Dr R D LeleHon. Chief Physician and Director of Nuclear Medicine,Jaslok Hospital and Research Center, MumbaiLilavati Hospital and Research Center, Mumbai.Emeritus Professor of Medicine (for Life) andEx Dean, Grant Medical College and Sir J.J hospital, Mumbai.Emeritus Professor, National Academy of Medical Sciences, India.Chairman Research Advisory Committee, Haffkine Institute

Mission Mumbai HealthMicro Health Insurance:

with Micro Financing

Current Scenario of Health Insurance in India• Employee State Insurance Act(1948)• Mandatory social insurance scheme in formal

sector.• ESIS introduced in 1952.• Benefit to 33.4 million workers with income less

than Rs 6,500 per month, along with their families.• Limit now raised to Rs. 15,000 pm• 136 Hospitals, 1443 dispensaries• 6542 M.O.s, 2988 GPs

GOVT EXPENDITURE IN HEALTH CARE 0.9% OF GDPFAR LESS THAN WHO RECOMMENDATION – 5%

OF GDP

Current Scenario of Health Insurance in India ( Contd….)

• CGHS introduced in 1954. 4.5 million beneficiaries • Railways 8 million• Defense 6.6 million• Ex Servicemen 7.5 million• Public Sector (Mining, Plantation) 4

million • Other Public Sector Undertakings – 8

million

ESIS and CGHS cover 35 million

MEDICLAIM scheme of General Insurance Corporation introduced in 1986.

Pays for in-patient services onlyDoes not cover MTP and tubectomy, preventive

care( immunisation against HBV) or OPDGroup MEDICLAIM for organisations available for age 5-80 children age between 3m – 5 years Minimum Premium Rs 213 per annum for Rs

15000 Highest Premium Rs 17156 for Rs 500,000

Health Insurance as an integral component of HMO pre paid managed care – urgent need for a paradigm shift.

by DR R D LELEKey note address at The Asian Health Insurance Congress,

September 1,2; 2004 at Taj Mahal Hotel, Mumbai.

JAPI 2004 Dec. Vol 52, 947-950

UHI scheme for BPL families.In 2003 Govt. of India introduced Universal Health Scheme. All the four public sector non-life insurance companies offer this scheme at a premium of Rs. 365 a year from an individual or Rs. 548 for a family of 5. government provides subsidy of Rs. 100 per BPL family.

“HEALTH INSURANCE IN ITS PRESENT FORM HAS NO

FUTURE IN INDIA” – Dr R D Lele, 2004 : Keynote address- Asian

Health Insurance Conference2004- Claim Ratio 140%;180% for Group Health

Insurance. Private Health Insurance Companies lost Rs

273.83 crores in 2007-08, Rs 243.98 crores in 2008-09.State owned New India, Oriental, National and

United India lost Rs 638.27 crores in 2007-08, Rs 1248.73 crores in 2008-09.

High share of group health insurance – main cause of losses.

Raising premium rates and denying claims eg maternity benefits –

Vicious circle with dissatisfaction to everyone.

PRIVATE HEALTH INSURANCE COVERS LESS THAN

15 MILLION PEOPLE

IRDA Act 1999 stipulated a specific percentage of insurance business in rural and social sector (unorganized sector, informal sector, economically vulnerable or backward classes) in urban areas.

The 1 crore poor citizens of Mumbai-Thane-Navi Mumbai fall in this category.

IRDA: 2005 Guidelines to promote Micro-insurance

= life micro-insurance products= general micro-insurance products-health,

accident minimum Rs. 5000, max Rs. 30,000 cover.Scope for LIC, SBI to collaborate in providing micro-finance and micro-insurance for the poor citizens of Mumbai, with the help of NGOs and self help groups.

Micro-insurance is the most effective instrument for the poor. Micro-insurance can impower the groups and through then help individual members.

Integration of MFI and MI is very critical success story- SEWA- Ela Bhat- Ahmedabad India.

When Health is SecurityEla Bhatt Times of India Jan. 24, 2012Health Insurance has to be within the

mandate of microfinance institution (MFIs)Deposit-linked life and health insurance

collaboration between MFIs and health sector

Income security and health security are two sides of the same coin, especially for the poor who are at the heart of MFIs.

SEWA Ahmedabad : Success story

LIC-Jeevan Madhur – micro-insurance policy with a term of 5-15 years SA minimum Rs. 5000 maximum Rs. 30,000

TATA-AIG life: Nava Kalyan Yojana: 5 year

Samapoorn Bima Yojana- 15 years protection

Ayushman Yojana- single premium 10 year micro-insurance protection plan.

Birla Sunlife: Bima Suraksha Super

Bima Dhan Sanchay

5, 10, 15 year policy tenure.

SBI Life Insurance: Grameen Shakti

IRDA Act 1999 stipulated a specific percentage of insurance business in rural and social sector (unorganized sector, informal sector, economicaly vulnerable or backward classes) in urban areas.

The 1 crore poor citizens of Mumbai-Thane-Navi Mumbai fall in this category.

CHARACTERSTICS OF UNORGANIZED SECTOR WORK FORCE

PoorSelf-Employed Employers not identifiableIlliterateMigratoryLack of skills

New Pension System (NPS)For self-employed profession and others in the unorganized sector, to be part of Mission Mumbai Health. Pension Fund Regulatory and Development Authority PFRDA- for implementation of NPS.Elderly population growing at 3.8% as against overall population growth of 1.8%, hence the importance & urgency of extending NPS to the vast urban unorganized poor sector, through microfinance (MFI)and micro-insurance.

Successful MFIsGrameen Bank (Bangla Desh)Bank Rakyat (Indonesia)Banco Sol (Bolivia)Community –based banks (Latin America)

Rashtriya Swasthya Bima Yojana

Rs 30 per family per year from beneficiaries75%Premium from Central Government25% Premium from State GovernmentBoth public and privete sector providers are eligible to be part of the provider network

Acute Illness 61% of episodes 37% of costs

Chronic illness 17% of episodes 32% of costs

Hospitalization 11% of aggregate costs

SWASTHYA BIMA YOJANABENEFITSTotal sum insured of Rs 30,000 per BPL family on

a family floater basisPre-existing diseases to be coveredCoverage of health services related to

hospitalization and services of surgical nature which can be provided on a day-care basis

Cashless coverage of all eligible health services.Provision of Smart Card.Provision of pre and post hospitalization

expenses.Transport allowance @ Rs.100 per visit upto

maximum of Rs 1000

Major Deficiency of RSBY

Covers only hospitalisation costs – 11% of poor man’s illness expense

Does not cover cost of drugs (48%), diagnostic tests(7%), and doctors’ fees(34%) of illness expense.

No component of preventive care

Rajiv Gandhi Jeevandai Arogya Yojna

Over 20 million poor, alloted identity cards will walk into any public or private empanelled hospital to get treatment for 972 surgical procedures with free medical treatment upto Rs. 1.5 lacs per annum.

Hospitals must keep 10% of their beds reserved for this

Hospitals must adhere to the costs set up for surgery

Courts have order hospitals to keep 2% of their revenue aside for subsidising poor patients with income below Rs. 50000/- per year.

RGJAY now applicable to 16.24 lakh beneficiaries (families earning less than Rs. 1 lakh/ yr.) in Mumbai and its suburbs.Free Hospital treatment upto Rs. 1.5 lakhs for card holders 972 medical procedures will be covered. So far 4.5 lakhs out of 16.24 lac beneficiaries received health cards.

SMART CARD

My Recommendation to Government

Upgrade RSBY card to my Bronze card and provide micro finance to BPL Indians.

The poor do not need charity.. they need micro finance support.

Health of Urban Poor (HUP)Supported by Govt. of IndiaFunded by USAIDMaternal and child Health (MCHN)Post-partum Family Planning PPFPPost-partum Intra-uterine contraceptive

device.Roel of ANMs, ASHAs, Mamtas PPIUCDEmergency Contraceptive PiU utilization

urban / rural. Migration, poverty and Access to Health Care.

Current Experience in Health ExpenditureShare of Hospitalisation 11% of aggregate health care

costsShare of Consultation 33%Share of Medicines 49%Share of Diagnostic test 7%

My HMO Pre Paid Care Project Covers consultations, diagnostic tests , medicines and

hospitalization AND IN ADDITION PREVENTIVE CARE FOR ALL Involves trusted community representation in claim

settlement and benefits package design Increases transparencyReduces administrative costs and eliminates need for

TPAs

Muhammad Yunus : Grameen BankMicro Finance: Innovation and RevolutionSocial Business Enterprise to maximise

benefits to poor people without incurring losses, not to maximise profits.

Social business is not charity to the poor but “benevolent capitalism”, as against “greed capitalism”.

Micro financing and micro health insurance a success story in Bangladesh.

For 60 Takas per year Bangladeshi woman gets Health Insurance.

ELA BHATT: SEWA Ahmedabad 1974Providing micro finanace banking services to poor women employed in unorganised sector.

Microfinance in India is workable. “Poor are bankable”VIMO-SEWA successful micro insurance scheme for the poor.

Micro Financing in IndiaICICI Bank: 16 managers each oversees

work of 6 co-ordinators.10000 SH Groups – 200000 customers at

BOPFormation of SHG with 20 members in each

group – loan given to SHGs, not individual.10000 SHGs with ICICI is an ecosystem.Hindustan Liver Limited(HLL) with

ShaktiAmmasITC with Sanchalaks in the E-Choupals.

Micro Finance LoansGovernment: Rs 24,000 crores

NABARD (National Bank for Agricultural and Rural Development) SIDBI ( Small Industries Development Bank of

India)Rashtriya Mahik Kosh (RMK)SHG Bank Linkage (SBL)Joint Liability Approach

Non Government:

Micro Finance Institutes(MFI s): Rs 11734 crores85% of MFIs are non profit, account for 25% of

loans, serving 38% of borrowersAverage Loans Rs 2500 – Rs 10000 38%> Rs 10000Total active borrowers - 2.26 crores 90% women, majority small scale self employed,

only a few daily labourers.Bharat Micro Finance Report: March 2009.7.66 crore micro finance accounts.Loans Rs 35900 crores.

Community Health Insurance Projects (CHI) in India

NGO/CBO Membership basedLarge ( >1 million):

Yeshaswini – Bangalore

VimoSEWA - Ahmedabad

Arogya-Shree - APMedium (about 50000)

Karuna Trust, ACCORDSmall (5-20000)

KKVS

DHANHallo Foundation- Andur. Dr. Shashikant Ahankari

Pilot Description – Rural Maharashtra

Partnered with an NGO, working in ~1200 villages in rural Maharashtra on women empowerment through various initiatives like SHG formation, livelihood promotion, etc.

Designed a comprehensive health scheme targeted at people in rural Maharashtra

Launched in 12 villages of Latur district in April 2009, followed by 40 villages of Solapur in Oct 2009; and then another 80 in Osmanabad in January 2010

Scheme launched and supported by marketing events in the villages

NGO employed part time sales agents in each village and sales co-ordinators to supervise them

~5,000 lives enrolled across ~120 villages

Created a network of 20 health service providers across clinics, pharmacies, labs, nursing homes and hospitals

Managing network and claims processing on an ongoing basis to ensure hassle free service

Community health workers launched to provide health services at village level

Pilot Description – Bangalore Slums

Partnered with an NGO working for 3 years to form a collective of unorganised sector workers (e.g. electricians, housemaids, drivers, plumbers)

NGO had ~22,000 members across Bangalore

Designed a comprehensive health scheme for members of NGO

Launched the health scheme in slums of north-east Bangalore in July 2009

Sales staff of the NGO promoted the scheme

~1000 lives enrolled till Jan 31, 2010

Created a network of ~20 health service providers - clinics, pharmacies, labs, nursing homes and tertiary hospitals - in Bangalore

Managing network and claims processing on an ongoing basis to ensure hassle free service

Each admission and discharge facilitated by a network facilitator

Out of pocket expenditure on health care..Rural and urban poor:OPD- Rs 144 per person per yearIPD- Rs 3202 per person per yearIllness is the common cause of indebtedness.30 crore Indians living on less than a dollar a

day.Less than 5 percent of them have access to

mirofinance.

CURRENT SCENARIO…80% of Health care expenditure comes from private pockets – rich as well as poor

Current Scenario in DharaviThe poor in Dharavi pay 600 to 1000

percent interest to local money lenders.Vegetable vendors borrow at even 10%

a dayA micro finance bank with access to this

market can do good business by offering credit at 25 percent.

Is this Excessive??The BOP customer finds the cost of

credit down from 600% to 25% a boon.

Continued…

85 % of households in Dharavi own a TV set.75% own a pressure cooker and blender.56% own a gas stove. 21% have telephone

Feasibility Study in DharaviDr R D Lele, January 20061360 families surveyed

Continued… Dharavi family spends on an average ( per year)Rs 1116 for doctors fee: upto Rs 2500.Rs 1753 for medicine: upto Rs 5000.Rs 814 for medical tests: upto Rs 2000.Major illness and hospitalisation makes them

bankrupt Majority agree to pay Rs 2500 as premium which

gives:Life Insurance to bread winnersAccidental cover and health insurance for the entire

familyPreventive and curative care by an assigned family

physician

C K Pralhad : Fortune at the bottom of pyramid

“Stop thinking of the poor as a burden on society requiring charity and subsidies to be permanently doled out by state, and start recognising them as resilient and creative entrepreneurs and value conscious customers.”

Hindustan Times, 7 th April, 2010

Financing and delivery of health care through per capita pre-payment, so that the physician organization has a budget for the care it will provide and an incentive to use the resources wisely.

Maintenance of continuous healing relationship of the family physician (FP) with the voluntarily enrolled population ( 1 FP for 500 – 1000 families ), to provide promotive, preventive and curative care to 3000 to 6000 individuals for which the FP will be handsomely remunerated ~ 1 lakh per month.

Salient Features of My Mission

Physicians and multi-disciplinary specialist teams can design and execute best care processes, in a most cost-effective manner.

Hospital facilities, complex diagnostic equipment and laboratory investigations can be deployed on a regional basis where it can be used with greatest efficiency and economy, backed by insurance cover.

Electronic patient record (EPR) which provides an accurate and comprehensive picture of each patient. EPR avoids unnecessary duplication of tests, facilitates collaboration and coordination of care among specialties, and allows monitoring of compliance with the practice guidelines to ensure high quality of care.

Computerized prescription in the patient’s own language, gives detailed instructions about how to take the drugs and alerts for adverse reactions. It eliminates medication errors and transforms the care process.

Over-use and mis-use of tests and procedures, so common currently, is strongly discouraged while early detection and prevention and early treatment and chronic disease management are strongly encouraged.

There is great emphasis on patient education and information.

Patients are encouraged to come in early and have their symptoms checked so that any potential illness can be treated sooner and at much less cost. Emphasis on prevention reduces the need for inpatient hospital care especially for Diabetes. Hypertension, congestive Heart Failure and Asthma.

The medical peer group, not an insurance company, determines the clinical policies, which technologies and procedures will be employed and covered under the pre-payment, and health insurance .

The medical peer group develop the drug formulary themselves. The drug selection is based on its therapeutic efficacy, safety and cost. Physicians have the freedom to over-ride the formulary to prescribe what they believe is medically necessary in a particular case.

This approach is most effective in cost control. In the current fee-for service scenario of medical practice, new single source patent protected drugs are aggressively promoted by drug manufacturers with little head-to head comparison with older, effective and often less expensive drugs.

HMOs use evidence-based approach to promote drugs of choice.

Impact of preventive care of life style illness will be measurable by the drastic reduction in critical illness claims which are a major cause of losses made by health insurance companies at present.Time for paradigm shift.

HMO managed care will not only ensure the elimination of the widely prevalent gender discrimination against females, it will actually put major emphasis on the care of the mother and the female child and adolescent girl eg nutrition, menstrual hygiene, sanitary napkins, prevention of iron deficiency, sex education and prevention of STD / HIV, emergency contraception and family life education, women’s reproductive health and promotion of breast-feeding.

Care of the pregnant women will ensure that

no baby is born with a birth weight less than 2.5 kg.

Action Plan for city of Mumbai

Annual Income

Annual Premium

Bronz Card 40000-100,000 Rs 2500

Silver Card Over 100,000 Rs 5000

Gold Card Over 200,000 Rs 7500

Platinum Card Over 500,000 Rs 10000

Micro Finance for Bronz Card holders

For bronz card holders•Life Insurance for bread winner•Accident cover and Health Insurance cover for entire family of five•No exclusions•Preventive and curative care by assigned family physician

Unique featuresPreventive dental carePreventive mental care.Accident PreventionBlood Doner directory automated with SMS

Thyrocare Dr. A. Velumani Ph. D

an active partner in Mission Mumbai Health, committed to provide all essential laboratory tests at an affordable cost to the poor citizens of Mumbai.

350 essential generic drugs provided at low cost through bulk-buying

The benefit of low cost will be passed on to patients.

DiagnosticLab

Drugs and Pharmacy

mgmt

Hospital /NursingHome

Doctor

Manage provider network

Prevention-promotive techniques

Feedback on quality of service

Consumer awareness

Front line – CHWs and OMs

Consumer adoption & awareness

Re-insurance

Basic insurance risk mgmt

Financial structuring

Financially self-sustaining

Tight operationa

l control

Cash flow mgmt

Claimsmgmt

Consumer data mgmt

Healthcare Quality Control

Consumer support services

Components of a health system

HMO tie up with…… Life Insurance and Health Insurance Companies. Family Physicians and Specialists Laboratories and Diagnostic Centres. Drug Companies – bulk buying at discounted rates Nursing Homes and Hospitals

Hospitals are urged to expand their roles as HMOs and provide pre paid preventive care through assigned family physicians.

Electronic Health Record for each member of family of 5-6. Computerised prescription for patientsHMO: Health Care Management: Preventive Care Through PCP Curative Care Drugs Diagnostic Tests – Hospitalisation and Rehabilitation

55

1. Hospitalisation / Surgeries• Cashless treatment at empanelled hospitals upto a limit of Rs 30,000• Co-pay for every hospitalisation of Rs 50-200• Few exclusions – HIV / AIDS, war, nuclear explosion2. Outpatient care• 1 free annual health checkup for entire family after 3 months of enrolment• First aid and basic health services (e.g.BP measurement) from a community health worker (CHW)

• Consultation at empanelled doctors at Rs 15 per visit (50% discount to market)• Quality, generic drugs at 30-50% discount to market rates• Common diagnostic tests at 30-50% discount to market rates 3. Disease prevention and health improvement measures

Customer benefits

• 30%+ reduction in total healthcare costs• Access to quality healthcare (hospitals, nursing homes, doctors, drugs, labs)• Protection from “health shocks”, both hospitalisation as well as OPD• Preventive health measures / education reducing disease incidence over time

Coverage

Pricing

• Only family enrolment, no individual enrolment allowed • Annual premium of Rs 850 for a family of 5

Illustrative product / scheme design

Taiwan ModelI visited Taiwan on 9- 13th May 2010 to see at first

hand the National Health Insurance of Taiwan working successfully since 2004. All 23 million citizens of Taiwan have universal health insurance. Each citizen has electronic health record, computerised prescription and links to clinics and hospitals.

Taiwan Health Insurance is making losses since preventive Health Care is not integrated with Health Insurance.

Mumbai, Thane and New Bombay together have a population of 23 million.

We can do better than Taiwan in this respect by combining preventive Health care with Health Insurance.

IRDA- comprehensive micro-insurance guidelines incorporating product, distribution, administration, regulation, etc. to promote health insurance among the poorer sections of society.

Mission Mumbai Health will implement the same objective.

Future of Health Care in IndiaNGO partnership with State Governments

is the only way to provide Micro Insurance through Micro Financing to the BPL (37 crore) and APL (70 crore) Indians.

Todays Health care is only illness care. Promotion of positive health and

prevention of illness are the primary aims of the physicians.

This message is known to India for over 5000 years. (Charaka and Sushruta)

AVIVA: example of corporate social responsibility (CSR)

LIC-CSR activities:20th October 2006- Golden Jubilee Foundation

- Relief of poverty or distress- Advancement of education- Medical relief- Advancement of any other object of

general public utility.

For the 70 lakh poor citizens of Mumbai, micro finance budget of Rs 15000 crores is required

At 25% interest, it is a viable social business venture.

MISSION MUMBAI HEALTH IS NOT

MISSION IMPOSSIBLEImpossible can easily be broken down into possibilities as a cooperative effort involving :

Jayant Banthia, Ex-Chief Secretary, Govt. of Maharashtra

Municipal corporation of Greater Mumbai (Sitaram Kunte)

Rotary club of Bombay SNEHA (Dr. Almeida Fernandes) Kevim Bhatnagar – Pension specialist Arogya Bharati