P.c.james

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p. c james

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P.c.james

  1. 1. HEALTHCARE & HEALTH FINANCING AN OVERVIEW ASSOCHAM NATIONAL SUMMIT P C James Executive Director - IRDA
  2. 2. RISE OF HEALTHCARE & HEALTH FINANCING <ul><li>The Burden of Disease/Disability </li></ul><ul><li>Its linkage to Development </li></ul><ul><li>Costs - hard infrastructure </li></ul><ul><li>- soft infrastructure </li></ul><ul><li>The need for Financing- Government </li></ul><ul><li>- Community </li></ul><ul><li>- Family </li></ul>
  3. 3. HEALTH SYSTEM <ul><li>HEALTH PROMOTION REQUIRES </li></ul><ul><li>HEALTH INFRASTRUCTURE </li></ul><ul><li>HEALTH SERVICES </li></ul><ul><li>HEALTH FINANCING </li></ul><ul><li>STEWARDSHIP </li></ul><ul><li>NEED TO MOVE FROM OUT OF POCKET TO POOLING </li></ul>
  4. 4. HEALTH INSURANCE IS : <ul><li>RISK TRANSFER </li></ul><ul><li>Ind. Family Org. Community </li></ul><ul><li>Insurer / Govt. / Community </li></ul><ul><li>Revenue Transfer </li></ul><ul><li>(healthy to sick) </li></ul><ul><li>Hospitals / Providers </li></ul>
  5. 5. ONE BILLION PEOPLE TO PROTECT <ul><li>Opportunities & Challenges for </li></ul><ul><li>Health providers - creating availability </li></ul><ul><li>Government - Facilitation/ Basic Regulator Infrastructure </li></ul><ul><li>Govt./Insurer/ - Affordability </li></ul><ul><li>Communities </li></ul><ul><li>Allied Organizations - Facilitation / service </li></ul>
  6. 6. MODELS OF HEALTH COVERAGE <ul><li>Taxes </li></ul><ul><li>Compulsory Social or Community Insurance </li></ul><ul><li>Private Insurance </li></ul><ul><li>Medical Saving Schemes </li></ul><ul><li>Need to create an Indian Model </li></ul>
  7. 7. UNIVERSAL HEALTH FINANCING COULD ULTIMATELY BE A MIX OF <ul><li>General Revenues </li></ul><ul><li>Social Insurance </li></ul><ul><li>Private Insurance </li></ul><ul><li>Self Insurance Pools </li></ul>
  8. 8. CONSTRAINTS IN EXTENDING COVERAGE <ul><li>75% of the population works in the informal sector </li></ul><ul><li>25% of the population below poverty line </li></ul><ul><li>70% of the population in rural areas </li></ul><ul><li>Under insured country </li></ul><ul><li>Health insurance an ill understood subject </li></ul>
  9. 9. IDEAL HEALTH PROTECTION ENVIRONMENT <ul><li>Insurers Providers Service </li></ul><ul><li>Pharma Cos. Providers TPA </li></ul><ul><li> CONSUMER CENTRED </li></ul><ul><li> WELLNESS </li></ul><ul><li>Government Courts Consumer </li></ul><ul><li>Regulators Bodies </li></ul>
  10. 10. Policy Holders Insurance Company Third Party Administrator HEALTHCARE PROVIDER Insurance Premiums Insurance Coverage Health Services Benefits Administration, Provider Network TPA Fees Payments Claims Cashless Treatment FRUSTRATIONS IN THE SECTOR
  11. 11. ISSUES IN HEALTH INSURANCE <ul><li>Need for a variety of products </li></ul><ul><li>micro – insurance to international coverage birth to old age </li></ul><ul><li>Clarity in policy terms, conditions, exclusions </li></ul><ul><li>Need for Services </li></ul><ul><li>Cashless, toll free nos., quick response </li></ul><ul><li>Curtailment of Costs </li></ul>
  12. 12. CONCERNS IN HEALTH <ul><li>Patient Care / Safety </li></ul><ul><li>Patient Rights / Service </li></ul><ul><li>Quality </li></ul><ul><li>Costs </li></ul>
  13. 13. COST DRIVERS IN HEALTH INSURANCE <ul><li>Technology / Specialization </li></ul><ul><li>Prescription Drugs </li></ul><ul><li>Medical Inflation </li></ul><ul><li>Moral Hazard / Adverse Selection </li></ul><ul><li>Usage Increase </li></ul><ul><li>New treatments </li></ul><ul><li>Unnecessary treatments </li></ul>
  14. 14. RESPONSE OF HOSPITALS <ul><li>Licensing </li></ul><ul><li>Certification </li></ul><ul><li>Accreditation </li></ul><ul><li>Rating </li></ul><ul><li>Standardization </li></ul>
  15. 15. COSTS / CONCERNS TO BE JUSTIFIED BY <ul><li>Clinical Audits </li></ul><ul><li>Clinical Effectiveness Establishment of Standards / Protocols / Guidelines / Pathways </li></ul><ul><li>Medical Audits </li></ul><ul><li>Clinical Governance </li></ul>
  16. 16. PROBLEMS FROM INSURERS <ul><li>Policy condition problems </li></ul><ul><li>Customer Ignorance </li></ul><ul><li>Pre-Existing Condition Issues </li></ul><ul><li>Disputes with hospitals / insured </li></ul><ul><li>Delays </li></ul>
  17. 17. PROBLEMS FROM TPAs <ul><li>Lack of Infrastructure </li></ul><ul><li>“ There are no holidays in Health care” yet </li></ul><ul><li>offices not open on holidays, telephone access unavailable, etc </li></ul><ul><li>No qualified doctor / staff </li></ul><ul><li>Delay in settlement </li></ul><ul><li>Deduction in bills without basis </li></ul><ul><li>Increased paperwork </li></ul>
  18. 18. ROAD TO THE FUTURE <ul><li>Need to Create our own models </li></ul><ul><li>USA X </li></ul><ul><li>UK X </li></ul><ul><li>Current Indian X </li></ul>
  19. 19. PATHWAYS TO THE FUTURE <ul><li>IRDA Initiatives </li></ul><ul><li>- Data Management & Warehousing </li></ul><ul><li>- Standalone Health Insurance Cos. </li></ul><ul><li>- Policy innovation / removal of customer difficulties </li></ul><ul><li>- Regulation/guidelines </li></ul><ul><li>- Third Party Administrators </li></ul>
  20. 20. A BILLION LIVES TO COVER <ul><li>Focus on rural / micro insurance </li></ul><ul><li>Dialogue between Providers, Insurers, TPAs. </li></ul><ul><li>Increase in numbers & premiums </li></ul><ul><li>Working with Government </li></ul>
  21. 21. CREATING HEALTH VIRTUOUS CYCLE More Coverage Secure Payments Better Health Infrastructure More Affordability
  22. 22. CYCLE OF COSTS & CARE <ul><li>What we can pay Vs. What we need. </li></ul>CARE Premium Costs Claims
  23. 23. INSURER INTERVENTION <ul><li>a) Managed Care </li></ul><ul><li>Gate keeping </li></ul><ul><li>Second Opinions </li></ul><ul><li>Case Management </li></ul><ul><li>Care Review </li></ul><ul><li>Cost Negotiation </li></ul>
  24. 24. INSURER INTERVENTION (Contd..) <ul><li>b) Sublimits - Capping </li></ul><ul><li>Amount per procedure </li></ul><ul><li>Deductibles </li></ul><ul><li>Co payment </li></ul><ul><li>Restricted Covers </li></ul><ul><li>High Premium rates </li></ul><ul><li>Rejections </li></ul>
  25. 25. UNIVERSALISING HEALTH INSURANCE <ul><li>GOVERNMENT STEWARDSHIP </li></ul><ul><li>CREATING HOLISTIC LINKAGES </li></ul><ul><li>MICRO-INSURANCE SCHEMES FOR THE POOR </li></ul><ul><li>INTERMEDIATION AND CAPACITY BUILDING </li></ul><ul><li>PARTICIPATION BY BENEFICIARIES </li></ul><ul><li>MONITORING COSTS </li></ul><ul><li>SUBSIDY AND TAXATION INCENTIVES </li></ul>
  26. 26. CONCLUSIONS <ul><li>Creating awareness & meeting the demand for health care & financing </li></ul><ul><li>Creating modules for aligning the services of all concerned </li></ul><ul><li>Focusing on enhancing affordability & reducing costs </li></ul><ul><li>Rapid coverage and health benefit to all </li></ul>
  27. 27. <ul><li>Thank You </li></ul>

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