1. Prospects and Problems Healthcare Provider Dr. P. Prabhakar Chief Operating Officer Kamineni Hospitals

2. Overview India is a low-income country with 26% of the population living below the poverty line, and 35% of the population illiterate and with skewed health risks. Private sector is the dominant sector; 50 % of those seeking indoor care, and 60-70% of those seeking ambulatory care, do so from private health facilities.

3. Overview contd… Despite the higher cost, a majority of both rural and urban Indians prefer private care because of the perceived inferior quality of public care. The entire burden of cashless, prepaid private care is shared among 500 odd private care providers in the country, who are approved by insurance companies for this purpose

5. Entry Barriers In a number of cases applicants of older ages have been refused admission to the Mediclaim scheme due to the unnecessary conservatism of companies since it is felt that the outgo of these schemes will be more than the premium collected. Companies are also refusing to upgrade or increase the sum assured for older patients.

6. Entry Barriers contd… There is an excessive emphasis on disqualification because of pre-existing conditions and post-claim underwriting. Because of these practices health insurance has become one of the largest litigation areas for insurers, exceeded only by motor third party cases. No standardized tool available to assess the risk before taking the policy.

8. Problems Service provider are always at a disadvantage (only at the receiving end, patient approach the hospital directly for any ailment) Patient not made aware of exclusions, fixed package rates, non-payable expense. All these have to be explained by the provider.

9. Problems contd… There are reports of fraud and manipulation by clients and providers, which have implications for the growth and development of this sector. Monitoring systems are weak. There are chances that if the doctor and patient collude, they can do more harm to the system.

11. Problems contd… Preferred Provider Network (PPN) screening focuses on tariffs rather than markers of Clinical Outcomes or cost effective care. Policies providing a ceiling of the assured sum and fixed tariff for procedures could result in difficulty for the hospital to provide quality care.

13. Problems contd… But it is providers who now face the risks of not getting reimbursements from TPAs. Besides, once patients are admitted and if treatment costs exceed the sum insured, providers may not get the difference in treatment cost and the sum-insured.

14. Problems contd… TPAs not updated about the renewal immediately, causing unnecessary delay in pre-auth. Providers also penalized for oversight of TPAs while given preauthorization for higher amount than the policy.

15. Conclusions Fixing of responsibilities and stringent action can act as deterrent for all the erring sections. Analysis of hospital bills across providers for similar disease patterns / diagnosis will prove that there is no incentive for being cost effective. Payment timelines should be well defined and adhered to.

16. Areas for industry and government action Work towards creating standards for high quality healthcare. Invest in training and developing healthcare manpower. Work with health insurers to improve coverage. Create public – private partnerships in healthcare. Mechanism to provide incentives for providers, who provider cost-effective care with better clinical outcomes.

17. Questions remain! Govts offer different prices for the same services BPL and the RICH are in some way or the other taken care of, what about the middle 60% of the population Higher insurance penetration is sure to raise the cost of care as evidenced in the west, this will further make it difficult for the people who are not insured Health of the citizen is a state responsibility, but there is no one accountable and no one asking the fundamental questions

18. Thank you

19. Kamineni Group Vibrant and high-quality healthcare sector in India