role of health insurance in india 20th sept

8/6/2019 Role of Health Insurance in India 20th Sept

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Role of health insurance

in indiao

o

Dr. Trupti Pate l

Dr. Bhavna SumraMs Elgin KurusuMr BalrajDr. Shelar GiteshDr. Shilpa Jain

Mr. Md. Je ze e lDr. Misbah KhanDr. Veena SalunkeDr. Vishal Gaikwad


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grapple with newer challenges inspiteof significant gains in terms of

municable disease & increasing problem of non communicable diseas


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HEALTH INSURANCE

The ILO defines health insurance as:

The reduction or elimination of the uncertain risk of loss forthe individual or household by combining a larger number

of similarly exposed individuals or households who areincluded in a common fund that makes good the loss causedto any one member

(ILO,1996)

In simple terms can be put as

An individual or group purchasing in advance; healthcoverage by paying a fee called "premium".


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Today insurance sector is growing at a rate of

15 20%Together with banking services, insurance services

add about 7% to the countrys GDP

Out of this more than 70% is Out of pocket

expense.Currently about 200 million people in India have

health or medical benefits under schemes for

government employees, railways, armed forces

personnel and through ESIS, RSBY and


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DIFFERENT CATEGORIES OF INSURANCE

SCHEME


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Health insurance Definition and originin 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 andhouseholds.

- in a narrow sense would be an individual or group purchasing health carecoverage 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 InsuranceAct was passed (Devadasan 2004) while the current version of theInsurance Act was introduced in 1938.

Since then there was little change till 1972 when the insurance industry wasnationalized and 107 private insurance companies were brought under theumbrella of the General Insurance Corporation (GIC).

Private and foreign entrepreneurs were allowed to enter the market with theenactment of the Insurance Regulatory and Development Act (IRDA) in1999.

The health insurance market in India is very limited covering about 10% ofthe total population.


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PUBLIC HEALTH INSURANCESCHEMES


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BENEFITS AND ELIGIBILITY

PUBLIC HEALTH

SCHEMES

BENEFITS ELIGIBILITY

ESISMEDICAL BENEFIT,MATERNITYBENEFIT,SICKNESSBENEFIT,EXTENDED SICKNESSBENEFIT,DEPENDANTBENEFIT,PREVENTIVE HEALTH CARESERVICES,FUNERAL EXPENSESETC.O.P.D,HOSPITALIZATION,MEDICIN

E PRIVATE PRACTIONER

.COVERS EMPLOYEES OF NONSEASONAL POWER USING FACTORIESAND NON-POWER ESTABLISHMENTWITH BASIC SALARY LESS THANRs.6.500

CGHSDOMICILIARY CARE,MATERNITY AND

CHILD CARE, FAMILY WELFARESERVICES, HOSPITALIZATION,SPECIALIST CONSULTATIONFACILITIES AND HEALTH EDUCATION.

ALL GOVERNMENTEMPLOYEES,PENSIONERS JUDGES OFHIGH COURT AND SUPREMECOURT,FREEDOM FIGHTERS,PREIMEMINISTER AND MEMBERS OFPARLIAMENT

RASHTRIYASWASTHYA BIMAYOJANA

HOSPITALIZATIONEXPENSES,CASHLESS ATTENDANCE,TRANSPORTATION COST.PRE-EXISTING DISEASES COVERED ANDTOTAL SUM INSURED IS Rs.30,000 PERANNUM.

UNORGANIZED SECTOR WORKER ANDHIS FAMILY,BPL FAMILIES


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STAKEHOLDERS AND FINANCINGSCHEMES STAKEHOLDERS FINANCIAL

CONTRIBUTIONS

ESIS Employees and their dependants.Employers.State government.Public He alth fac ilitie s suc h ashospitals and dispensaries.Private practioners.State government grievance cell.

A)Employers 4.75% of thepremiumB)Employees 1.75% of thepremiumC)State government 12.5 % oftotal shareable expenditurewithin a per capita ceiling ofRs.600 per insured person per

annum

CGHS a)beneficiaries.b)Central governmentc)Private practitioners and hospital.d)Private agencies providing drugs.c)CGHS network of hospital anddispensaries.

Central government

RASHTRIYAAROGYABIMAYOJANA

Central government.State government.Beneficiaries.Insurance companies.Hospitals (private and public).Implementing agency and Nodalagency

Central government(GOI) 75%.State go vernme nt 25%.


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esisLIMITATIONS RECOMMENDATIONS

Patient satisfaction not up to thedesired level Acceptable standards for patientcare

Deficient management of thehospitals and dispensaries ,Lowutilization of hospital

Management of the Healthfacilities

Deficient internal control

mechanism

Substantial improvement in

financial management of thescheme.

Acceptability and Accountabilitydue to poor design.

Increasing the fixed payment for providingthe services, introducing co- payment,deductibles and co-insurance to improveaccountability

Lack of Access to servicesespecially in rural areas.

Opening to the general publichospitals

Conflicts between regulatorybodies.

Scheme to be made autonomousmanaged by the workers and theemployers

High turnover of staff. Employee retaining strategies.


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Contd

LIMITATIONS RECOMMENDATIONBS

UNSATISFACTORY MIS Effective management informationsystem , Create database of the

insured persons to prevent misuse.


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CGHS

LIMITATIONS RECOMMENDATIONS

Equity Balance between the contribution made bythe workers and the extent of benefits.

Demand side moral hazard Close monitoring of the expenditure on

private medical care; Mechanism to regulateundue referrals to private practitioners

Poor quality care Standardization of the medical facilities inthe network hospitals and dispensaries.

High out of pocket expenditure Encouraging the use of public healthfacilities ; Mechanism to regulate unduereferrals to private practitioners.

Long waiting periods Efficient and adequate staffing ;Timemanagement strategies in the health facilities.


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Other options in Indian health insuranceScenario

Merger of ESIS and CGHS ,reconstituted as Social Health InsuranceCorporation of India.

Envisioned by Prime Minister Nehru while launching the CGHS Schemein 1954.

What it will do?

Stimulate the establishment of similar health insurance companieswhich will double and upscale helath insurance industries.

Levy uniform charges on all employees which will bring down the ratioof employee-government contribution reducing the financialburden.

Vertical integration of network of hospital and dispensaries andconverting them into Trusts and autonomous units extending theirservices/membership to those not covered under this scheme bycharging user fees. This option have the following advantages-

A. Administrative expenditure will come down.B. Optimize the utilization of the facilities.

C. Provide access to urban slum and rural poor population to healthservices.

D. Facilitate the establishment of reinsurance program in India.

E. Facilitate a mechanism for equalizing risk


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Rashtriya SWATHYA bima yojana

LIMITATIONS RECOMMENDATIONS

Selection of the beneficiaries(BPL)populations

Efficient Monitoring mechanism forimplementing agency

Implementation conflicts in states. Fixing the cost of medical procedures atnational level.

Po o r q uality c are Fo rm ulating natio nal g uide line s fo rstandardization o f Hea lth Fac ilitie sin the network delivery centres.

Claims and reimbursementproblems

Ensuring TAT is met by the TPAs ,Increasing awareness about the

benefits, rights and procedures ,Efficient grievance department .Moral hazard Introduction of users charges, co payment, deductible and co insurance ; efficient monitoringme chanism to de tec t Frauds andmalpractices


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Community based health

insurance


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It is defined as,any not-for-profit insurance

scheme that is aimed primarily at the informalsector and formed on the basis of a collective

pooling of health risks, and in which themembers participate in its management.

----Atim(1998)


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Nature


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Financed By


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Premium collection


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Beneficiaries


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OVIDER + INSURER

COMMUNITY

CAR

E

EMIUM

iderMODEL

INSURER (NGO)

PROVIDER

COMMUNITY

PREMIUM

FEES

CARE

Mutual MODEL

INSURANCE COMPANY

NGO

PROVIDER

COMMUNITY

PREMIUM

REIMBU

RSEMENT

CARE

PREMIUM

Linked MOD

.g. ACCORD, RAHA e.g. DHAN, Yeshasvini

e.g. SEWA,

Karuna trust


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Limitations


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Contd..


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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 largeno. of people with mandatory enrolment ofgroups and family with comprehensive

referral systems. Effective and credible community based

organization. An affordable premium.

Legality of these schemes.


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Recommendations contd

Encourage public-private partnerships toreduce cost of health microinsurance.

Constitute a separate regulatory frameworkfor micro insurance.

Permit self-regulation of the industry through afederation of mutuals or a trade association

Improve micro-insurers management skills.

Require that self-insured programs be not-for-

profit.To reduce public subsidization of services for

those who have ample ability to pay. E.g.Apollo Hospital gets public loan.


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08/17/11

MBC

2

28

Private Health Insurance


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08/17/11

MBC

2

29

PRIVATIZATION


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HEALTH INSURANCE COMPANIES

Apollo DKV Insurance company ltd.

Aviva life insuranceBajaj Allianz general insurance co.ltd

HSBC health insurance

ICICI lombard general insurance co.ltd

Metlife India assurance companyReliance 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


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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


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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


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THANK YOU!!!

role of health insurance in india 20th sept

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