HEALTHCARE

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HEALTHCARE HEALTH FINANCING AN OVERVIEW
ASSOCHAM NATIONAL SUMMIT

• P C James
• Executive Director - IRDA

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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

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HEALTH SYSTEM

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

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HEALTH INSURANCE IS

• RISK TRANSFER
• Ind. Family Org. Community
• Insurer / Govt. / Community
• Revenue Transfer
• (healthy to sick)
• Hospitals / Providers

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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

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MODELS OF HEALTH COVERAGE

• Taxes
• Compulsory Social or Community Insurance
• Private Insurance
• Medical Saving Schemes
• Need to create an Indian Model

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UNIVERSAL HEALTH FINANCING COULD ULTIMATELY BE A
MIX OF

• General Revenues
• Social Insurance
• Private Insurance
• Self Insurance Pools

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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

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IDEAL HEALTH PROTECTION ENVIRONMENT

• Insurers Providers Service
• Pharma Cos. Providers TPA
• CONSUMER CENTRED
• WELLNESS
• Government Courts Consumer
• Regulators Bodies

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FRUSTRATIONS IN THE SECTOR
Cashless Treatment
Policy Holders
Third Party Administrator
Claims
Payments
Health Services
HEALTHCARE PROVIDER
Insurance Coverage
Benefits Administration, Provider Network
Insurance Premiums
TPA Fees
Insurance Company
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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

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CONCERNS IN HEALTH

• Patient Care / Safety
• Patient Rights / Service
• Quality
• Costs

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COST DRIVERS IN HEALTH INSURANCE

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

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RESPONSE OF HOSPITALS

• Licensing
• Certification
• Accreditation
• Rating
• Standardization

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COSTS / CONCERNS TO BE JUSTIFIED BY

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

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PROBLEMS FROM INSURERS

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

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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

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ROAD TO THE FUTURE

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

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PATHWAYS TO THE FUTURE

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

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A BILLION LIVES TO COVER

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

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CREATING HEALTH VIRTUOUS CYCLE
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CYCLE OF COSTS CARE

• What we can pay Vs. What we need.

CARE
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INSURER INTERVENTION

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

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INSURER INTERVENTION (Contd..)

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

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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

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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

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• Thank You