health insurance in india-gc chaturvedi presntn

7/31/2019 HEALTH Insurance in India-GC Chaturvedi Presntn

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HEALTH INSURANCE IN INDIA


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Health Insurance

Health Preventive no regulation

Promotive no regulation

Curative Partly regulated

Curative- OPD

- IPD


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Insurance

Life

Non-life

Reinsurance: All of them are regulated Life: critical illness

Non-life: Medi-claim


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Some basic concepts of insurance

Risk ?

Risk pooling: law of large numbers,low&high, rich&poor, young&old

Risk avoidance: LPG godown

Risk mitigation: preventive

Adverse selection vs risk selection Moral hazard vs induced demand

(deductible & co-payment)


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Present scenario

1. Enormous mismatch in global healthcare financing

2. Developing countrieshave 84% of population & 90% of diseaseburden

3. By 2020, world population-7.5 billion

By 2050, world population 9 billion

Most of the growth in developing countries.

4. According to NHA of India 2001-02, sources of finance in healthsector

Household 68.8%

Central Govt. 7.2%

State Govt. 14.4%

Private Firms 3%

Public Firms 2%

External Funds 2%

Local Govt. 2.2%


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(continued)

Govt. spending on health care of GDP0.9%

Private spending 4 to 4.5% of GDP

Overall Out of Pocket Expense80%

(incentivises supplier induced demand)

In Bihar & UP, it is 90%

NSS (1995-96) showed that rich consumedpublic service 3 times > the poor


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BPL POPULATION - FAMILIES 2001 Figures In Million

BPLURBAN

BPLRURAL

TOTALBPL

BPLURBANFamilies

RURAL

Families

TOTALBPL

067.0 193.2 266.2 017.8 048.6 065.4

BPL POPULATION - FAMILIES 2004 Figures In Million

BPLURBAN BPLRURAL TOTALBPL BPLURBANFamilies

RURALFamilies

TOTALBPL

80.79 220.93 301.72 020.1 055.23 075.33


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Present status

2% - By Insurance Policies.

10% - By self funded Govt. Scheme i.e. CGHS,Railways, Defense, PSUs organization. ESI etc.

1.1% - Rural / BPL population { UHIS / CommunityInsurance}.

86.9% - Depend upon Govt. / Private Hosp.

40% - Unable to take treatment.


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(continued)

REASONS- Unable to take treatment.

Mostly illiterate and poor.

First priority is food. Rest later.

Prefer traditional / local / home made remedies. Public facilities:

a. far from reach distance and

b. if managed to reach poor quality treatmentc. to purchase medicines etc from out side

Cant afford high treatment cost: in Pvt. Hosp.

Borrowing money, sale of propertymake them

poorer.


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Financing Options

Self pay (include user fees)

General tax revenue financing

Insurance:

Social insurance: Compulsory; Public orprivate management

Private: Voluntary

Community Financing Individual Savings Account/Catastrophic

insurance


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Comparison of risk pooling and

equity of financing methods

Financing method Risk pooling Equity

General revenue Widest risk pooling Most equitable

Social insurance Within the covered

population

Redistributive within

the coveredpopulation

Private insurance

Group Within a group Redistributive withina group

Individual Within an age/sex group Not equitable

Community Financing Within a community Redistribution withina community

User fees No risk pooling Not equitable

t O


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1st NATIONAL HEALTH SCHEMEFOR BPL- UHIS

BENEFITS

Sum Insured Rs.30,000

Limit for Anesthesia, Blood, Oxygen, etc. Rs. 4,500/- Limit for any one illness Rs. 15,000/- Personal Accident Cover Rs.25,000/- Pre Existing Diseases NOT COVERED Waiting period 30 days First Year Exclusions NOT COVERED

Maternity Benefits NOT COVERED Bystander Allowance NOT COVERED PREMIUM (for a family of five) (Sub-300) Rs.548 BPL Family Pays Rs.248

IT FAILED


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Performance under UHIS

Name of theCo No. ofPolicies No. ofFamilies No. of.Persons Premium Claims Paid

(Rupees in lakhs)2004-05 52,772 65,718 1,82,641 280.655 40.022005-06 67,259 76,605 2,47,801 350.53 154.012006-07 1,14,432 1,42,704 4,65,638 739.98 335.442007-08(Up to

Dec07)69745 81494 308238 396.40 10.057


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REASONS FOR FAILURE OF UHIS

Lack of willingness of Insurers / other Stake holders.

Absence of Nodal implementing agency

Improper identification system of beneficiaries.

Inadequate coverage / benefits.

Huge premium burden Rs 165/- min per personhence Unaffordable in spite of govt. subsidy (Rs 200(1),

300(5) & 400(7).

Lack of awareness / publicity.

Cost of collection of premium more than the premium

No confidence of public about treatment in case of need


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Yashashvini

1. Benefits available to all members of all types of ruralcoops such as:

Fisherman, Milk

WeaversIndustrial

Artisans

SHG/Stree-shakti groups

2. Age: newborn to 75 Years

3. Period starts from 1st June


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Participation Number Premium per farmer

Year (in Million) per Annum

Year-1 (2003-04) 1.6 Rs. 60/=Year-2 2.0 Rs. 60/=

Year-3 1.05 Rs. 120/=

(Rs.60 per child below 18 Years)

Year-4 1.9 Rs. 120+60/=

Year-5 (2007-08) 2.3 Rs. 120/=(for adult & child)

With 15% discount on 5 or more members of family


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1. Coverage upto Rs 2. lakh per year and Rs. 1 lakh per hospitalization.

2. 1600 surgical procedures @ 40% to 50% of price

Normal delivery IV Year

Neonatal Care IV YearFree OPD

Discounted Lab tests

Defined Medical Emergencies IV Year

3. Surgery package includes everything during hospital stay

4. Coverage for stabilization of defined Medical emergencies. Hospitalfor 2 days for

Snake-bite

Bull Gore injury

Electric Shock

Drowning

Dog bite

Injuries with agri equipments


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Procedure

1. Member approaches Network Hospital with IDCard

2. Network hospital intimates TPA for validation &

extent of cashless facility3. Hospital sends claim docs to TPA for

reimbursement


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1. Pre- Existing disease no bar to avail thebenefit.

2. 100% Cashless Treatment

3. Laminated Photo ID

4. Choice of Hospital available

5. Administrative Cost Minimal


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2003-04 2004-05 2005-06 2006-07 2007-08(sept07)

Free OPD 35814 50174 52892 206977 22428

Surgeries 9047 15236 19677 39570 12765


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YEAR03-04 04-05 05-06 06-07

Members(in lakh) 16.1 20.2 14.7 18.7Contribution of

Members(In crore) 9.7 11.97 16.3 21.5Contribution Govt.(in crore) 4.5 3.58 11.0 20.0Total(in crore) 14.2 15.55 27.3 41.5Surgery Cost 10.65 10.47 26.16 38.72

(in crore)Cost/Member 66 92 174 204Collection/Member 60 60 120 120Total Admin.Cost 40.02 12.78 43.61

(in lakhAdmn.Cost/insured 2.5 1.6 2.3(in Rs)


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TPA (FHPL) FUNCTIONS

1. Enrolment & Photo ID Card

2. Cashless Treatment

3. MIS

4. District Coordinator

5. Member help-line/Call Centre

6. Medical/Case Management

7. Claims Management


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Network Hospitals Spread Across 113 Locations :ExclusiveFront Desk Counter

2003-04 114

2004-05 137

2005-06 197

2006-07 299

2007-08 310


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Sustainable - NO

1. Risk selection (voluntary) & not risk diversification

2. Renewal Rate: Y3 43%;Y4 62%

3. No Reinsurance

4. Individual Contract Vs. Community Contract

5. Low Insurance Premium

6. Misuse by Hospitals

7. Mandatory rather than voluntary


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CLAIMS

Year 1 Year 2 Year 3 Year 4 Claim Incidence 5.6 8.6 14.1 24.6

per 1000 Insured

Claim Cost per 66 104 187 253 Insured(in Rs)

Prem./Ins. (in Rs) 60 60 120 120

No. of Claims 9008 14963 19439 37330

Total Claims 10.65 18.08 25.78 38.40

(Rs in cr.)

Average Claims 11822 12083 13262 10286


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Claim Incidence per Thousand age groupwise/ Claim cost per insured

Year 2 Year 3 Year4

0-2 Yrs 26.6/963 50.7/1687 63.9/1532

3 - 7 12.1/306 23.8/627 21.2/449

38-43 5.6/64 8.4/97 13.9/139

73-78 19.7/216 18.1/205 58.4/456

Women Participation 40%

Top 5 Hospitals Claim share 51.5%

Average of Top 5 Hospitals increased from Rs.18230/(Y2) to Rs. 39600 (Y4)

Average of remaining hospitals remained almost the same at Rs 640/=

EFFORTS BY STATES NRHM


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EFFORTS BY STATES- NRHM

A.P.- CRITICAL ILLNESS- 3 Districts

Formation of a State Trust Enrolment by family photo electronic ration card

(Biometric Card). 20 lakh (1 phase), 48 lakh (II phase)

Pilot project in 3 District. (5 more districts from 7/12/07) Coverage for 5 critical surgeries(heart,kidny,cancer,neuro

and burns-now trauma also added). Negotiations of tariffs etc for 163 defined surgeries. (213) Cash less facilities.

Sum Insured Rs.1.50 lakh. Government and private hospitals as part of scheme. Serviced by Star health - Private Insurer. 100% premium by Govt. for BPL families.

Proposing to extend to 7 districts from 1/04/08


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DistrictNo.

Surgeries

Amount

In millions

No. ofcamps

Patientsscreened

Referredfor

admission

PHAS

E1

From 01/04/07

Mahboobnagar 2501 124.2 276 42223 3903

Anantapur 3201 175.9 335 64424 5296

Srikakulam 2943 118.9 216 43855 4092

Total 8645 419.1 827 150502 13921

From 07/12/07

PHASE

2

East Godavari 440 21.7 56 15234 3226

West Godavari 558 29.5 53 31438 3956

Chittor 167 07.5 67 42341 3136

Ranga Reddy 305 16.1 38 9847 1513

Nalgonda 374 17.2 63 14752 2674

Total 1844 92.2 277 113612 14505


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RAJASTHAN - NRHM

Enrolment of families by Health Card based on

BPL Data.Pilot project in 5 District. Sum Insured - Primary

Cover Rs 30,000 and 7 critical surgeries for Rs1,35,000.

Premium Rs 480 + ST

Beneficiaries 8 lakh BPL Families

Negotiations of tariffs etc for all procedures

Cash less facilities.Use of Government and private hospitals both

Serviced by State Health Insurance Fund Agency.

100% premium by Govt. for BPL families.


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EFFORTS OF OTHER CENTRALMINISTRIES

Textile Ministry: Scheme for

weavers(16lakh).Rural Development Ministry : Health for

BPL.

Labour Ministry: Rashtriya Swasthya BimaFisheries Department : Scheme for

fishermen.

Finance Ministry: UHIS

Chemical & fertilizer Ministry: Drugs.Ministries are interested in launching their own

Insurance schemes.


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RASHTRIYA SWASTHYA BIMAYOJANA

Benefits Total sum insured of Rs 30,000 per BPL

family on a family floater basis

Pre-existing diseases to be covered

Coverage of health services related tohospitalization and services of surgical

nature which can be provided on a day-care basis


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RASHTRIYA SWASTHYA BIMA

YOJANA

Benefits

Cashless coverage of all eligible healthservices.

Provision of Smart Card.

Provision of pre and post hospitalizationexpenses.

Transport allowance @ Rs.100 per visit


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FUNDING Contribution by GOI : 75% of the estimated annual

premium of Rs 750, subject to a maximum of Rs. 565per family.

Contribution by the State Governments: 25% of the

annual premium and any additional premium beyond Rs750.

Beneficiary to pay Rs. 30 per annum as RegistrationFee/ Renewal Fee

Administrative cost to be borne by the StateGovernment.

Cost of Smart Card to be borne by the CentralGovernment. An additional amount of Rs.60 perbeneficiary would be available for this purpose.


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REQUIREMENTS

Insurance with adequate Sum Insured.

Affordable premium.Simple terms and conditions of the policy.

Coverage of pre existing diseases.

Adequate capping on various proceduresto stop misuse of the scheme.

Identification and Networking of good &

small private hospitals/ specialised daycare centers

Easy mechanism of collecting premium

OPD and Drug cost

health insurance in india-gc chaturvedi presntn

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