Role of health insurance in india

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Dr.T ruptiPate l Dr.BhavnaSumra MsElg inKurusu MrBalraj Dr.She larGite sh Dr.ShilpaJ ain Mr.Md.J ze e l e Dr.MisbahKhan Dr.Ve e naSalunke Dr.VishalGaikwad

ograpplewithnewerchallengesinspiteofsignificantgainsintermsofh

mmunicabledisease&increasingproblemofnoncommunicabledisease

HEALTHINSURANCE
TheILOdefineshealthinsuranceas:

Thereductionoreliminationoftheuncertainriskoflossfor theindividualorhouseholdbycombiningalargernumber ofsimilarlyexposedindividualsorhouseholdswhoare includedinacommonfundthatmakesgoodthelosscaused toanyonemember (ILO,1996)

Insimpletermscanbeputas

Anindividualorgrouppurchasinginadvance;health coveragebypayingafeecalled"premium".

Todayinsurancesectorisgrowingatarateof 1520% Togetherwithbankingservices,insuranceservices addabout7%tothecountrysGDP Outofthismorethan70%isOutofpocket expense. Currentlyabout200millionpeopleinIndiahave healthormedicalbenefitsunderschemesfor governmentemployees,railways,armedforces personnelandthroughESIS,RSBYand

DIFFERENTCATEGORIESOFINSURANCE SCHEME

Health insurance Definition and origin in India

Definition in Indian context:-In its broader sense, it would be any arrangement that helps to defer, delay ,reduce or altogether avoid payment for health care incurred by individuals and households.

- in a narrow sense would be an individual or group purchasing health care coverage in advance by paying a fee called premium.

SOCIAL SECURITY FOR MEDICAL EMERGENCIES IS NOT NEW TO THE INDIAN ETHOS. -piruvu (a collection) to support a household with a sick patient.

Health insurance was introduced only in 1912 when the first Insurance Act was passed (Devadasan 2004) while the current version of the Insurance Act was introduced in 1938. Since then there was little change till 1972 when the insurance industry was nationalized and 107 private insurance companies were brought under the umbrella of the General Insurance Corporation (GIC). Private and foreign entrepreneurs were allowed to enter the market with the enactment of the Insurance Regulatory and Development Act (IRDA) in 1999. The health insurance market in India is very limited covering about 10% of the total population.

PUBLIC HEALTH INSURANCE SCHEMES

BENEFITS AND ELIGIBILITY PUBLIC HEALTH BENEFITS SCHEMES ESIS

MEDICAL BENEFIT,MATERNITY BENEFIT,SICKNESS BENEFIT,EXTENDED SICKNESS BENEFIT,DEPENDANT BENEFIT,PREVENTIVE HEALTH CARE SERVICES,FUNERAL EXPENSES ETC.O.P.D,HOSPITALIZATION,MEDICIN E PRIVATE PRACTIONER

ELIGIBILITY
.COVERS EMPLOYEES OF NON SEASONAL POWER USING FACTORIES AND NON-POWER ESTABLISHMENT WITH BASIC SALARY LESS THAN Rs.6.500

CGHS

DOMICILIARY CARE,MATERNITY AND CHILD CARE,FAMIL YWELFARE SERVICES,HOSPITALIZATION, SPECIALISTCONSUL TATION FACILITIESANDHEAL THEDUCATION.

ALL GOVERNMENT EMPLOYEES,PENSIONERS JUDGES OF HIGH COURT AND SUPREME COURT,FREEDOM FIGHTERS,PREIME MINISTER AND MEMBERS OF PARLIAMENT

HOSPITALIZATION RASHTRIYA EXPENSES,CASHLESS ATTENDANCE, TRANSPORTATION COST.PRESWASTHYA BIMA EXISTING DISEASES COVERED AND TOTAL SUM INSURED IS Rs.30,000 PER ANNUM. YOJANA

UNORGANIZED SECTOR WORKER AND HIS FAMILY,BPL FAMILIES

STAKEHOLDERS AND FINANCING SCHEMES STAKEHOLDERS FINANCIAL CONTRIBUTIONS Emplo ye e sandthe irde pe ndants. A)Emplo ye rs4.75% o fthe ESIS Emplo ye rs. pre mium
State go ve rnme nt. Public He althfac ilitie ssuc has ho spitalsanddispe nsarie s. Private prac tio ne rs. State go ve rnme ntgrie vanc e c e ll. a)beneficiaries. b)Central government c)Private practitioners and hospital. d)Private agencies providing drugs. c)CGHS network of hospital and dispensaries. Ce ntralgo ve rnme nt. State go ve rnme nt. Be ne ficiarie s. Insuranc e c o mpanie s. Ho spitals(private andpublic ). Imple me ntingage nc yandNo dal age ncy

CGHS

B)Emplo ye e s1.75% o fthe pre mium C)State go ve rnme nt12.5% o f to talshare able e xpe nditure withinape rc apitac e ilingo f Rs.600pe rinsure dpe rso npe r annum Central government

RASHTRIYA AROGYA BIMA YOJANA

Ce ntralgo ve rnme nt(GOI)75% . State go ve rnme nt25% .

esis
LIMITATIONS
Patie ntsatisfac tio nno tupto the de sire dle ve l De fic ie ntmanage me nto fthe ho spitalsanddispe nsarie s,Lo w utilizatio no fho spital De fic ie ntinte rnalco ntro l me c hanism Ac c e ptabilityandAc c o untability due to po o rde sign.

RECOMMENDATIONS
Ac c e ptable standardsfo rpatie nt c are Manage me nto fthe He alth fac ilitie s Substantialimpro ve me ntin financ ialmanage me nto fthe sc he me . Increasing the fixed payment for providing the services, introducing co- payment, deductibles and co-insurance to improve accountability Ope ningto the ge ne ralpublic ho spitals Sc he me to be made auto no mo us manage dbythe wo rke rsandthe e mplo ye rs Employee retaining strategies.

Lacko fAc ce ssto se rvic e s e spe c iallyinruralare as. Co nflic tsbe twe e nre gulato ry bo die s.

Highturnoverofstaff.

Contd
LIMITATIONS
UNSATISFACTORY MIS

RECOMMENDATIONBS
Effe c tive manage me ntinfo rmatio n syste m,Cre ate database o fthe insure dpe rso nsto pre ve ntmisuse .

CGHS
LIMITATIONS
Equity

RECOMMENDATIONS
Balance between the contribution made by the workers and the extent of benefits.

De mandside mo ralhazard

Close monitoring of the expenditure on private medical care; Mechanism to regulate undue referrals to private practitioners Standardization of the medical facilities in the network hospitals and dispensaries. Encouraging the use of public health facilities ; Mechanism to regulate undue referrals to private practitioners. Efficient and adequate staffing ;Time management strategies in the health facilities.

Po o rqualitycare

Higho uto fpo c ke texpe nditure

Lo ngwaitingpe rio ds

Other options in Indian health insurance Scenario

Merger of ESIS and CGHS ,reconstituted as Social Health Insurance Corporation of India. Envisioned by Prime Minister Nehru while launching the CGHS Scheme in 1954.

What it will do? Stimulate the establishment of similar health insurance companies which will double and upscale helath insurance industries. Levy uniform charges on all employees which will bring down the ratio of employee-government contribution reducing the financial burden. Vertical integration of network of hospital and dispensaries and converting them into Trusts and autonomous units extending their services/membership to those not covered under this scheme by charging user fees. This option have the following advantagesA. Administrative expenditure will come down. B. Optimize the utilization of the facilities. C. Provide access to urban slum and rural poor population to health services. D. Facilitate the establishment of reinsurance program in India. E. Facilitate a mechanism for equalizing risk

Rashtriya SWATHYA bima yojana

LIMITATIONS RECOMMENDATIONS

Se le ctio no fthe be ne ficiarie s(BPL) Effic ie ntMo nito ringme c hanismfo r po pulatio ns imple me ntingage nc y Imple me ntatio nc o nflic tsinstate s. Po o rqualitycare Fixing the cost of medical procedures at national level. Fo rmulatingnatio nalguide line sfo r standardizatio no fHe althFac ilitie s inthe ne two rkde live ryc e ntre s. Ensuring TAT is met by the TPAs , Inc re asingaware ne ssabo utthe be ne fits,rightsandpro c e dure s, Effic ie ntgrie vanc e de partme nt. Intro duc tio no fuse rsc harge s,c o payme nt,de duc tible andc o insuranc e ;e ffic ie ntmo nito ring me c hanismto de te c tFraudsand malprac tic e s

Claimsandre imburse me nt pro ble ms Mo ralhazard

Community based health insurance

 It is defined as,any not-for-profit insurance scheme that is aimed primarily at the informal sector and formed on the basis of a collective pooling of health risks, and in which the members participate in its management. ----Atim(1998)

Nature

Financed By

Premium collection

Beneficiaries

viderMODEL MutualMODEL LinkedMODE

INSURANCECOMPANY REIMBURSEMENT

ROVIDER+INSURER INSURER(NGO) PREMIUM

FE ES

REMIUM

PROVIDER
RE CA

PREMIUM

COMMUNITY

.g.ACCORD,RAHA

CARE

PROVIDER CARE

NGO

COMMUNITY

PREMIUM

e.g.DHAN,Yeshasvini

COMMUNITY e.g.SEWA, Karunatrust

Limitations

Contd..

Recommendations
Strong stewardship from govt. CBHI to be implemented as CORE BUSINESS addressing poor. Comprehensive benefit package to convince the community. To control adverse selection and moral hazards the CBHI group should enrol large no. of people with mandatory enrolment of groups and family with comprehensive referral systems. Effective and credible community based organization. An affordable premium. Legality of these schemes.

Recommendations contd
Encourage public-private partnerships to reduce cost of health microinsurance. Constitute a separate regulatory framework for micro insurance. Permit self-regulation of the industry through a federation of mutuals or a trade association Improve micro-insurers management skills. Require that self-insured programs be not-forprofit. To reduce public subsidization of services for those who have ample ability to pay. E.g. Apollo Hospital gets public loan.

Private Health Insurance

08/17/11 MBC 2

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PRIVATIZATION
08/17/11 MBC 2

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HEALTH INSURANCE COMPANIES

Apollo DKV Insurance company ltd. Aviva life insurance Bajaj Allianz general insurance co.ltd HSBC health insurance ICICI lombard general insurance co.ltd Metlife India assurance company Reliance health Royal sundaram alliance insurance company limited Max New York life insurance Star health and allied insurance company limited

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STAKEHOLDERS

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Limitations
Moral Hazard Adverse Selection Asymmetric Information High claim Ratios High premiums Overcharging by Hospitals Frauds Concentrated in urban areas

Recommendations
Effective risk management program Premium structure Out patient coverage Limit exclusions for pre-existing diseases Greater efficiency in claims management Marketing Greater monitoring of frauds and excessive fees

More Recommendations
To encourage health insurance to the vulnerable Subsidized insurance plans for the vulnerable Maternity coverage Coverage for indigenous forms of treatment Explore the rural market

THANK YOU!!!