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Served Insurance for the Poor HMO Model for Primary Care.

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Presentation on theme: "Served Insurance for the Poor HMO Model for Primary Care."— Presentation transcript:

1 Served Insurance for the Poor HMO Model for Primary Care

2 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

3 Challenge…  Design a suitable product  Address the problems  Consider changing healthcare scenario & public sector initiatives  Target Voluntary enrollment and annual growth  Seek support/cost saving from collateral sources  Marketing and selling it  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  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

4 PROBLEMS WITH RSBY  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

5 RSBY Model Govt. Insurance company TPA Hospital Network

6 CARE Model CARE consortium Hospital Coordinator Village Health Champion Network GOVT 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 Hospitals

7 Differentiators  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  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 back- end 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

8 The service network  Central Call center and claims office  Hospital level coordinator with HIS/EHR interface  Mobile enabled Village Health Champion  Telemedicine 24x7  Survey & Data Collection  Coordinate Periodic Camps  Transport facilitation  6 Preventive interventions 1.Drinking water 2.Vector control, Toilets and Public drains 3.Reproductive health 4.Vaccination 5.HT/DM control 6.Health Education,

9 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

10 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

11 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  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

12 Virtuous cycle for renewal Improve Product Reduce premium Increase coverage Reduce co-pay Improve salability Increased enrollment Higher premium collection Invest in Research & innovation Improve operational efficiency Save Costs Prevent disease Encourage Co- Payment Control Hospital Bills Administrative expenses

13 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.  2 nd phase we can enter in to agreement for managing PHCs and build capacity for delivering efficient services at grassroots  3 rd 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  4 th 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.

14 Give us a chance to transform … THANKYOU

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