1. VISHWAS 2017
Insurance / TPA – Empanelment and Affiliation –Strengthening the Payer & Provider relationship
February, 2017

2. Usual Health Insurance Policies for which hospitals deal with health insurance companies / TPAs
Group Health Insurance Policies
Individual Health Insurance Policies
Government Health Insurance Policies
Source: IRDA Annual Report

3. How it all started
In 2003, IRDA formulated the TPA (Third Party Administrator) regulations
TPAs started operating as administrative arms of health insurance companies – government insurance companies – United, New India, Oriental, National – being the key ones
TPAs tied up with hospitals all over the country for providing care to their card holders without charging upfront cash
Therefore, it was creation of primarily a financial credit network and less a care network
Today, pre-packaged pricing has been added to the agreements, but the basic nature of the relationship has remained same

4. How this will and has to change
INDIA
SAUDI ARABIA
UAE
~ 1.3 billion
~ 32 million
~ 9.2 million
Population
~ USD 105 billion
~ USD 80 billion
~ USD 25 billion
Healthcare Spend
~ USD 3 billion
~ USD 5 billion
~ USD 7.5 billion
Health Insurance Premium
Health Premium to Health Spend
~ 2.9%
~ 6.25%
~ 30%
Therefore, health insurance premium will only go up in India
Approximate numbers for 2015

5. How this will and has to change
Now let’s look at the India numbers in a bit more detail:
Healthcare Spend
Health Insurance Premium
In-patient Spend
~ USD 105 billion
~ USD 21 billion
~ USD 3 billion
Out-patient Spend
~ USD 84 billion
14.3% of In-patient spend is insured
In large metros and cities it ranges from 30%-40%, and for some specialty care facilities it can be as high as nearly 50%
Approximate numbers for 2015

6. How this will and has to change
Why health insurance will go up further:
RSBY coverage is going up from 30,000 per family to 1,00,000 and 1,30,000
Government schemes are being expanded to include APL families also
There are already 6 stand-alone health insurance companies, and 2-3 more are on their way
Consumers are seeking more health insurance as healthcare cost is going up rapidly
Health insurance companies are exploring to expand their coverage to cover out-patient expenses

7. How this will and has to change
So the relationship between hospitals and health insurers has to change:
Currently the relationship is adversarial
The relationship has to change to collaborative

8. How this will and has to change
Possible areas of collaboration:
Today the admission, care approval, and discharge processes are as cumbersome and un- friendly as it can be
How the processes can become seamless and customer friendly
Process
Today there is lot of questioning by health insurance companies regarding care process and cost
Can hospitals and health insurance companies jointly develop care and cost protocols
Can hospitals look at possible ways of risk sharing for care outcomes with insurers
Care
Today hospitals are only servicing whatever coverage the health insurance companies are providing
Can hospitals work jointly with health insurance companies to develop appropriate and targeted coverage for the healthcare customers
Product

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