HEALTHCARE & HEALTH FINANCING

AN OVERVIEW

ASSOCHAM NATIONAL SUMMIT

P C James Executive Director - IRDA

RISE OF HEALTHCARE & HEALTH FINANCING

The Burden of Disease/Disability Its linkage to Development Costs hard infrastructure soft infrastructure
The need for Financing- Government - Community - Family

HEALTH SYSTEM
HEALTH PROMOTION REQUIRES HEALTH INFRASTRUCTURE HEALTH SERVICES HEALTH FINANCING STEWARDSHIP NEED TO MOVE FROM OUT OF POCKET TO POOLING

HEALTH INSURANCE IS :
RISK TRANSFER Ind. Family Org. Community

Insurer / Govt. / Community Revenue Transfer (healthy to sick) Hospitals / Providers

ONE BILLION PEOPLE TO PROTECT

Opportunities & Challenges for Health providers creating availability Government Facilitation/ Basic Regulator Infrastructure Govt./Insurer/ Affordability Communities Allied Organizations Facilitation / service

MODELS OF HEALTH COVERAGE

Taxes Compulsory Social or Community Insurance Private Insurance Medical Saving Schemes

Need to create an Indian Model

UNIVERSAL HEALTH FINANCING COULD ULTIMATELY BE A MIX OF

General Revenues Social Insurance Private Insurance Self Insurance Pools

CONSTRAINTS IN EXTENDING COVERAGE

75% of the population works in the informal sector 25% of the population below poverty line 70% of the population in rural areas Under insured country Health insurance an ill understood subject

IDEAL HEALTH PROTECTION ENVIRONMENT

Insurers Providers Pharma Cos. Service Providers TPA

CONSUMER CENTRED WELLNESS

Government Regulators

Courts

Consumer Bodies

FRUSTRATIONS IN THE SECTOR

Cashless Treatment

Policy Holders

Third Party Administrator

HEALTHCARE PROVIDER

Insurance Company

ISSUES IN HEALTH INSURANCE

Need for a variety of products micro insurance to international coverage birth to old age Clarity in policy terms, conditions, exclusions Need for Services Cashless, toll free nos., quick response Curtailment of Costs

CONCERNS IN HEALTH
Patient Care / Safety Patient Rights / Service Quality Costs

COST DRIVERS IN HEALTH INSURANCE

Technology / Specialization Prescription Drugs Medical Inflation Moral Hazard / Adverse Selection Usage Increase New treatments Unnecessary treatments

RESPONSE OF HOSPITALS

Licensing Certification Accreditation Rating Standardization

COSTS / CONCERNS TO BE JUSTIFIED BY

Clinical Audits Clinical Effectiveness Establishment of Standards / Protocols / Guidelines / Pathways Medical Audits Clinical Governance

PROBLEMS FROM INSURERS

Policy condition problems Customer Ignorance Pre-Existing Condition Issues Disputes with hospitals / insured Delays

PROBLEMS FROM TPAs

Lack of Infrastructure There are no holidays in Health care yet offices not open on holidays, telephone access unavailable, etc No qualified doctor / staff Delay in settlement Deduction in bills without basis Increased paperwork

ROAD TO THE FUTURE

Need to Create our own models USA X UK X Current Indian X

PATHWAYS TO THE FUTURE

IRDA Initiatives - Data Management & Warehousing - Standalone Health Insurance Cos. - Policy innovation / removal of customer difficulties - Regulation/guidelines - Third Party Administrators

A BILLION LIVES TO COVER

Focus on rural / micro insurance Dialogue between Providers, Insurers, TPAs. Increase in numbers & premiums Working with Government

CREATING HEALTH VIRTUOUS CYCLE

Better Health Infrastructure

More Coverage

Secure Payments

More Affordability

CYCLE OF COSTS & CARE

What we can pay Vs. What we need.

Claims CARE

Premium

Costs

INSURER INTERVENTION
a) Managed Care Gate keeping Second Opinions Case Management Care Review Cost Negotiation

INSURER INTERVENTION (Contd..)

b)

Sublimits - Capping Amount per procedure Deductibles Co payment Restricted Covers High Premium rates Rejections

UNIVERSALISING HEALTH INSURANCE

GOVERNMENT STEWARDSHIP CREATING HOLISTIC LINKAGES MICRO-INSURANCE SCHEMES FOR THE POOR INTERMEDIATION AND CAPACITY BUILDING PARTICIPATION BY BENEFICIARIES MONITORING COSTS SUBSIDY AND TAXATION INCENTIVES

CONCLUSIONS

Creating awareness & meeting the demand for health care & financing Creating modules for aligning the services of all concerned Focusing on enhancing affordability & reducing costs Rapid coverage and health benefit to all

Thank You