB 01 Empreendimentos e Participações Ltda 3 - ADIX Empreendimentos Imobiliários Ltda 08012.005539/2012-70 2012 1 - Rede D’Or São Luiz S.A Hospital 2 - Hospital Santa Luzia S.A 3 - Hospital do Coração do Brasil S.A. 08012.005540/2012-02 2012 1 - Jorge Nevai Moli Filho Health Insurance 2 - Pedro Junqueira MolI 3 - Paulo Junqueira MolI 4 - Santa Luzia Assistência Médica S.A 08012.006134/2012-59 2012 1 - ESHO - Empresa de Serviços Hospitalares S.A Hospital 2 - Sociedade Civil Clinvac LTDA 08700.004065/2012-91 2012 1 - Qualicorp Administradora de Benefícios S.A Health Insurance 2 - Qualicorp Corretora de Seguros S.A 3 - Aliança Administradora de Benefícios de Saúde Ltda 4 - GA Consultoria, Administração e Serviços Ltda 08700.004150/2012-59 2012 1 - Rede D’Or São Luiz S.A Hospital 2 - Medgrupo Participações S.A 3 - Hospital Santa Lúcia S.A 08700.004151/2012-01 2012 1 - Rede D’Or São Luiz S.A Hospital 2 - Acreditar Oncologia Ltda 08012.003324/2012-14 2012 1 - Qualicorp Administradora de Benefícios S.A Health Insurance 2 - Qualicorp Corretora de Seguros S.A 3 - PS - Padrão Administradora de Benefícios Ltda 4 - Padrão Administração e Corretagem de Seguros Ltda 5 - PS Brasil Administração e Corretagem de Seguros Ltda 6 - Voloto Consultoria Empresarial Ltda 08700.005472/2012-15 2012 1 - VSAP 21 Fundo de Investimento em Participações Hospital 2 - Oncoclínicas do Brasil Serviços Médicos S.A 08700.008474/2012-66 2012 1 - CLIDEC - Clínica Dentária Especializada Cura D’ars Ltda Health Insurance 2 - Fleury Centro de Procedimentos Médicos S.A 3 - Papaiz Associados Diagnósticos por Imagem S/S Ltda 08700.010284/2013-90 2013 1 - Swiss Re Direct Investments Company Ltd Health Insurance 2 - 1NG Insurance International B.V 3 - Sul América S.A 08700.005729/2013-10 2013 1 - Unimed Odonto S.A Health Insurance 2 - Unimed Vitória Cooperativa de Trabalho Médico 08700.006494/2013-83 2013 1 - Unimed-Rio Cooperativa de Trabalho Médico do Rio de Janeiro Ltd Health Insurance 2 - Golden Cross Assistência Internacional de Saúde Ltda 08700.008540/2013-89 2013 1 - Amil Assistência Médica Internacional S.A Hospital and Health Insurance 2 - Seísa Serviços Integrados de Saúde Ltda 3 - Hospital Carlos Chagas S.A 08700.003059/2013-05 2013 1 - Sulasapar Participações S.A Health Insurance 2 - ING Insurance Intemational B.V 08700.005730/2013-44 2013 1 - Unimed Odonto S.A Health Insurance 2 - Unimed Recife Cooperativa de Trabalho Médico 08700.006171/2013-90 2013 1 - Odontoprev S.A Health Insurance 2 - BB Seguros Participações S.A 08700.007610/2013-81 2013 1 - Rede D’Or São Luiz S.A Hospital 2 - Hospital Norte D’Or de Cascadura S.A 08700.009118/2013-40 2013 1 - UNIMED - Rio Participações e Investimentos S.A Hospital and Health Insurance 2 - Oncoclínica - Centro de Tratamento Oncológico Ltda 08700.010530/2013-03 2013 1 - Unimed Seguros Saúde S.A Health Insurance 2 - Tempo Saúde Seguradora S.A 08700.000181/2014-00 2014 1 - Rede D’Or São Luiz S.A Hospital 2 - Brospar Participações Ltda 3 - Proncordis - Pronto Atendimento Cardiológico Ltda 4 - Rede Lav Lavanderia Industrial Hospitalar Ltda 08700.001329/2014-16 2014 1 - Caixa Seguros Holding S.A Health Insurance 2 - Tempo Participações S.A 3 - Odonto Empresas Convênios Dentários Ltda 4 - Prevdonto Odonto Empresa Assistência Odontológica Ltda 08700.002568/2014-93 2014 1 - Bain Capital Brazil Participações Ltda Health Insurance 2 - Intermédica Sistema de Saúde S.A 3 - Interodonto - Sistema de Saúde Odontólogica Ltda 4 - Notre Dame Seguradora S.A 08700.004443/2014-06 2014 1 - Qualicorp S.A Health Insurance 2 - Connectmed CRC Cons, Adm e Tecnologia em Saúde Ltda 3 - Gama Saúde Ltda 08700.010625/2014-08 2014 1 - Rede D’Or São Luiz S.A Hospital 2 - Hospital Vilia-Lobos Ltda 08700.011555/2014-05 2014 1 - Rede D’Or São Luiz S.A Hospital 2 - Associação Hospitalar Sino Brasileiro 3 - Tomo-Med Centro de Diagnóstico e Tratamento Ltda 08700.003676/2015-64 2015 1 - ESHO - Empresa de serviços hospitalares S.A Health Insurance 2 - COl - Clínicas Oncológicas S.A 08700.001601/2015-49 2015 1 - Rede D’Or São Luiz S.A Hospital 2 - Hospital e Maternidade Bartira Ltda 08700.002317/2015-90 2015 1 - Broad Street Principal Investments, L.L.C Hospital 2 - Oncoclínicas do Brasil Serviços Médicos S.A 08700.003123/2015-10 2015 1 - BTG Pactual Saúde Fundo de Investimento em Participações Hospital 2 - Rede D’Or São Luiz S.A 08700.003337/2015-88 2015 1 - Rede D’Or São Luiz S.A Hospital 2 - Oncologia Rede D’Or S.A 08700.005963/2015-17 2015 1 - AXA Corporate Solutions Brasil e América Latina Resseguros, S.A Health Insurance 2 - SulAmérica Companhia Nacional de Seguros 08700.008189/2015-98 2015 1 - Notre Dame Intermédica Saúde S.A Hospital and Health Insurance 2 - Santamália Saúde S.A 3 - Hospital Bosque da Saúde S.A 4 - Hospital Montemagno S.A 5 - Acqua Blue Transporte de Água LTDA 6 - Acqua Magma Lavanderia LTDA 08700.010373/2015-06 2015 1 - ESHO - Empresa de Serviços Hospitalares S.A Hospital and Health Insurance 2 - Hospitais Associados de Pernambuco Ltda 3 - Diagnóstico por Imagem Ltda 4 - Dilab Medicina Nuclear Ltda 5 - Multiângio Ltda 6 - Hemonefro - Hemodiálise e Nefrologia Ltda 7 - Medalliance Net Ltda 08700.011192/2015-99 2015 1 - Fundo de Investimento em Participações Genoma I Hospital 2 - CM Hospitalar Ltda 3 - CM Logística Hospitalar Ltda 4 - BSB Comércio de Produtos Hospitalares Ltda 08700.012624/2015-89 2015 1 - ESHO - Empresa de serviços hospitalares S.A Hospital and Health Insurance 2 - Sociedade Hospital Samaritano 08700.012652/2015-04 2015 1 - São Francisco Sistemas de Saúde Sociedade Empresária Ltda Health Insurance 2 - Fundação Waldemar Barnsley Pessoa 08700.011951/2015-13 2015 1 - Pacific RDSL Participações S.A Hospital 2 - Rede D’Or São Luiz S.A 3 - Banco BTG Pactual S.A 08700.008541/2015-95 2015 1 - Carlyle HILL South America Buyout Fund, L.L.C Health Insurance 2 - America HILL do Sul Investimentos, L.L.C 3 - SA Partners HILL, L.L.C 4 - Brazil HILL Buyout Coinvestment, L.L.C 5 - Fundo Brasil de Internacionalização de Empresas - FIP 11 6 - Tempo Participações S.A. 08700.005620/2016-25 2016 1 - GIF V Fundo de Investimento em Participações Hospital and Health Insurance 2 - São Francisco Sistemas de Saúde Sociedade Empresária Limitada 3 - Hospital São Francisco Sociedade Empresária Ltda 4 - São Francisco Odontologia Limitada 5 - São Francisco Resgate Limitada 08700.000266/2016-42 2016 1 - Rede D’Or São Luiz S.A Hospital 2 - Hospital Memorial São José Ltda 3 - NEOH-MEMORIAL Núcleo Especializado em Oncologia e Hematologia Ltda 4 - Memorial Imagem e Diagnóstico Ltda 5 - Maximagem - Diagnóstico por Imagem Ltda 6 - HEMATO - Serviços de Hemoterapia Ltda 7 - IPASA - Investimento Participação e Administração S.A. 08700.000430/2016-11 2016 1 - Fundo de Investimento em Participações Genoma I Hospital 2 - CM Hospitalar S.A 3 - CM Logística Hospitalar S.A 4 - BSB Comércio de Produtos Hospitalares S.A 08700.003459/2016-55 2016 1 - Amil Assistência Médica Internacional S.A Hospital and Health Insurance 2 - ESHO - Empresa de Serviços Hospitalares S.A 3 - Santa Helena Assistência Médica S.A. 4 - Hospital Santa Helena S.A 5 - Elual Participações S.A 08700.006574/2016-81 2016 1 - Notre Dame Intermédica Saúde S.A Health Insurance 2 - UNIMED do ABC - Cooperativa de Trabalho Médico 08700.007004/2016-17 2016 1 - Rede D’Or São Luiz S.A Hospital 2 - Hospital Ribeirão Pires Ltda 08700.007555/2016-72 2016 1 - Rede D’Or São Luiz S.A Hospital 2 - GEM Assistência Médica Especializada Ltda 08700.007556/2016-17 2016 1- Rede D’Or São Luiz S.A. Hospital 2 - Hospitais Integrados da Gávea S.A 08700.008061/2016-13 2016 1 - Amil Assistência Médica Internacional S.A Hospital and Health Insurance 2 - Hospital Alvorada Taguatinga Ltda 3 - Santos Administração e Participações S.A 4 - Plano de Saúde Ana Costa Ltda 5 - Hospital Ana Costa Ltda 08700.005455/2017-92 2017 1 - Notre Dame Intermédica Saúde S.A Hospital and Health Insurance 2 - Organização Médica Cruzeiro do Sul S.A 3 - Cruzeiro do Sul Serviços de Assistência Médica S.A 4 - Laboratório de Análises Clínicas Cruzeiro do Sul LTDA 08700.004084/2017-21 2017 1 - Rede D’Or São Luiz S.A Hospital 2 - Acreditar Oncologia S.A. 3 - Oncobrasília - Instituto Brasiliense de Oncologia Clínica Ltda 08700.001221/2017-76 2017 1 - Notre Dame Intermédica Saúde S.A Hospital and Health Insurance 2 - Hospital São Bernardo S.A 08700.005859/2017-86 2017 1 - Serviço de Medicina Transfusional SMTS Ltda Hospital 2 - Banco de Sangue de São Paulo e Serviços de Hemoterapia Ltda 08700.002013/2017-94 2017 1 - São Francisco Sistemas de Saúde Sociedade Empresária Ltda Health Insurance 2 - Amhpla Cooperativa de Assistência Médica 08700.008007/2017-41 2017 1 - Hospital Esperança S.A. Hospital 2 - UDI Hospital - Empreendimentos Médico-Hospitalares do Maranhão Ltda 3 - UDI Cárdio - Unidade de Diagnóstico e Tratamento Cardiológico Ltda 4 - UDI Imagem - Unidade de Diagnóstico por Imagem Ltda 08700.004255/2017-12 2017 1 - Abaporu Participações S.A Hospital 2 - Hospital São Lucas S.A 08700.003803/2017-97 2017 1 - Athena Saúde Holding S.A Hospital and Health Insurance 2 - Brazilian Private Equity V - Fundo de Investimento em Participação 3 - Med Imagem S/C 4 - Hospital São Pedro S/C 5 - Hospital Vitória de Timon S/C 6 - Hospital Santa Maria Ltda 7 - Humana Assistência Médica Ltda 8 - Medplan Assistência Médica Ltda 08700.002450/2017-16 2017 1 - Notre Dame Intermédica Saúde S.A Hospital and Health Insurance 2 - Hospital e Maternidade Nova Vida Ltda 3 - Med Vida Assistência Médica Hospitalar Ltda 4 - Nova Vida Assistência Médica Hospitalar Ltda 08700.002164/2017-42 2017 1 - Fundo de Investimento em Participação Abaporu Hospital and Health Insurance 2 - Hospital Vera Cruz S.A 3 - Vera Cruz Associação de Saúde

Process	Year	Stakeholder	Sector of the main stakeholder (s)
08012.007443/2009-41	2009	1 - São Francisco Saúde Sociedade Empresária LTDA	Health Insurance
		2 - Amico Saúde LTDA
08012.009906/2009-17	2009	1 - Amil Assistência Médica Internacional LTDA	Health Insurance
		2- Medial Participações S.A
		3 - Medial Saúde S.A
08012.002248/2009-24	2009	1- Intermédica Sistema de Saúde S.A	Hospital and Health Insurance
		2 - Medicamp Assistência Médica LTDA
08012.008325/2009-50	2009	1 - Tempo Participações S.A	Health Insurance
		2 - Unibanco Saúde Seguradora S.A
08012.008989/2009-19	2009	1 - Bradesco Dental S.A	Health Insurance
		2 - Odontoprev S.A
08012.003389/2010-06	2010	1 - AMIL Assistência Médica Internacional LTDA	Health Insurance
		2 - ASL Assistência a Saúde LTDA.
		3 - CEAME Centro Especializado de Atendimento Médico LTDA.
08012.004902/2010-78	2010	1 - ESHO - Empresa de Serviços Hospitalares LTDA	Hospital
		2 - Hospital Pró-Cardíaco S.A
08012.006190/2010-21	2010	1 - Sul América Seguro Saúde S.A	Health Insurance
		2 - BB Seguros Participações S.A
08012.010274/2010-60	2010	1 - FMG Empreendimentos Hospitalares S.A	Hospital
		2 - São Luiz Operadora Hospitalar S.A
08012.000917/2010-67	2010	1 - UNIMED Porto Alegre Sociedade Cooperativa de Trabalho Médico LTDA.	Health Insurance
		2 - UNIMED Centro Sul, Sociedade Cooperativa de Trabalho Médico LTDA.
08012.004756/2010-81	2010	1 - FMG Empreendimentos Hospitalares S.A	Hospital
		2 - Hospital e Maternidade Brasil S.A
08012.010675/2010-10	2010	1 - FMG Empreendimentos Hospitalares S.A	Hospital
		2 - Hospital e Maternidade Assunção S.A
		3 - Assunção Imagem S.A
		4 - Ressonância Assunção S.A.
08012.010734/2010-50	2010	1 - Amil Assistência Médica Internacional LTDA	Health Insurance
		2 - Excelsior Med LTDA
08012.011280/2010-34	2010	1 - FMG Empreendimentos Hospitalares S.A	Hospital
		2 - Casa de Saúde e Maternidade Rio de Janeiro S.A
		3 - Casa de Saúde e Maternidade Joari S.A
		4 - JMJB Diagnósticos e Serviços Hospitalares S.A
		5 - LE Participações Societárias S.A
		6 - Medise Medicina Diagnóstico e Serviços S.A
		7 - Hospital Realcordis S.A
08012.012150/2010-19	2010	1 - FMG Empreendimentos Hospitalares S.A	Hospital
		2 - Prontolinda S.A
08012.013181/2010-97	2010	1 - Sul América Companhia de Seguro Saúde	Health Insurance
		2 - Dental Plan Ltda
08012.013200/2010-85	2010	1 - Hospital das Clínicas de Niterói	Hospital
		2 - Clínica Médico-Cirúrgica Botafogo S.A
08012.008112/2010-61	2010	1 - The Carlyle Group	Health Insurance
		2 - Qualicorp Participações S.A
08012.000596/2011-81	2011	1 - Hospital Norte D’Or de Cascadura S.A	Hospital and Health Insurance
		2 - Unimed-Rio Participações e Investimentos S.A
08012.002872/2011-46	2011	1 - Medgrupo Participações S/A	Hospital
		2 - Hospital Renascer Ltda
08012.004596/2011-51	2011	1 - Hospital e Maternidade São Luiz S.A	Hospital
		2 - Oncotech Oncologia Ltda
		3 - Cotefil Hospital Geral Ltda
08012.006525/2011-92	2011	1 - Centro de Tratamento em Oncologia S.A	Hospital
		2 - Oncologistas Associados Serviços Médicos Ltda
		3 - Instituto Oncológico de Pernambuco Ltda
08012.006542/2011-20	2011	1 - AMIL Assistência Médica Internacional S.A	Health Insurance
		2 - LINCX Sistemas de Saúde LTDA
08012.009232/2011-67	2011	1- Qualicorp S.A	Health Insurance
		2 - Medlink Conectividade em Saúde Ltda
08012.009582/2011-23	2011	1 - Centro de Tratamento em Oncologia S.A	Hospital
		2 - Instituto Oncológico de Pernambuco Ltda
08012.011059/2011-67	2011	1 - Rede D’Or São Luiz S.A	Hospital
		2 - Vivaile Serviços de Saúde Ltda
08012.011421/2011-08	2011	1 - Oncotech Oncologia Ltda	Hospital
		2 - Centro Radioterápico da Gávea Ltda.
		3 - Serviços de Radioterapia São Peregrino Ltda.
		4 - CORAL - Centro de Oncologia e Radioterapia Ltda
		5 - LFC Serviços Médicos Ltda
		6 - Scanmed - Aluguel de Máquinas e Equipamentos Ltda
08012.011602/2011-26	2011	1 - Rede D’Or	Hospital
		2 - MAIS - Multi Assistência Incorporada à Saúde Ltda
		3 - Centro Hospitalar São Marcos S.A
08012.004653/2011-00	2011	1 - Qualicorp Administradora de Benefícios S.A.	Health Insurance
		2 - Qualicorp Corretora de Seguros S.A.
		3 - Divicom Administradora de Benefícios Ltda.
		4 - Divicom Gestão de Benefícios Ltda.
		5 - Divicom Corretora de Seguros S.S
		6 - Divicom Assessoria e Negócios S.S.
08012.009575/2011-21	2011	1 - Qualicorp Administradora de Benefícios S.A	Health Insurance
		2 - Qualicorp Corretora de Seguros S.A
		3 - Adplan Administração e Planejamento de Benefícios Ltda
		4 - Destak Corretora de Seguros Ltda
08012.002189/2012-90	2012	1 - Central Médica de Prevenção LTDA	Health Insurance
		2 - UNIMED Porto Alegre Sociedade Cooperativa de Trabalho Médico LTDA
08012.005776/2012-31	2012	1 - Pio Sodalicio das Damas de Caridade de Caxias do Sul	Health Insurance
		2 - UNIMED Nordeste RS Sociedade Cooperativa de Serviços Médicos LTDA
08012.000309/2012-14	2012	1 - Qualicorp Administradora de Benefícios S.A	Health Insurance
		2 - Qualicorp Corretora de Seguros S.A.
		3 - Afinidade Administradora de Benefícios Ltda
		4 - Equilibrar Corretora de Seguros Ltda
08012.002520/2012-71	2012	1 - Rede D’Or São Luiz S.A	Hospital
		2 - Sinisgalli Administração e Participações S.A
		3 - Hospital e Maternidade Nossa Senhora de Lourdes S.A
		4 - Instituto de Especialidades Pediátricas de São Paulo S.A
		5 - Angiodinâmica S.A
		6 - Lithocenter S.A
		7 - Centro Diagnóstico NSL S.A
08012.002680/2012-11	2012	1 - Carpevie — Centro de Medicina Integrada Ltda	Hospital
		2 - LAF — Empresa de Serviços Hospitalares Ltda
		3 - Mariliz Lima — Ginecologia e Obstetrícia e Erickson ÉIun — Cirurgia do Aparelho Digestivo Ltda
08012.002866/2012-70	2012	1 - Carpevie — Centro de Medicina Integrada Ltda	Hospital
		2 - EGB 01 Empreendimentos e Participações Ltda
		3 - ADIX Empreendimentos Imobiliários Ltda
08012.005539/2012-70	2012	1 - Rede D’Or São Luiz S.A	Hospital
		2 - Hospital Santa Luzia S.A
		3 - Hospital do Coração do Brasil S.A.
08012.005540/2012-02	2012	1 - Jorge Nevai Moli Filho	Health Insurance
		2 - Pedro Junqueira MolI
		3 - Paulo Junqueira MolI
		4 - Santa Luzia Assistência Médica S.A
08012.006134/2012-59	2012	1 - ESHO - Empresa de Serviços Hospitalares S.A	Hospital
		2 - Sociedade Civil Clinvac LTDA
08700.004065/2012-91	2012	1 - Qualicorp Administradora de Benefícios S.A	Health Insurance
		2 - Qualicorp Corretora de Seguros S.A
		3 - Aliança Administradora de Benefícios de Saúde Ltda
		4 - GA Consultoria, Administração e Serviços Ltda
08700.004150/2012-59	2012	1 - Rede D’Or São Luiz S.A	Hospital
		2 - Medgrupo Participações S.A
		3 - Hospital Santa Lúcia S.A
08700.004151/2012-01	2012	1 - Rede D’Or São Luiz S.A	Hospital
		2 - Acreditar Oncologia Ltda
08012.003324/2012-14	2012	1 - Qualicorp Administradora de Benefícios S.A	Health Insurance
		2 - Qualicorp Corretora de Seguros S.A
		3 - PS - Padrão Administradora de Benefícios Ltda
		4 - Padrão Administração e Corretagem de Seguros Ltda
		5 - PS Brasil Administração e Corretagem de Seguros Ltda
		6 - Voloto Consultoria Empresarial Ltda
08700.005472/2012-15	2012	1 - VSAP 21 Fundo de Investimento em Participações	Hospital
		2 - Oncoclínicas do Brasil Serviços Médicos S.A
08700.008474/2012-66	2012	1 - CLIDEC - Clínica Dentária Especializada Cura D’ars Ltda	Health Insurance
		2 - Fleury Centro de Procedimentos Médicos S.A
		3 - Papaiz Associados Diagnósticos por Imagem S/S Ltda
08700.010284/2013-90	2013	1 - Swiss Re Direct Investments Company Ltd	Health Insurance
		2 - 1NG Insurance International B.V
		3 - Sul América S.A
08700.005729/2013-10	2013	1 - Unimed Odonto S.A	Health Insurance
		2 - Unimed Vitória Cooperativa de Trabalho Médico
08700.006494/2013-83	2013	1 - Unimed-Rio Cooperativa de Trabalho Médico do Rio de Janeiro Ltd	Health Insurance
		2 - Golden Cross Assistência Internacional de Saúde Ltda
08700.008540/2013-89	2013	1 - Amil Assistência Médica Internacional S.A	Hospital and Health Insurance
		2 - Seísa Serviços Integrados de Saúde Ltda
		3 - Hospital Carlos Chagas S.A
08700.003059/2013-05	2013	1 - Sulasapar Participações S.A	Health Insurance
		2 - ING Insurance Intemational B.V
08700.005730/2013-44	2013	1 - Unimed Odonto S.A	Health Insurance
		2 - Unimed Recife Cooperativa de Trabalho Médico
08700.006171/2013-90	2013	1 - Odontoprev S.A	Health Insurance
		2 - BB Seguros Participações S.A
08700.007610/2013-81	2013	1 - Rede D’Or São Luiz S.A	Hospital
		2 - Hospital Norte D’Or de Cascadura S.A
08700.009118/2013-40	2013	1 - UNIMED - Rio Participações e Investimentos S.A	Hospital and Health Insurance
		2 - Oncoclínica - Centro de Tratamento Oncológico Ltda
08700.010530/2013-03	2013	1 - Unimed Seguros Saúde S.A	Health Insurance
		2 - Tempo Saúde Seguradora S.A
08700.000181/2014-00	2014	1 - Rede D’Or São Luiz S.A	Hospital
		2 - Brospar Participações Ltda
		3 - Proncordis - Pronto Atendimento Cardiológico Ltda
		4 - Rede Lav Lavanderia Industrial Hospitalar Ltda
08700.001329/2014-16	2014	1 - Caixa Seguros Holding S.A	Health Insurance
		2 - Tempo Participações S.A
		3 - Odonto Empresas Convênios Dentários Ltda
		4 - Prevdonto Odonto Empresa Assistência Odontológica Ltda
08700.002568/2014-93	2014	1 - Bain Capital Brazil Participações Ltda	Health Insurance
		2 - Intermédica Sistema de Saúde S.A
		3 - Interodonto - Sistema de Saúde Odontólogica Ltda
		4 - Notre Dame Seguradora S.A
08700.004443/2014-06	2014	1 - Qualicorp S.A	Health Insurance
		2 - Connectmed CRC Cons, Adm e Tecnologia em Saúde Ltda
		3 - Gama Saúde Ltda
08700.010625/2014-08	2014	1 - Rede D’Or São Luiz S.A	Hospital
		2 - Hospital Vilia-Lobos Ltda
08700.011555/2014-05	2014	1 - Rede D’Or São Luiz S.A	Hospital
		2 - Associação Hospitalar Sino Brasileiro
		3 - Tomo-Med Centro de Diagnóstico e Tratamento Ltda
08700.003676/2015-64	2015	1 - ESHO - Empresa de serviços hospitalares S.A	Health Insurance
		2 - COl - Clínicas Oncológicas S.A
08700.001601/2015-49	2015	1 - Rede D’Or São Luiz S.A	Hospital
		2 - Hospital e Maternidade Bartira Ltda
08700.002317/2015-90	2015	1 - Broad Street Principal Investments, L.L.C	Hospital
		2 - Oncoclínicas do Brasil Serviços Médicos S.A
08700.003123/2015-10	2015	1 - BTG Pactual Saúde Fundo de Investimento em Participações	Hospital
		2 - Rede D’Or São Luiz S.A
08700.003337/2015-88	2015	1 - Rede D’Or São Luiz S.A	Hospital
		2 - Oncologia Rede D’Or S.A
08700.005963/2015-17	2015	1 - AXA Corporate Solutions Brasil e América Latina Resseguros, S.A	Health Insurance
		2 - SulAmérica Companhia Nacional de Seguros
08700.008189/2015-98	2015	1 - Notre Dame Intermédica Saúde S.A	Hospital and Health Insurance
		2 - Santamália Saúde S.A
		3 - Hospital Bosque da Saúde S.A
		4 - Hospital Montemagno S.A
		5 - Acqua Blue Transporte de Água LTDA
		6 - Acqua Magma Lavanderia LTDA
08700.010373/2015-06	2015	1 - ESHO - Empresa de Serviços Hospitalares S.A	Hospital and Health Insurance
		2 - Hospitais Associados de Pernambuco Ltda
		3 - Diagnóstico por Imagem Ltda
		4 - Dilab Medicina Nuclear Ltda
		5 - Multiângio Ltda
		6 - Hemonefro - Hemodiálise e Nefrologia Ltda
		7 - Medalliance Net Ltda
08700.011192/2015-99	2015	1 - Fundo de Investimento em Participações Genoma I	Hospital
		2 - CM Hospitalar Ltda
		3 - CM Logística Hospitalar Ltda
		4 - BSB Comércio de Produtos Hospitalares Ltda
08700.012624/2015-89	2015	1 - ESHO - Empresa de serviços hospitalares S.A	Hospital and Health Insurance
		2 - Sociedade Hospital Samaritano
08700.012652/2015-04	2015	1 - São Francisco Sistemas de Saúde Sociedade Empresária Ltda	Health Insurance
		2 - Fundação Waldemar Barnsley Pessoa
08700.011951/2015-13	2015	1 - Pacific RDSL Participações S.A	Hospital
		2 - Rede D’Or São Luiz S.A
		3 - Banco BTG Pactual S.A
08700.008541/2015-95	2015	1 - Carlyle HILL South America Buyout Fund, L.L.C	Health Insurance
		2 - America HILL do Sul Investimentos, L.L.C
		3 - SA Partners HILL, L.L.C
		4 - Brazil HILL Buyout Coinvestment, L.L.C
		5 - Fundo Brasil de Internacionalização de Empresas - FIP 11
		6 - Tempo Participações S.A.
08700.005620/2016-25	2016	1 - GIF V Fundo de Investimento em Participações	Hospital and Health Insurance
		2 - São Francisco Sistemas de Saúde Sociedade Empresária Limitada
		3 - Hospital São Francisco Sociedade Empresária Ltda
		4 - São Francisco Odontologia Limitada
		5 - São Francisco Resgate Limitada
08700.000266/2016-42	2016	1 - Rede D’Or São Luiz S.A	Hospital
		2 - Hospital Memorial São José Ltda
		3 - NEOH-MEMORIAL Núcleo Especializado em Oncologia e Hematologia Ltda
		4 - Memorial Imagem e Diagnóstico Ltda
		5 - Maximagem - Diagnóstico por Imagem Ltda
		6 - HEMATO - Serviços de Hemoterapia Ltda
		7 - IPASA - Investimento Participação e Administração S.A.
08700.000430/2016-11	2016	1 - Fundo de Investimento em Participações Genoma I	Hospital
		2 - CM Hospitalar S.A
		3 - CM Logística Hospitalar S.A
		4 - BSB Comércio de Produtos Hospitalares S.A
08700.003459/2016-55	2016	1 - Amil Assistência Médica Internacional S.A	Hospital and Health Insurance
		2 - ESHO - Empresa de Serviços Hospitalares S.A
		3 - Santa Helena Assistência Médica S.A.
		4 - Hospital Santa Helena S.A
		5 - Elual Participações S.A
08700.006574/2016-81	2016	1 - Notre Dame Intermédica Saúde S.A	Health Insurance
		2 - UNIMED do ABC - Cooperativa de Trabalho Médico
08700.007004/2016-17	2016	1 - Rede D’Or São Luiz S.A	Hospital
		2 - Hospital Ribeirão Pires Ltda
08700.007555/2016-72	2016	1 - Rede D’Or São Luiz S.A	Hospital
		2 - GEM Assistência Médica Especializada Ltda
08700.007556/2016-17	2016	1- Rede D’Or São Luiz S.A.	Hospital
		2 - Hospitais Integrados da Gávea S.A
08700.008061/2016-13	2016	1 - Amil Assistência Médica Internacional S.A	Hospital and Health Insurance
		2 - Hospital Alvorada Taguatinga Ltda
		3 - Santos Administração e Participações S.A
		4 - Plano de Saúde Ana Costa Ltda
		5 - Hospital Ana Costa Ltda
08700.005455/2017-92	2017	1 - Notre Dame Intermédica Saúde S.A	Hospital and Health Insurance
		2 - Organização Médica Cruzeiro do Sul S.A
		3 - Cruzeiro do Sul Serviços de Assistência Médica S.A
		4 - Laboratório de Análises Clínicas Cruzeiro do Sul LTDA
08700.004084/2017-21	2017	1 - Rede D’Or São Luiz S.A	Hospital
		2 - Acreditar Oncologia S.A.
		3 - Oncobrasília - Instituto Brasiliense de Oncologia Clínica Ltda
08700.001221/2017-76	2017	1 - Notre Dame Intermédica Saúde S.A	Hospital and Health Insurance
		2 - Hospital São Bernardo S.A
08700.005859/2017-86	2017	1 - Serviço de Medicina Transfusional SMTS Ltda	Hospital
		2 - Banco de Sangue de São Paulo e Serviços de Hemoterapia Ltda
08700.002013/2017-94	2017	1 - São Francisco Sistemas de Saúde Sociedade Empresária Ltda	Health Insurance
		2 - Amhpla Cooperativa de Assistência Médica
08700.008007/2017-41	2017	1 - Hospital Esperança S.A.	Hospital
		2 - UDI Hospital - Empreendimentos Médico-Hospitalares do Maranhão Ltda
		3 - UDI Cárdio - Unidade de Diagnóstico e Tratamento Cardiológico Ltda
		4 - UDI Imagem - Unidade de Diagnóstico por Imagem Ltda
08700.004255/2017-12	2017	1 - Abaporu Participações S.A	Hospital
		2 - Hospital São Lucas S.A
08700.003803/2017-97	2017	1 - Athena Saúde Holding S.A	Hospital and Health Insurance
		2 - Brazilian Private Equity V - Fundo de Investimento em Participação
		3 - Med Imagem S/C
		4 - Hospital São Pedro S/C
		5 - Hospital Vitória de Timon S/C
		6 - Hospital Santa Maria Ltda
		7 - Humana Assistência Médica Ltda
		8 - Medplan Assistência Médica Ltda
08700.002450/2017-16	2017	1 - Notre Dame Intermédica Saúde S.A	Hospital and Health Insurance
		2 - Hospital e Maternidade Nova Vida Ltda
		3 - Med Vida Assistência Médica Hospitalar Ltda
		4 - Nova Vida Assistência Médica Hospitalar Ltda
08700.002164/2017-42	2017	1 - Fundo de Investimento em Participação Abaporu	Hospital and Health Insurance
		2 - Hospital Vera Cruz S.A
		3 - Vera Cruz Associação de Saúde

Publication Dates

• Publication in this collection
  26 July 2021
• Date of issue
  2021

History

• Received
  11 June 2020
• Reviewed
  21 Jan 2021
• Accepted
  24 Feb 2021