Download Served Insurance for the Poor

Served Insurance for
the Poor
HMO Model for Primary Care
Some Problems…
 Health is not important priority in rural mindset, as
compared to basic needs like food, livelihood and
shelter
 Insurance illiteracy- no concept of risk management
 Feel that premium paid is money lost if unclaimed
 Poor user experience due to exclusion criteria and
unfriendly claim settlement process
 No value in day to day healthcare requirements
 Unknown, unseen provider difficult to trust without a
local face
 Recurring nature of premium payment
 Compare with free services available at the govt.
hospital and want everything free after buying
insurance
Challenge…
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Design a suitable product
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Marketing and selling it
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Address the problems
Consider changing healthcare scenario & public sector initiatives
Target Voluntary enrollment and annual growth
Seek support/cost saving from collateral sources
Well packaged with perceived value to the customer
Use parallel marketing & sales channels
Education/ awareness and sales campaign
Renewal incentives
Serving it well
 At all levels
 Transparency in transactions
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Keep the costs low
 Reduce administrative cost
 Cross subsidization – Differential premiums, cross selling other products
 Cost Sharing by the govt. or private donations or grants
PROBLEMS WITH RSBY
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Little emphasis on building insurance literacy (which will build self
responsibility for healthcare) - leading to poor utilization pattern and
customer satisfaction
No local coverage for day to day needs like basic consultation diagnostic,
drugs, Day-care procedures. Patient has to go all the way to the
empanelled hospital for basics - spending on transport, loss of wages,
food etc. which makes free consult meaningless.
Lack of co-payment leaves room open for moral hazard
No provision for public health measures, preventive and promotive
interventions which actually reduced disease burden
Limited Coverage of 30,000 which may not extend to tertiary level care
(which actually bears highest risk)
No control on the providers to follow best practices and may lead to high
claim ratio
Missing the opportunity for meticulous patient record maintenance into a
central database for further research and product/service refinement
The lack of gatekeeper function is major risk which insurance companies
cover by hiking the premium
RSBY Model
Govt.
Hospital Network
TPA
Insurance
company
CARE Model
GOVT
Hospitals
Hospital
Coordinator
Village Health
Champion Network
CARE
consortium
Insurance
Company
Brings expertise of
understanding health care
delivery and Insurance both &
weave together a seamless
service mechanism with highest
possible efficiency that can be
globally benchmarked
Differentiators
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RSBY
 Delivery only at district hospital
level
 No focus on prevention
 No co-pay system
 No focus on early diagnosis and
disease management locally
 No support to clinical practice
guidelines (CPGL) and improving
standard of care
 Fragmented user experience
 Higher risk to Insurance
companies, thus they demand
higher premium
 The coverage remains low and
may not extend to tertiary level
care if needed.
 Limited information exchange
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CARE Consortium
 Village & district level delivery
mechanism
 Save claims rate by prevention
 Reduce moral hazard by co-pay
 Save hospitalization by treating
timely and locally
 Control hospital bills by
emphasizing CPGL with daily
peer review and DRG system
 Build seamless user experience
 Negotiate better rates with backend insurer/s
 Benefits of cost savings passed
on to the consumer as increased
coverage (up to 1.5 Lakhs)
 Transparency of each
transaction between partners
The service network
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Central Call center and claims office
Hospital level coordinator with HIS/EHR interface
Mobile enabled Village Health Champion
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Telemedicine 24x7
Survey & Data Collection
Coordinate Periodic Camps
Transport facilitation
6 Preventive interventions
1.
2.
3.
4.
5.
6.
Drinking water
Vector control, Toilets and Public drains
Reproductive health
Vaccination
HT/DM control
Health Education,
Coverage
 Preventive care interventions, education and discounts on
products like water filter, nutritional supplements, bed-nets,
mosquito repellants, toilet construction etc. (Channel partnerships)
 Eye and dental treatment at camps (Channel partnerships)
 OPD- Free Consult, Free + Discounted Medications, Diagnostics
 Pre hospitalization care – Guidance, First Aid, Transport
 Facilitate Hospitalization for families uncovered by RSBY or
Diseases uncovered by RSBY at the Govt. Hospital/ Medical
College (facilitate the treatment and support with drugs or
disposables etc. not available there upto an amount of … Rs.)
 Post Hospitalization Medication - ensure delivery and intake
 Coordinate with ongoing programs and govt. schemes
 Wage Loss compensation
 Death & Disability compensation
 Child Survivor benefits (education/marriage)
 Savings Component
Risk control
 Biometric identity validation
 Doctor does the triage and screening (Virtual
Gatekeeper)
 Self managed –no TPA (may involve standard
Insurance agency as back-end risk career)
 Strong IT based management
 Easy to treat illness managed locally
 Transactions done through mobile banking (for co-pay)
 We clearly document what if scenarios to avoid hassles
 Tertiary referrals, non-availability of service, co-pay refusal,
inappropriate claim etc.
 Second Insurance for epidemics
Premium calculation
 Paid by user (co-pay) & Govt.
 Family floater – Premium based on family size
and composition
 Based on RSBY cover
 Premium for BPL subsidized by Govt.
 Non BPL may pay full premium.
 Expenses to be covered
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Education and enrollment campaign costs
Claim processing fee , administrative charges
Premium to back-end insurer and second insurer
Other expenses for the network for an year
Virtuous cycle for renewal
Save Costs
Prevent disease
Encourage Co-Payment
Control Hospital Bills
Administrative expenses
Invest in Research & innovation
Improve operational efficiency
Improve Product
Reduce premium
Increase coverage
Reduce co-pay
Improve salability
Increased enrollment
Higher premium collection
Moving forward the PPP
way…
 We will start with building health demand, ensuring good user
experience with an innovative insurance product that brings
immediate benefits to the Govt. and people alike.
 2nd phase we can enter in to agreement for managing PHCs and
build capacity for delivering efficient services at grassroots
 3rd Phase – we will construct hospitals of NABH standards in each
town & district to increase bed capacity and link them to primary
care network & tertiary care hospitals
 4th Phase – World class center of excellence for training and
capacity building – Its agenda would include research, innovation
and tool development for making healthcare cost-effective and
equitable for Indian Masses.
Give us a chance to
transform …
THANKYOU