Transcript
HEALTHCARE & HEALTH FINANCING AN OVERVIEW
ASSOCHAM NATIONAL SUMMIT
P C JamesExecutive 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 SYSTEMHEALTH PROMOTION REQUIRES HEALTH INFRASTRUCTURE HEALTH SERVICES HEALTH FINANCING STEWARDSHIPNEED 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 ServicePharma Cos. Providers
TPA
CONSUMER CENTRED WELLNESS
Government CourtsConsumer
Regulators Bodies
Policy Holders
Insurance Company
Third Party Administrator
HEALTHCAREPROVIDER
Insurance PremiumsInsurance Coverage
Health
Services
Bene
fitsAd
ministr
ation
,
Provid
er Ne
twork
TPA F
ees
Paym
entsCla
ims
Cashless Treatment
FRUSTRATIONS IN THE SECTOR
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”
yetoffices 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
modelsUSA XUK XCurrent 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
More Coverage
Secure Payments
Better Health Infrastructure
More Affordability
CYCLE OF COSTS & CAREWhat we can pay Vs. What we need.
Premium
Costs
ClaimsCARE
INSURER INTERVENTIONa) Managed Care
Gate keepingSecond OpinionsCase ManagementCare ReviewCost Negotiation
INSURER INTERVENTION (Contd..)
b) Sublimits - CappingAmount per procedureDeductiblesCo paymentRestricted CoversHigh Premium ratesRejections
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