uplift health mutuals
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Uplift Health Mutuals. Saurabh Sharma. Uplift Health Mutuals. Community based health fund (CBHIs, MHOs) Uplift Mutuals: Group of Social Sector Organisations Based in Maharashtra & Rajasthan . Uplift Health Mutuals: A Case Study. Purpose of Study - PowerPoint PPT PresentationTRANSCRIPT
SAURABH SHARMA
Uplift Health Mutuals
Uplift Health Mutuals
Community based health fund (CBHIs, MHOs)
Uplift Mutuals: Group of Social Sector Organisations
Based in Maharashtra & Rajasthan
Uplift Health Mutuals: A Case Study
Purpose of Study Document the Uplift Model & Processes Review Key Performance Indicators, Sustainability, and Client
value
Method of Study Qualitative and Quantitative
Literature review Interviews with process managers, clients and senior management Secondary Data Analysis Observation of key procedures
Flow of Presentation
Community Based Health Insurance Uplift: Timeline, Model & ProductGrowth & Impact
KPIs Client Value
Program Sustainability Cost model Program Costs
Way Forward
Outreach of Community Based Insurance in India
Less than 1000
1000-5000
5001-10000
10,001-100,000
100,001-500,000
More Than 1 Million
0 2 4 6 8 10 12 14 16
4
10
5
15
5
2
Outreach
Challenges for community based risk solutionsSource: ILO, MIF
Low community participation
Lack of professional management
Small size of risk pool
Incomprehensive product
Isolation from formal insurance mechnisms
Uplift: Timeline, Model & Product
A Decade for Uplift
2003Uplift Mutuals established
2004Registration of Uplift India AssociationPSW Pune Joined
2007-08Product Modification Arogyanidhi 2 Launched
2010-11Enrollments crossed 100,0003 More partners Joined
2012-13125,000 MembersExpansion to Rajasthan
Partner MembersS NO Name Location Year of
JoiningPrimary Activities
1 Swabhimaan Pune, Maharashtra
2003 Microfinance & Health
2 Inter Aide (Technical partner and Grant Provider)
France 2003 Supporting Development Activities
3 Navnirman Samaj Vikas Kendra
Mumbai, Maharashtra
2011 Microfinance & Health
4 Parvarti Swayamrojgar Pune, Maharashtra
2004 Microfinance ,Enterprise Development & Family Program
5 Annapurna Parivar Vikas Samvardhan
Pune & Mumbai, Maharashtra
2003 Microfinance , Enterprise Development & Health
6 Disha Kendra Pune, Maharashtra
2004 Microfinance
7 Annapurna Mahila Mandal Credit Cooperative Society
Mumbai, Maharashtra
2003 Credit Cooperatives
8 Chaitanya Pune, Maharashtra
2010 Microfinance, SHG & federation promotion
9 PEDO supported Federations
Rajasthan 2012 SHG & federation promotion
Arogyanidhi: the product
Feature Uplift MutualsCompulsory/Voluntary Compulsory for MFI credit customers
Payment Type Reimbursement
Eligibility Criteria: No age limit
Premium Contribution For a family of four: Rs. 400 (approx. USD 8) per year
For individuals: Rs. 150 (approx. USD 3) per yearPeriod of Cover 12 months from the date of issue of policy
Sum Insured Rs. 15,000 per person per year subject to policy exclusions
Benefits Offered In patient hospitalization expenses for treatment in general ward
10 days of pre and post hospitalization cover including expenses for one time diagnosis of the ailment and the cost of medicines prescribed during this period
Pre-existing diseases covered from 3rd year onwards
Stipulation Pertaining to Health Care Providers 100% : Public Hospital 80% : Networked Private Hospitals No reimbursement : Non Networked Private
Hospitals, except emergencies
Value Added Services: Reducing Health Risk
Service Details
Outpatient care Beat doctor
Discounts on drugs and Diagnostics Networked pharmacy and diagnostic centresFree generic medicines
Health camps & Talks Health awareness sessions
Client education Sessions about insurance and the HMF program
24/7 helpline Helpline for guidance or referrals
Access to Uplift’s network of HCPs Uplift has established a network of more than 300 healthcare providers for better quality of care, and to control cost. Uplift signs MoU with these HCPs with negotiated medical costs.
Referrals/guidance Assistance by a service executive
Awareness Material Awareness Sessions
Health Education: Reducing Risk
How it Works
Uplift Mutuals
Uplift As TPA
Managers/ Astt Managers
Arogyasakhis
Arogyasakhi
Arogyasakhis
InterAide
Uplift as TPANegotiated RatesMonitoring HCPs
Health seekingGuided by Arogyasakhis
NetworkedHealth Care Providers
Claim Processing
Final Claim Settlement & Disbursement at community level
Growth & impcat
2003 2004 2005 2006 2007 2008 2009 2010 20110%
20%
40%
60%
80%
21%
0%
43%37%
53% 55%49%
54%
APVS Pune,
0.4 0.39
APVS Mumbai; 0.54
0%7%
29%
51%55% 56%
58%
72%PSW
Reviewing Growth: Renewals Ratio
Reviewing Growth: Number of Ongoing Members
Uplift: Efficiency & Client Value
24% Reduction in Out of Pocket expenditure Remarkable impact
Service Ratio at 56% Proportion of clients using IP/OP insurance Services
Claim rejection Ratio at 2% Initial high rate at 10.5% Key for Community Based Models
Voluntary enrolment at 8-10%
Client Value: PACE Analysis
Source: ILO, MIF
Reducing Out Of Pocket Expenditure
2008 20090%
20%
40%
60%
80%
100%
120%
50%
36%
27%
37%
23% 27%Cost reduction due to networked HCPs
Claim amount re-imbursed
Out of Pocket expense
2008 20090%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
65%
49%
35%
51%
Claim amount re-imbursed
Out of pocket expense
Improving Client Value
Challenges in improving client value Reimbursement based product High OP Care expenses leading to high OOP
Challenges in providing Cash less system Increase in negotiated prices Role of community diminished Increased chances of Fraud
Program sustainability
Costing Model
100% Gross Premium Collected 60%: Claim Fund
Claims Disbursed Solidarity Fund
20%: Uplift TPA Services Value Added Services Opex
20%: Partner Organization Value Added Services Opex
Subsidy Provided by Inter Aide Opex Value added services
Total Program Costs
APVS Pune
APVS Mumbai
Psw0%
10%20%30%40%50%60%70%80%90%
100%
41% 42%
24%
18% 19%
19%
41% 39%
59%
Claims Value Added Services
Opex TOTAL
APVS Pune
56.5 (41%)
24.3 (18%)
57.6 (41%)
138.4
APVS Mumbai
60.4 (42%)
26.6 (19%)
55.9 (39%)
142.9
PSW 45 (24%)
31 (17%)
107.9(59%)
183.9
Total Program Costs on Per Member basis for Partner Organizations Source: 2009
Dependency on Claim Funds
2003 2004 2005 2006 2007 2008 2009 2010 20110.0%
20.0%
40.0%
60.0%
80.0%
100.0%
120.0%
140.0%
43.0%
70.0%
54.0% 52.0%
72.0%
63.0%
99.0% 107.0%
88.6%
0
0.710000000000002
1.09 1.08
0.952900000000002
0.0%
48.0%
77.0%
58.0%
105.0%
88.0%
75.0%
120.0%
86.0%
0
0.4038 0.397200000000002
APVS Pune
APVS Mumbai
PSW
Chaitanya
Claim Ratios for Partner Organizations
Operating Expenses
Uplift APVS Pune PSW0
20
40
60
80
100
120
45.5
73.6
93.7
31.2
57.6
107.9
20082009
Operating Expenses on Per Member basis for Partner Organizations
Dependency on Subsidy
2008 2009 20100%
10%
20%
30%
40%
50%
60%
70%
80%
46%
31%23%
32%27%
68% 68%
UpliftAPVS MumbaiPWS
Way Forward
High Operating expenses for partner organizations Tripling the current outreach
Automation of routine functions
Enhancing Client Value Instant Cash Loan Product (Health Expenses)
Reinsurance facility to increase cover
Structural challenges Attrition of Service executives
Adverse Selection
Fund management at branch level
QUESTIONS?