P.c.james

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