Transcript
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HEALTH IS A HUMAN RIGHT
ITS AFFORDABILITY & ACCEPTABILITY HAS TO BE ASSURED FOR URBAN
A/W/A RURAL, WELL TO DO TO THE POORER SECTION OF THE SOCIETY.
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Agenda Healthcare and health insurance in India
• Macroeconomic trends and indices• Current schemes and coverage
Global experience and the objectives of health insurance reform
Devising an appropriate model for India• Segmenting the market• Framework for reform
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Health Care scenario• Before independence - dismal condition.• High morbidity, mortality and Infectious
diseases.• After independence - emphasis on PH care.• Present Problem-• High mortality, negligible MCH care.• Urban-Rural divide:70:30.• Population Size of the country.• Declining funds to HealthCare Sector-CG/State.
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Health Care Scenario……contd
At any given point of time 40 to 50 million of population on medication
for major sickness. About 200 million days are lost annually.
The annual rate (range) of out-patient: rural 30-152/1000, urban 9-81/1000 and for hospitalization: rural 16-76/1000, urban 5-38/1000.
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HEALTH CARE FINANCING IN INDIA
•The share of public financing in total health care is just about 1% of GDP compared to 2.8% in other developing countries.•Beneficiaries are both poor a/ w/ a well-fed section of society.•Over 80% of the total health financing is private financing,much of which is out-of-pocket payments (i.e. User charges) and not any prepayment schemes.
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2004 US UK Mexico Brazil China IndiaLife expectancy (avg. # of years)
77.4 78.3 72.6 71.4 72.5 64.0
# of Physicians per 1,000 people
2.7 1.9 1.7 1.2 1.7 0.4
Healthcare spend (USD per capita)
5,365 3,036 336 236 62 32
Healthcare spend (% of GDP)
13.2 8.4 5.5 7.5 5.0 5.3
Health care spend in India is considerably lower than that in other countries
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The proportion of insurance in health care financing in India is extremely low
0%
100%
Source of finance Means of finance
86% from out-of-pocket
expenses
83% from private sector
spending
Health care financing in India 2002, %
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The World Health Organization has defined possible approach to financing of health
expenditure
Total health expenditure
Public
Private
Social security
Externally funded
Tax-funded
Private health ins.
Externally sourced
Out-of-pocket
Using central / state revenues for health
Compulsory premium contributions to health
Channeling loans, grants etc. to healthcare
Payments to health care providers for servicesPremium contributions towards health supportChanneling donations etc. to healthcare
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Social Security: Concept
Defined as “the security that the society furnishes to some organizations against certain risks to which the members of society are exposed”
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Social Security: Advantage
The financial burden of sickness cannot be borne by the individual. It must be widely distributed throughout the country.
Sickness is not an individual’s misfortune but the calamity is to taken as community & state responsibility.
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Health insurance typically helps a patient manage health care costs beyond a threshold amount through pooling
As a contingent claim
instrument, health insurance
is an efficient way to help individuals prepare for health care
Insurer payment(from premium
pool)
Individual payment
Deductible Co-insured
Health care expenditure (INR)
Patient expenditure
(INR)
Stop-loss level
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WHAT IS HEALTH INSURANCE?
SYSTEM OF ASSURANCE TO MAKE CONTINGENCIES OF HEALTH CARE EXPENSES.
TO PROVIDE PROTECTION AGAINST FINANCIAL LOSS BY UNFORSEEN SICKNESS.
TO MEET COST OF GOOD MEDICAL CARE.
RELIEVES ANXIETY AND TENSION.Brought to you byThe Nurses and attendants staff we provide for your healthy
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Origin of Health Insurance: International 1883 Bismarck- sickness benefit to workers. 1911 Lloyd George- National Health Insurance
Scheme to cover sickness expense, medical relief, drugs & compensation of wages lost, to improve quality of life and improve industrial production.
J.F.Kimball: prepayment system of health care.
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Origin of Health Insurance: National:1923: Workman’s compensation Act.1948: ESI Act passed.1952: First ESI hospital established.Mudaliar Committee(1959-1961)
recommendations:1. Long range health insurance policy
for all.2. Small fee for availing health services.
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Origin of Health Insurance…contd
National: 1999: IRDA act passed. 2001: Insurance amendment Act: Emphasis on TPAs.
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Forms of Insurance Available Indemnity Insurance: where the insurer first
pay to the hospital and claim is made. E.g. Jeevan Asha II, Asha Deep II, Mediclaim.
Cashless Claim Facility:TPAs who bear the expenses on behalf of insurance company. Patients need not to pay directly as a rule e.g. Bajaj Alliance.
CBHI (Community Based Health Insurance).
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The key issue related to financing of health care in India revolves around the lack of
adequate insurance . . . Limited coverage
– Only around 10% of the population is covered through health financing schemes
– Geographic spread in terms of health care facilities and financing awareness is limited
– Selection criteria by suppliers often restricts the poor (and more likely to be ill) from affordable pre-payment schemes
Moral hazard and Adverse selection– Claims ratios for Mediclaim and Jan Arogya policies
have been in the range of 120 – 130%.
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The key issue related to financing of health care in India revolves around the lack of adequate
insurance … contd
System leakages– Provider malpractices leading to over-
charging or pre-selection / selective recommendation
Lack of universal schemes– Limitations in terms of coverage of illnesses
as well as treatment options – Alternative therapies often not considered /
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The experience of different countries suggests that private insurance has an
important role to play in overall health care Source of health insurance in countries with
targeted, non-universal access to health care coverage e.g. Netherlands restricts public health coverage to
an income threshold Private health insurance has enhanced access to
timely hospital care e.g. In UK, waiting time reduction and private health
insurance coverage have led to a virtuous cycle.
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The experience of different countries suggests that private insurance has an
important role to play in overall health care Private health insurance has increased service
capacity and supply by injecting financial resources up front e.g. In the US, private health insurance has financed hospitals in terms of doctors and facilities through the HMO set-up
Private health insurance increases choice (provider, benefits, cost-sharing) for the individual e.g. In Australia, private health insurance offer the option of access to spare capacity and elective care in non-public institutions
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Global experience provides some key learning on health insurance policy design Balancing risk-spreading and incentives offered
– Balancing the need to encourage health insurance against moral hazard (individuals choose more care) and principal-agent problems (providers supply more care)
Integration of insurance and health care provision– Managing doctor loyalties with patient and insurer
under managed care
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Global experience provides some key learning on health insurance policy
design . . .contd
Approach to competition and portability– Balancing the need for consumer choice
against adverse selection (sick preferring more generous plans)
Focus on health as against financing of health care– The over-riding objective should be to
improve health rather than the financing of health care services
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Some key considerations related to formulation of approach to HI in India . . .
Differential approach -Formal sector (government and non-government workers)
– Self-employed segment– Poor / Unemployed segment
Scope and structure of health insurance cover– Product and segment coverage– Portability across service providers– Cap on premium amounts– Risk-adjusted approach
Nature of fiscal incentives– Subsidies and tax incentives for health insurance as against health
care
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As a result, the traditional model for health insurance needs to change...
Individual
Insurer/
Provider
Government / Employer
Fixed feesService charges
Voluntary premiums
Mandatory premium
Mandatory premium
Costs up to deductible
Could be allied to insurer or be a government approved provider
Inter-mediaries
TPAs etc.
Financial flowsService flows
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… to one that allows the flexibility to serve different segments of the
population, in an efficient manner
• Health insurance providers may need to align themselves to overall health care including financing, preventive health care and health outreach in order to grow coverage
• Regulations and policy must be designed to encourage this
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Community-based initiatives have been particularly cost- efficient in reaching out to the poor / unemployed
segmentsRole in Community-based health initiative (CBHI)
Health intermediary
Health manager
Health provider
Example of some CBHIs / NGOs
SEWA / ACCORD
Tribhuvandas Foundation
Sewagram / VHS
Nature of health risk covered
Inpatient, non-health related
Inpatient Inpatient, Outpatient
Access to benefits After certain period
At time of discharge
At time of utilization
Administrative costs Moderate Low Low
Nature of pool formation
Occupation / geography-based
Occupation / geography-based
Geography-based
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How CBHI can be made Reachable
Effort for social mobilization & strengthening of people organization
Training and capacity building, special emphasis on PRIs and Women Organization
Demand Driven social services, Building of alliances and partnerships
Advocacy for Pro poor policies.Brought to you byThe Nurses and attendants staff we provide for your healthy
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Managing the reform process would require several infrastructural and
market changes to be effected Appropriate market segmentation, awareness initiatives,
product innovation, and incentives Easing of entry norms for specialist health insurance
companies Provider rating and credentialing Centralized database for health insurance experience
statistics Efficient back-office support for underwriting and claims
processing
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Conclusion
Health insurance is an emerging important financial tool in meeting health care needs
of the people of INDIA. CBHI is to be further explored so that the disadvantaged section
get maximum benefit. In India at present no Pan-India Model of HI.
All different forms need to be explored.
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