Role of Health Insurance in India 20th Sept
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Transcript of 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!!!