Financing Universal Healthcare in India

India has long had a commitment to offer comprehensive healthcare to all citizens. This has been reaffirmed in the 12th Five-year Plan as well as in the more recent National Health Assurance Mission. However, despite this, India has not been able to realize this goal. It is not clear if it has embarked on a path that will make it possible to do so even in the distant future.

The most important reason for this relates not to the absolute availability of resources but to the fundamental flaws in the design of the health system. At 4% of gross domestic product, the country expends more than enough money to deliver good quality healthcare to all citizens.

However, 70% of this money is spent on an out-of-pocket basis at the point-of-service (OOP-POS) with the actual expenditure at any point of time varying from zero to more than Rs.10 lakh, and it is spent to pay for care that is often not necessary or for conditions that would have been easier and less expensive to treat if they had been detected earlier or those that have a slow onset or are asymptomatic until they reach an advanced stage.

This produces financial hardship for all but the top 1% of the population and leads to low levels of well-being across all income segments. The high variability of OOP-POS expenditure on health and the deterrent effect it has on seeking care in a timely manner is also one of the key factors responsible for the re-entry of the middle classes into poverty. It is also a reason for the delayed progress of all below the poverty line, effectively reducing the rate of economic growth.

However, healthcare is not a standard market good and suffers from problems that result in people delaying care until they are really very sick; inability of patients to fully understand and properly evaluate the quality of advice and treatment that they receive and to determine if it is priced in a fair manner; a number of chronic diseases not being suitable for treatment within hospital settings; and the tendency of hospital insurance to result in overuse of hospital services leading to a steady increase in the insurance premium for such services, particularly when patients have received no primary care and have come directly to the hospital.

Developmental efforts of all successful health systems have simultaneously sought to address concerns relating both to financial protection of their citizens and the proper provision of healthcare, with a high degree of implied paternalism to compensate for the failure of traditional competitive market mechanisms to arrive at optimal solutions.

Some, like Japan, have flooded the market with healthcare providers which, in combination with tight regulations, have kept prices low and quality high, have required all the citizens to buy into a single national health insurance plan and have relied heavily on the general good health, healthy dietary practices and high levels of literacy to ensure their consumption of healthcare is optimal.

Others, like the UK, have ensured taxes pay for all healthcares, with the government contracting private doctors for primary care and directly providing higher level of care to all its citizens.

Even though there are a few notable exceptions at the state level, India, despite driven by a low tax-to-GDP ratio of 15%, allocates 10% for healthcare as a proportion of its total expenditure. Still it is unable to afford to pay for all the healthcare needs of its citizens through taxation alone. It will remain so until there is a sharp increase in the tax-to-GDP ratio or the government decides to increase its allocation towards healthcare disproportionately at the expense of other social services.

Any such scheme must have three key components. First, the scheme should provide and pay for a comprehensive essential health package (EHP) and not just restrict its attention to maternal and child health or only to financial protection. Historically, health insurance schemes in India, including those offered by governments, have restricted coverage to in-patient hospital-based treatments.

Secondly, such a scheme would have to be designed from its conception stage to serve both the poor and the non-poor. This would mean the quality dimension would need to be paid attention to, as well as the look-and-feel of the facility itself. Based on the collections from direct taxes on income in the current assessment year in India, such a system of pre-payments from the non-poor who are part of the formal sector could raise between Rs.14,000 crore and Rs.34,000 crore with a total contribution ranging from 5-12% of salaries. This amount on its own has the potential to contribute up to 18% of the required health budgets, without the deadweight loss associated with generalized increased in taxation that hurts growth.

In any developing economy, and India is no exception, there is a large section of the population that is above the poverty line but is not a part of the formal sector. Innovative pre-payment mechanisms can be designed to cover this segment, including explicit sale of the integrated insurance-healthcare product to them on a full-cost basis. Kyrgyzstan is an example of a country that has an informal agricultural sector, which has successfully devised mechanisms to collect contributions towards health insurance from these groups, and has thus, been able to extend health coverage to more than 80% of the population.

The successes of the Swavalamban Scheme and the microfinance movement in India suggest the informal non-poor have the willingness and the ability to pay for schemes that directly add value to them.

[Source: http://blog.livemint.com/Opinion/X4F3daIPrtCj3uxyzrpSVN/Financing-universal-healthcare-in-India.html ]

Consumer-driven health care is the future

“Health care Consumerism” otherwise known as “Consumer-Driven Health care” is aimed at restructuring care around consumers and patients. Typically, in India’s current system, the government and employers take a “paternalistic” role via their health coverage and government-based hospitals shoulder the responsibility of providing health care, negotiating rates with pharmaceuticals, and arriving at a market rate for doctors and services. 

However, in a consumer-driven economy, consumers take centre-stage, dictating the modes and methods of care delivery, giving rise to a consumer-focussed marketplace.

There are a number of trends stemming from this important shift towards a focus on consumers. All health care stakeholders, including hospitals, insurance companies, pharmaceuticals, and clinics that ride these changes, may be in a better position to stay financially sustainable where patient satisfaction can make or break chances of success. Here are some things that will help you understand health consumerism better.

1. Consumers are biggest winners of the trend: Consumers will benefit with lower costs and better quality of service in hospitals and clinics. With the advent of technologies that can track health statuses real-time, patients can proactively manage their health and become more involved in their treatment processes. In India, such a system will be a huge shift from our current doctor-driven care and result in patients making health care decisions along with their care providers. Digital health trackers and health apps are great examples of what a consumer-driven health economy will look like.

2. Hospitals, doctors and clinics need to up their game: Hospitals, clinics, and doctors will need to prepare and face a market which is driven by customer satisfaction. In our current incentive structure, these providers get paid for the number of services they provide such as number of patient visits, number of surgeries, etc. However, in a consumer-driven marketplace, they will be paid for reducing hospital stays, improving safety and quality, and providing tools for consumers to manage their own health.

3. Health insurers need to reinvent themselves: While health insurance marketplace is naive in India, it is still one of the fastest growing segments of business. Health insurers will have to carefully reinvent themselves by appealing to consumers who are increasingly involved in the health care landscape. In the US, insurance companies provide tools and technologies that help with real-time diagnosis via Google and Apple Apps, provide cost transparency so that consumers are not shocked to see their final bills, and pay for wellness programmes which have shown to reduce cost over the long run. These are some of the trends expected in the near future.

It is important to point out that while India still needs to tackle its basic access to care issues, consumerism is inevitable. Several white papers have already pointed to a future state of health care where patients and consumers will engage with health providers and insurance companies in the same way as they are engaged in buying a product from Flipkart or Amazon. I firmly believe that such an economy will improve health care access by reducing the cost of care while improving our quality.

 [Source: http://forbesindia.com/blog/health/consumer-driven-health-care-is-the-future/]

New Health Insurance Portal Simplifies Enrollment for Small Firms

San Francisco, Calif.-based Group Hub, a portal that simplifies the health insurance enrollment process for small- and medium-size companies, is one of seven health care-related start ups chosen by Blueprint Health accelerator for its winter class, in an announcement made Feb. 5.

The company, which launched in mid-2014 in the classic basement-start up model, works with health insurance brokers who serve small to midsize companies with less than 100 employees. The Group Hub portal allows brokers to immediately enroll and validate hundreds of applications and to comply with HIPAA electronic compliance mandates that w

ill become effective in 2016.

Since its launch, the company has signed up brokers who represent 30,000 companies and 600,000 people. The founders have amassed $500,000 in seed capital.

Group Hub was chosen for Blueprint Health accelerator’s Winter 2015 round from a pool of more than 300 applicants, Jean-Luc Neptune, executive director of the Bluprint Health accelerator, told India-West.

“Small and mid-size employers are still the driver of the health insurance market,” said Neptune, noting that 60 million companies across the nation had fewer than 100 employees. Currently, employers and brokers are heavily paper-based, said Neptune, who is a physician. “Group Hub provides a tool for efficiency,” he said, noting that he chooses health care start-ups for the three-month accelerator program that have talented founders with a variety of skills “attacking a real market where there is a real opportunity.” Through the accelerator program, start-ups are connected to mentor networks and investor networks and typically emerge with a second round of funding, said Neptune.

Kunal Mukherjee, operations director and co-founder of Group Hub, told India-West that the company aims to provide health care access to more Americans, the first step in preventing chronic conditions.

“The onerous, eligibility- based, model of healthcare that we have all dealt with is designed to be an obstacle course, discouraging medical attention until it is catastrophic,” he stated.

Mukherjee’s own battle with the U.S.’s Herculean health insurance system came as he tried to get benefits for his Indian American parents. The family struggled to navigate the complex system of enrolling for health insurance after Mukherjee’s mother suffered a stroke.

His elderly parents returned to India in 2012, “tired of humiliating interrogation by government agencies to show eligibility for any medical attention,” for what had now become a chronic condition, said the Indian American. Both parents died a year after returning to India.

GroupHub works with brokers serving companies with less than 100 employees. Mukherjee and his partners Allen Byerly, a software engineer, and Gabriel Roybal, a molecular biologist, launched Group Hub in Mukherjee’s basement, in classic start-up mode. The team waterproofed their flooded workspace, moved boxes around, got a white board and an Ikea desk to brainstorm, make cold calls and apply to incubator programs.

“We trusted in Providence, never taking any of this too seriously but playing it day by day,” said Mukherjee, whose debut novel, “My Magical Palace,” was released the previous year.

Roybal, chief of business development, told India-West that Group Hub was launched with the belief that the current health care insurance model is broken. After an abrupt personal health care crisis in 2013, Roybal had to quit his job while receiving medical treatment.

“Facing long-term management of a chronic illness, I suddenly faced a complicated and time consuming health insurance marketplace. I knew that health insurance did not need to be this complicated, and that many other people were facing similar challenges,” said Roybal. “I committed myself to identifying a way that I could use my professional and personal experience to disrupt the existing insurance marketplace.”

Byerly, chief of product development, noted there are a number of competitors in the same market, but added: 

“We are the first electronic enrollment product designed exclusively for insurance brokers that is truly compliant with all the laws and regulations and completely automates the process.”“To the consumer we help individuals select the best benefits options for their needs and make it super easy and simple to enroll in those benefits,” said Byerly. “The vision of the company is to provide a single place for anyone to select, enroll, and then manage all of their benefits and get the most out of them and live a healthier and wealthier life,” he said.

[Source: http://www.indiawest.com/news/global_indian/new-health-insurance-portal-simplifies-enrollment-for-small-firms/article_2f951588-b3b3-11e4-8060-7f099026fa34.html]

Standardization in Health Insurance: Streamlined Business & Satisfied Consumers!

Health Insurance continues to be one of the most dynamic and fast evolving sectors of the Indian insurance industry. Gross written premiums by insurance companies has increased from Rs.17565 cr in FY’ 2005 to Rs.59898 cr in FY’2012 showing a very healthy 19% CAGR growth. The industry has shown significant improvement in operational parameters even as claims ratios continue to remain high. However, the growth is fraught with numerous challenges including efficiency, affordability and accessibility of health insurance. The efficiency in the health insurance system is also plagued by mistrust between providers and insurers due to non-standardized practices and formats in an evolving industry. Standardization therefore is critical to enhance quality delivery of health insurance, encourage innovation and greater penetration of health insurance in the country.

Health Insurance Guidelines 2013

The IRDA recently notified the health insurance guidelines 2013 to standardize health insurance in the country. The regulator has mentioned that the guidelines are meant to reduce ambiguity and enable all stakeholders to provide better services and enable customers to interact more effectively with insurers, third-party administrators and providers. The guidelines includes various facets of standardization including definitions of critical illnesses, definitions of commonly used insurance terms, list of excluded items in hospitalization indemnity policies, billing formats, discharge summary and standard contracts between TPA, insurers and hospitals. Undoubtedly, this represents a very important milestone in ushering standardization in the health insurance sector. Let’s dwell on each of these facets to appreciate the importance of this initiative.

The Guidelines aim to reduce the existing ambiguity between the insurer/reinsurer, provider and consumer due to varied critical illnesses definitions. The differences in the definitions of Critical Illnesses adopted by the different insurers have created confusion in the minds of consumers wherein products are difficult to compare and the industry especially at the time when insurers and re-insurers have to arrive at a point where lump sum payment is made. The availability of standard definitions would now ensure better comparability and uniformity in the understanding of critical illness definitions.

Another grey area that has been addressed is the list of excluded items.  As there is has been no detailed listing of such excluded expenses, and the interpretation of these exclusions is highly varied across different payers in the industry, many a times various items under the claims filed by hospital providers or individual policyholders are repudiated by the insurers but are disputed by the claimants. This is, thus, one major cause of acrimony between Insurance Companies and healthcare providers and also puts the consumer in inconvenience as out of pocket expenses goes up. The excluded items list driven by a  consensus between all the stakeholders of the industry and a uniform understanding of such ‘exclusions’ would be the key for better understanding of policy conditions by the policyholders and hospitals, which would in turn facilitate speedier roll out of health insurance in the country.

Standardizing billing formats would enable mapping of hospital information systems to specific data requirements of the Insurance companies for faster claim processing and enhanced analysis of data.

This would also facilitate electronic transmission of provider bills to the payers for processing and payment. The standardized format would now be part of the standard contract between insurers/TPA and the providers. Similarly, varied Discharge Summary format specific to payers often leads to delay in processing claims as requests have to be sent to providers to provide additional information. The standardized discharge summary would now be used across providers for benefit of all stakeholders and facilitate processing of claims at the payer end. The relevant information would integrate seamlessly with standard claim form and provider bills.

The guidelines also specify the minimum standard clauses of the service level agreement entered between the Insurer and the TPA as well as agreement between the healthcare provider and the Insurer/TPA. A skeletal framework for the contract would bring uniformity, more clarity about the service standards and minimize the chances of disputes over interpretation. The document would be instrumental in streamlining other standard processes and documents like pre-authorization form, discharge summary form, bill formats, etc.

FICCI’s health insurance advisory group has developed the above standardization initiatives incorporated in the IRDA guidelines which have been submitted to the regulator over the years. This therefore marks an important landmark and achievement of the multi stakeholder consensus driven group.  The effectiveness of insurance standardization will be further enhanced once the healthcare sector adopts standard treatment guidelines for common disease conditions. The group’s work in this area has been the precursor to the development of National Standard Treatment Guidelines. The Ministry of Health & Family Welfare, Government of India is in the process of rolling out the guidelines as part of the provisions of Clinical Establishment Act. These STGs were developed by eminent clinical experts facilitated by FICCI.

The release of the health insurance guidelines also marks a new journey for the FICCI health insurance advisory group which would now look at new domain areas in health insurance including combating health insurance fraud, product innovation, data analytics and promoting quality in healthcare through health insurance. The group would continue to work towards realizing an ideal universe of health insurance business with satisfied customer at its core, greater penetration of health insurance products and affordable quality healthcare for the masses.

There are other facets of standardization in the IRDA guidelines including the Standard Insurance Termsand Standard Pre-authorization and Claim form. Insurance terms continue to remain jargons for the laymen. Terms notified in the guidelines would reduce ambiguity, enable all stakeholders to provide better services and enable customers to interact more effectively with insurers, TPAs and providers.  A common industry wide pre-authorization and claim form will significantly streamline processes at all stages. This will also enhance the ability of providers to obtain a timely prior authorization. By implementing it in an optical character recognition (OCR) format, the ability to transfer data from a handwritten paper based form to IT systems has been enhanced thus reducing the data entry issues for TPAs and insurers. Every company shall attach set of claim forms along with policy terms and conditions to the policyholder.

This is significant in the background of health ministry’s efforts to develop standards for making and maintenance of Electronic Health Records in the country being coordinated by FICCI. This is the single most standard tool which will help in data warehousing, monitoring and portability which would greatly reduce diagnostic time and help in creating a national health database. It should also pave the way for an all encompassing Health information portal which has detailed demographic data helping in periodic review of disease-wise, city-wise and region-wise information. Healthcare delivery would certainly be improved tremendously with all these measures.

 [Source : http://blog.ficci.com/health-insurance-india/3345/]