MUMBAI: Leading state-run general insurer New India Assurance Company today said it will soon launch a new premium Mediclaim product as a part of its efforts to resolve the issue over the cashless health cover, which the state-run players had discontinued early July alleging inflated billing by hospitals.
The move is also aimed at bringing corporate hospitals under its fold, Ramadoss said, adding it is adding three Delhi-based leading corporate hospitals-Gangaram, Max and Medicity to its empanelled list of hospitals for this scheme. The IRDA Chairman's remarks came a day after the Delhi High Court asked the insurance regulator to sort out the imbroglio over the cashless facility to policyholders in major hospitals across the country. The regulator, however, held the view that it could do nothing in this regard. "We have long moved away from the administered price regime and it is for the market forces to determine the price of their products," Narayan further said, adding there might be co-payees or higher premium products for these five-star hospitals, which the insurers should decide. Clarifying on the PSU insurers' recent decision to discontinue cashless policies, Ramadoss said, the company was never against cashless claims but wanted some clarity on the tariffs being charged by most of the hospitals empanelled, which the insurance industry felt were inflated.
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Experts from Medimanage.com give their opinion:
Sudhir Sarnobat:
Though the idea may sound promoting the Free Market regime, there is inherent flaw in the thought process.
In India, when the insurance is still not reached to masses, we are already jumping to provide benefit for Class. This way, we are also promoting the thought of luxury lifestyle in healthcare when thousands of people do not have basic access to healthcare.
How an ordinary person will know when he will need treatment at “Premium Corporate Hospital” hospital? The basic mistake is in classifying these hospitals as “Big Corporate Hospital”. They are tertiary care hospitals & are competent to handle complex cases. A person cannot predict when s/he will have disease that can be treated only at such hospitals. Then how such person will decide in life whether to buy such product or not.
The insurers should classify the ailments as primary, secondary & tertiary care and then accredit the hospitals on same basis. Then insurer could define the rates at such hospitals & ensure that quality treatment is made available at such hospitals for given price. If the customer still wishes to go to Tertiary care hospital (as per insurers, Big Hospital), s/he can do so but should be paid only the amount that one would spend at secondary or primary care hospital.
Mahavir Chopra:
I agree with Sudhir.
When does a common man like you and me take decision of going to a Corporate Large Hospital. It’s in most cases when the case is complex or an emergency. Like Purandar once said, If someone suffers from a stroke he needs to be taken to a place where an MRI can be carried out. He cannot avoid going to a large hospital just because his policy does not cover this hospital.
The mass population does not look at going to a large hospital for small surgeries like a cataract of a hernia operation, he/she would go to a local nursing home through reference of his/her general physician. What is being done here is penalizing everyone for some people with hideous intentions to misuse the insurance for cashing the best out of the coverage. More scientific caps/limits to common treatments would help in getting control over such claims. In addition to room rent limits which already brings in some amount of control, the associated costs increase due to higher room rent should be brought under capping under the policy wordings.
New studies suggest that those who drink moderately throughout their lives live longer than those who do not drink at all. In fact even heavy drinkers outlive teetotallers! Before you hurry to bring out that bottle, note by moderate drinking, we mean 1 to 3 drinks a day.
In a study conducted over a period of 20 years, it was found that 69% of non-drinkers died, where as 60% of the heavy drinkers died and only 41% of the moderate drinkers There may be other factors involved but according to statistics those who drank out lived those who didn’t.
Another study at the University of Athens found that caffine actually helps in warding off heart diseases. So, having your morning cup of coffee can actually keep you healthy!
So looks like all those drinks that we thought would be unhealthy practices might actually help our health. But more research is required to back it up before you start sitting with your evening pegs drinking to your fine health!
To read the epaper click here
Most teens are resorting to this very option. With increasing intake of junk food and horribly unhealthy diets, the number of obese kids between the ages 14-18 has increased three fold. And now they are resorting to the option of bariatric surgery.
Bariatric surgery or weight-loss surgery is a procedure wherein the size of the stomach is reduced — often by removing up to 90 per cent of the organ. The surgery reduces the quantity of food the individual can consume.Thereby helping them lose weight. Dr. H Chandalia, eminent Diabetologist, says “This surgery is very effective but there are restrictions like you can only drink a very small amount of water at a time which may cause discomfort. In a way these surgeries are just one way to impose the lifestyle changes which the patient could otherwise not inculcate”.
Where the average size of a teenager’s stomach is about the size of a football, post surgery it becomes the size of an egg. The after effects result in immediate rapid weight loss and the individual almost never has a full meal again.
Not a Standard Procedure
There are certain situations where the child’s health is at stake, like with high BP or type 2 Diabetes, where this surgery is the only option out. But it is being clubbed with a well balanced diet structure and psychotherapy; post the operation, to help the kids deal with their condition.
But it is not a permanent solution for losing weight as without a balanced diet and proper nutrition the person can gain weight again. For teenagers who are not dangerously over weight, and have no other complications, they should resort to safer and natural methods of weight loss. Most doctors are not even sure of the consequences of changing an adolescents’ digestive system like this. Many turn down all or almost all teenagers as they do not consider this option as viable for children, especially those that come at a very young age of 12 and 13. They suggest rigorous weight loss programs instead.
While this option may become increasingly popular, especially among those who can afford it, it seems most popular among those with horrible lifestyles and high junk food intake. So instead of waiting until it comes to the point of surgery, cut down on the unhealthy food and increase your activity levels!
http://epaper.hindustantimes.com/PUBLICATIONS/HT/HM/2010/08/29/ArticleHtmls/ht-SPECIAL-Obese-teens-go-under-knife-to-29082010001017.shtml?Mode=1
http://epaper.hindustantimes.com/PUBLICATIONS//HT/HM/2010/08/29/PagePrint/29_08_2010_013.pdf
Come October 1 and third party administrators (TPA) that service health insurance claims will double the service charges they claim from non-life insurance companies. This may lead to a hike in health insurance premiums if insurers choose to pass it on to consumers. At present, TPA charges 5.25 per cent of the premium paid by policyholders as service fee. This is the amount insurance companies are charged for processing health claims, storage of data, issuing pre-authorization for cashless hospitalisation and checking fraudulent claims. “We will be asking public sector insurers to double service charges from 5 per cent to 10 per cent of the premium, as we will be out of business once public sector non-life insurance companies launch their own TPA. Since we are paid on a quarterly basis, in case the insurers refuse to pay, we will stop servicing new policies from January 1,” said the chief executive officer of a leading TPA who attended the EGM. SK Mahapatra, a spokesperson for the TPA association, confirmed the development. TPAs have also sought a meeting with the Insurance Regulatory and Development Authority (Irda) to present a comprehensive report, containing proof and details of wrong underwriting practices used by the public sector insurers, which are causing them losses in the health business. Similar facts were highlighted in a recent report of the Comptroller Auditor General (CAG) of India as well. “The report will contain names of 200 companies which were charged lower premium on renewals despite bringing huge claims in the previous years. The report will also show employees of insurance companies have been consciously selling health policies to sick people. We will submit this report to the government and the media as well,” said a CEO of a TPA.
TPAs are asking for hike in fees because they are expecting a loss in revenue when all four PSU insurers would come out with their own TPA. This cannot be the reason for fee hike. They should justify the value brought in OR should bring forward the components of various costs incurred by them and show the deficit between value/cost versus remuneration received by them. Loss in business or insurer’s faulty underwriting cannot be the basis for hike in fee percentage.
We are surprised to know that TPAs are making these comments & bringing out issues of wrong underwriting prctices only now when their existence is questioned. This shows that despite of being custodian of insurance company’s claims money (which means outflow), they did not share these concerns then & adopted an attitude of appeasement of insurers. TPAs should introspect & check what has brought them to this position. They will find that their own disregard for insurer’s interest & sloppy claims processing are major reasons why they are being blamed for overall mess in health insurance field.
Healthcare providers in Mumbai formed a core committee on Friday to deal with the controversial preferred provider network (PPN) programme unilaterally introduced by public sector general insurance companies under the cashless mediclaim facility.
“The rate for a procedure of cataract is about Rs24,000 under the PPN,” said Dr Sujata Rao, president of the AMC. Thus the maximum reimbursement that a hospital can claim for a cataract procedure would be Rs24,000. “This is not acceptable as only the lens used in the procedure costs that much.”
Because of this discrepancy, 75 of the 120 hospitals withdrew from PPN. “However, the insurance companies are not reporting this,” added Rao. According to Dr Nayan Shah of Paramount Health Services, about 25-30% of a hospital’s occupancy consisted of insurance patients, and hence the insurance companies would soon have to design an array of programmes to address their concerns.
The hospitals have come to defend their rights however; they also need to bring in discipline among their members who exploit the insurance system. Its fact that hospitals have been charging differential tariff & exploiting the facility meant for common good. While fighting for rights, they also need to build a code of conduct & suggest reprimands for incorrect behaviour. Else, it will become a typical trade unionist approach where power of group is used to extract benefits where ultimately the consumers bear the brunt.
Hospitals, proactively, should build & forward the categorisation criterion (they know healthcare the best & can comment on classification themselves) & ask TPAs to follow that. This kind of self-regulation will help the healthcare industry which is currently not regulated by anybody.
All kinds of news are currently floating in the media and the industry regarding the Cashless Mediclaim. After PSU Insurance Companies taking a stand to stop Cashless at some high ended hospitals in top cities, as a reverse salvo Hospitals in Mumbai have united against Insurance companies and decided to refuse cashless hospitalization.
There is always a danger of adverse reactions against unilateral decisions. A PPN can be successful only if it is a buyer’s market. Else there has to be a genuine consensus between the carriers and the providers. Here are some facts to get a perspective:
Currently India has beds to population ratio of 0.9 : 1000. The recommended WHO beds to population ratio is 3 : 1000 and in India, the recommended ratio is 2 : 1000. This deficit is over 50%. Critical care beds are generally 20% of the total beds. In India apart from the new breed hospitals most centers have up to 10-13% so one can imagine the paucity of critical and life saving beds in India.
Insurance penetration is mostly in the urban and semi urban sector and among the middle class and above population. Internationally, in the USA the current government is looking at 85 cents per dollar claim out go. Brazil, an economy similar to ours also has a similar outgo. In comparison, Indian health insurance claims are about 130%.
All the beds are not equitable. A general ward in a government hospital is crammed beyond capacity and sometimes over 1 one patient per bed. The nurse to patient ratio is probably 1 nurse for 15 patients. As opposed to this the private hospitals have a better nurse to patient ratio and super-specialty hospitals have close to 3 nurses per patient.
In the absence of a concerted governance mechanism, all the players (Carriers, TPAs and Providers) are pulling in their own direction stretching this social measure to break point.
Summary
India is clearly not a buyer’s market and the healthcare providers will continue to dictate the price at least for some time.
Insurance companies are here to making profits albeit marginal on this portfolio, but certainly losses are not acceptable.
With over 80% of the paid claims being for private hospitals, the preference of the customer is very obvious. This is a reality and hence a consensus most desired. One of the methods to do this is the RBRVS. This is the Resource Based Relative Value System. Giving a layman perspective, in this system, the pricing is done based on the resources used for a particular procedure. The insurer could identify a hospital well know for quality and ethics as the bench mark. In tandem with this hospital, the insurer could identify various procedures, the complexities involved, the resources utilized and the costing. This should cover the entire spectrum of hospitalization. Once this is done a tariff card can be brought out. This tariff is a relative value and will change with the type of hospital and the region.
A strong governance mechanism should be put in place (this is the responsibility of the health ministry) to ensure that at the end of the day the average citizen is not taken for a ride.
The association of third party administrators (TPA) has decided to move the Competition Commission of India (CCI) against the four public sector non-life insurance companies and their association, called General Insurers Public Sector Association of India (Gipsa), for forming a cartel and abusing their dominant market position in planning their own TPA outfit. “The TPA floated by Gipsa companies will result in cartelization, market dominance and monopolisation,” the TPA association alleged in its letter to the insurance regulator. The association said the move would lead to stopping of fresh investments and huge lay-offs by existing TPAs. “The entire business model introduced by the insurance regulator will get destroyed. This is anti-consumer and anti-competition,” Mahapatra said. When contacted, M Ramadoss, chairman and managing director of New India Assurance, said, “Let us first get the notice. We will then decide what we should do? The TPAs have all the right to do approach the CCI.” “The move will result in closure of all existing TPA companies. This will give rise to an arbitrary increase of premium, refusal of policies to the elderly, restrictions on cashless network, favouritism under the guise of preferred network of hospitals and corruption,” the TPAs alleged in their letter to Irda. “How can an organisation owned by the insurers be a TPA to service their clients?” the association asked.
All four Public Sector Insurance companies coming together & deciding for a single TPA could be interpreted as Cartelisation as these four govt. companies are separate legal entities.
However, the TPAs cannot force an insurance company to use their services & insurance companies have been selecting TPAs for their various offices based on capability, fees charged, claims processing quality & technology implementation. Instead of going for an open tender, all four companies can have a tacit understanding among them & select, may be just one TPA, for servicing all their claims. After-all, we have examples of Pvt. Insurers going in for their own TPAs & hence, you cannot stop Insurers from setting up their own TPA.
So it’s not what is being done that is questioned? It’s about who is doing it & the manner in which this is being done that makes it questionable.
NEW DELHI: “More and more hospitals will join the network (Preferred Provider Network) in coming days," said minister of state for finance Namo Narayan Meena while replying to a calling attention on the issue, raised by BJP member S S Ahluwalia, in the Rajya Sabha.
He said public sector insurance companies had to resort to rationalization of rates for cashless facilities as they suffered a loss of Rs 2,000 crore because of overcharging by hospitals in Mumbai, Delhi, Chennai and Bangalore. If the hospitals were allowed to overcharge, it could result in "serious consequences" leading to insolvency of the insurance companies, he added.
Citing an example, he said while the private hospitals were billing Rs 1.35 lakh from an insured for Caesarian operation, the rate was Rs 55,000 for uninsured and the CGHS rate was only Rs 15,000.
Raising the issue, Ahluwalia earlier said there was no standardization of rates. "The government was leaving the people at the mercy of hospitals. Patients should not suffer because of overcharging by hospitals and some cases of manipulation," he said.
Clarifying the issue during his reply, Meena said: "It may be noted that the Standard Health Insurance Policy does not provide for any assurance of cashless facility to the insured. However, in cases where a mention of cashless facility has been made it has been mentioned that the claims in respect of cashless facility will be through the agreed list of Network Hospitals/Nursing Homes/Day Care Centers and is subject to pre-admission authorization".
The minister has raised couple of important points which are at the heart of this issue.
It’s important to note that the cashless is not a service in itself but a way to ensure claim settlement. This is subject to “pre-authorisation” by TPA & hence, should not be taken for granted as right of insured. Also the insurer has right to add/remove hospitals from the network & hence, the network would always be dynamic. However, the insurer have been clearly declaring that they pay 5.5% to TPA for their services & the same is loaded on the basic premium. This has led to interpretation that cashless is right of insured as he/she has paid for that service.
The hon. Minister has brought forward the urgency & important of this issue by communicating about the losses made by insurers under Mediclaim portfolio & if the same are not reined in on time, insurance companies may become insolvent (will not be in position to pay claims for policies sold). This is very important for long term sustainability of insurers & for the larger interests of the policy holders who have paid the premiums for many years without claims & would have claims now. If the insurance company that they have trusted for years can’t pay the claim, they would be left high & dry. This would also be detrimental for policy-holders confidence in a developing insurance market like India where the insurance penetration is high & breach of trust can bring down the sales numbers which are direly needed for better spread of the risk.
Losing weight was never that easy. From dieticians to nutritionists to gym trainers, they all tell you the same thing. Eat less and exercise more, keep a watch on how many calories you intake and how many you manage to shed.
But what if you had a real time monitor over how much you were consuming and how much you were shedding? One that was in your mobile and you can use throughout the day - when you eat, when you exercise. The application can even recommend a good regime!
Weight loss applications that can be downloaded in phones like blackberry, I phone and other such phones are simple, mostly free and not to mention fun and effective, according to many users.
The process is simple; immediately after you have a meal you enter what you have eaten into the application. It instantly gives you a count of the number of calories that you have taken in.
Similarly you enter the kind of exercise that you have done and for how long and it tells you how many calories you must have burned! Sounds interesting doesn’t it?
But of course a doctor’s consultation is required for check on the app as a machine cannot be relied upon a 100%.
On Monday, J Harinarayan, Chairman, IRDA said “The mechanisms are being put in place to improve efficiency in health insurance and administration. Expert committees of industry bodies like CII and FICCI have recommended measures including uniform claim forms, re-authorization. We are also looking into aspects related to billing,” he said. As of July 1 328 hospitals were in the network for cashless facility across four cities namely Mumbai, Delhi, Chennai and Bengaluru. However, they withdrew from the same citing steep charges.
“They (hospitals) have renegotiated rates and as per the last count, over 390 have signed up with the partnership network,” he said.
The initiatives like Uniform Claims Form, Uniform Pre-authorisation form, though look very simple, will add greatly to simplicity of administration.
Apart from the major reforms like cashless hospitalisation, premium rationalisation, the administrative reforms like this would hugely benefit the customers.