Welcome to Medimanage Health India. Get Information on Health, Health Insurance, Weight, Diet, Skincare, Baby Health, Parents Health, Sex Life etc.
 
 

analyzing future of cashless mediclaim in India

Preamble

Last 3-4 days, we have been seeing a lot of news in various media about cashless network hospital list being brought down to fewer in numbers & this list does not have big hospitals where the treatment cost is high & hence, have a greater need for their presence in list. We fear that these news items have created confusion in our members’ mind & hence, here is small explanatory note from our team.

Genesis of the thought process

Insurance companies have been witnessing inflated, fraudulent & unwarranted hospitalisations claims when the patient had declared that he/she has insurance cover & wishes to go for cashless treatment. Also, an analysis of cashless claims brought out pointer that 80% hospitalisations (by amount) happen in only 25-30% hospitals. The advantages of curtailed list are envisaged as follows:

1). Limited hospital list (around 450 all over India) would offer better administrative control.

2). TPAs can drive more business to small number of hospitals & hence, can demand volume discounts.

3). With better administrative control, all bad claims (fraudulent, inflated & unwarranted) can be reduced to a greater extent.

Methodology adopted

New India Assurance Company (it’s the largest, has major Health Insurance exposure and their current CMD has good rapport with other PSU Insurers’ CMDs) had taken the lead & appointed four of its empanelled TPAs as nodal TPAs (one for each region i.e. East, West, South & North) & asked them to draw a list of around 100-125 hospitals in each region. Only these PPN (Preferred Provider Network) hospitals would qualify for cashless treatment. PPN is a very common concept in west & helps insurer have better control over claims without compromising the quality of care.

 How it impacts you?

1). Currently, this does not impact corporate members as this arrangement is meant for only retail / individual policy holders.

2). However, looking at the success of this arrangement, soon, this may get extended to corporate policy-holders too.  

3). Currently, only New India, Oriental Insurance & United India have agreed for following this network. National Insurance has their own ideas about how to implement this & hence, declined to be part of this network as of now (see news mentioned above).

What are the shortcomings of this system?

1). Cashless treatment becomes very useful when the treatment is costly. With no tertiary care hospitals in major cities being part of this Preferred Provider Network, members would be forced to raise the funds for cost of treatment before the treatment starts.

2). Cashless treatment has been one of the major attractions which has helped increased Mediclaim penetration in Urban & Semi-Urban India. With these kind of restrictions, the new policy sales may suffer an impact which is detrimental to overall claims experience. (New policies sale brings in premium without any claims in its initial years which help insurance companies improve their claims ratio.)

3). There is no proper methodology adopted for selection of these hospitals & many network hospitals are in dark about this change. Without any bench-marking, the quality of care may deteriorate & just for want of cashless, members may have to face inefficient service levels.

What should be done to implement this better manner?

  1. 1). A right mix of Tertiary, Secondary & Primary care hospitals should be ensured while finalising the city-wise Preferred Provider Network.

  2. 2). A stringent & transparent criterion should be adopted for selection of hospitals which should broadly look at following features:

    a). No. of Beds
    b). Infrastructure & Manpower quality
    c). Certifications & Statutory Compliances like minimum wages, PF etc.
    d). Published rates for various treatment & acceptance of Insurance Tariffs
     
  3. 3). A formal Third party annual audit & review methodology should be decided by the insurance company for these PPN hospitals.
  4. 4). In case of occurrence of fraudulent practices, the hospital should be banned for a period of three years and even reimbursement at such hospitals should not be allowed.

 

Summary

Though the initiative taken up by insurers has shaken up the hospital industry & made the consumers anxious, we have reasons to believe that this is a start of much needed changes in the Health Insurance industry. What we expect is well thought-out strategy derived out of data available with the insurers & then an efficient implementation of the same in phased manner to ensure that the consumer is not hassled unnecessarily. 

In case you have any queries, please feel free to connect with me at sudhir [at] medimanage.com


About Medimanage:

Medimanage is India’s first boutique health insurance broker, with an integrated service model which provides Unbiased Health Insurance Advisory, Technology based delivery and Professional Claims Assistance. To know more contact purandar [at] medimanage.com

 

More interesting news just today

Public sector insurers to push for a common claims settling agency (http://economictimes.indiatimes.com/personal-finance/insurance/insurance-news/Public-sector-insurers-to-push-for-a-common-claims-settling-agency/articleshow/6154912.cms)

  •  New Items for reference

Insurance Cos slash list of hospitals in Mumbai for making fraudulent claims(http://timesofindia.indiatimes.com/City/Mumbai/Insurance-cos-slash-list-of-hospitals-in-Mumbai-for-making-fraudulent-claims/articleshow/6145243.cms)

One PSU insurer stays with cashless Mediclaim

(http://timesofindia.indiatimes.com/India/One-PSU-insurer-stays-with-cashless-mediclaim/articleshow/6153259.cms)

 

 

Just read a story about experienced nurses migrating to developed countries in today's Hindustan Times, and found it very disturbing. I am no Healthcare expert, but common sense says that this definitely has large implications to the quality of Healthcare delivery in India. Nursing is an important and a niche profession in India, which has very few takers across the country (Have you heard of any little girl, saying she wants to become a nurse?) Migration can further mar the already bleak scenario of healthcare delivery in India.

Developed Countries have huge advantages as far as wages, working and living standards are concerned. Somethings that make experienced and talented people stop and stay back is the strong social network, stability or the belief in the India Story. 

The challenge that Hospitals and Healthcare in India face, is similar to a business, which employs freshers and takes them for granted (when they are new and when no one is willing to take them up) and later face a major challenge, when they arent able to retain staff, once they have got the good experience. 

If you have noticed, Nurses or "Sister" as we respectfully call them in our country, are generally emigrants most probably from Kerala. These people with their own sweet proprietory accent (in whichever language they speak to you), have already left their native and social circle for a job, and hence dont have a major social attachment. The language they speak is also different from what their patients speak. So what can really stop experienced nurses other than the attachment they could have with their peers and the organization they can work for?

Dissapointingly, if you read further in the same HT story, it also highlights that there have been 5 Strikes by Nurses in the last 6 months in New Delhi alone, which proves the dismal work conditions.

It seems no one cares for the Sisters of India, anymore. Sad.

Other sad highlights of Healthcare story:

1. India has a very low crisis like ratio of Healthcare Personnel to Population, a meagre 1.87 for every 1000 people. The Standard is 2.5. As per WHO, the risk of AIDS, Malaria, Maternal Deaths, Tubercolosis is multiply higher in countries where the Healthcare Personnel to Population ratio is low.

2. Nurses are so despondent for better living and working conditions in Inda, that they are ready to pay a one time fee of Rs. 50K to Rs. 500K to overseas job consultants, to get a job in a developed country.

Here's web link I could find to the entire article:http://www.hindustantimes.com/News-Feed/newdelhi/Nursing-a-foreign-dream/Article1-514546.aspx

Just yesterday, we were discussing Cholestrol levels in Medimanage Video Library Sessions. We discussed the thresholds, the causes, treatments  - the basics. The discussion reminded me of this article below from Forbes India, which touches upon, the umpteen number of instances, when Pharma companies lure Doctors to prescribe drugs, which may actually not necessary in the ideal sense.

Article reproduced "as is" below:

 

by Pravin Palande, Neelima Mahajan-Bansal, Shishir Prasad | Sep 14, 2009 | Original Article

When Radhika Nayyar, 47, at last agreed to take drugs to lower her cholesterol level, her cardiologist felt he had scored a mini victory. For months, the good doctor had tried to persuade her to go on a dosage of statins but she stoutly refused to do so. As the world’s largest selling drugs, statins have convinced millions of their power to reduce cholesterol and thereby the risk of heart attacks, but Nayyar is one of those other millions who believe them to be at best pills of dubious credibility and at worst, a tool of corporate conspiracy against humanity.

“Last time you ignored my prescription,” her doctor, a cardiologist, would say. “But one more time I’m requesting you to go on statins,” he would add painstakingly. But Nayyar would resist: “I am not classified as a heart patient. So why should I take drugs?”

Image: Abhijeet Kini

This sort of exchange went on several times before Nayyar’s cholesterol numbers became so high that she began to reconsider her decision. A compromise was then struck. She was put on a drug called Ezetimibe, a cholesterol lowering drug that is not a statin. It was only a partial victory for the doctor after all.

In Nayyar’s stubbornness lies the story of patients’ tussle with cholesterol and heart disease. Nobody argues with their doctors when put on medication because their upper blood pressure level is above 140 or blood sugar levels are above 140 milligram per decilitre (mg/dl). But when it comes to high cholesterol levels, people just don’t want to pop pills. Nayyar argued for long that she would change her lifestyle and her cholesterol would fall. That was never achieved.

The world over, cholesterol is one of the most controversial subjects in medicine and statins are among the most critiqued treatments. The connection between cholesterol and heart attacks is still challenged by some, but even among those who accept that link, there is a large group which says the pharmaceutical industry is raking in billions in profits by selling statins to people who don’t need them. These people say the fraternity of doctors also co-operates in this grand scheme. What’s the proof?

They point to the fact that the recommended cholesterol level has been lowered repeatedly over the last several decades. It is not that only laymen and activists hold this view. Some veterans in the business of mending hearts think so too. Dr. Devi Shetty, founder of Narayana Hrudayalaya which is the world’s largest centre for heart surgery, says the importance of statins as a drug to prevent heart attacks has been exaggerated. “Hundred percent it is the pharma companies. Pharma companies can influence the prescription process,” he says.

At the core of the debate is the threshold number for total cholesterol (TC) in a person that would require statin medication. This number is a blend of low-density lipoproteins (LDL), or “bad” cholesterol, and high-density lipoproteins (HDL) called the “good” cholesterol. For a person to escape statins, not only must the total cholesterol be low enough, but LDL should be within limits too. And the clinical world, after dozens of studies, has been lowering these threshold numbers bringing more and more people, previously considered healthy, under the category of cholesterol patients and statin pill-poppers.

Vishwas-Medimanage-MascotI took my first Life Insurance policy when I got my first salary in 1977. I guess some of you were not born by that time. My neighbourhood LIC agent, Vishwas got it done for me.

That was the beginning of a long, strong relationship of mutual respect. Since then, Vishwas has been taking care of all my insurances – all my subsequent Life Insurance policies, the insurance of the first Lambretta scooter I bought, my first Ambassador through to my current car, my home insurance, my health insurance.. the works. Vishwas has since become an integral part of my very family, present and participating in all my family functions and so on. So much so that, my son actually calls and considers him his ‘Vishwas Uncle’. When my son got a scholarship from MIT and went to US for studies, even his travel insurance was handled for me by Vishwas.

Much water has flown under the bridge since. My son is now married and settled in Florida. I had retired voluntarily and am living pretty comfortably with my wife. I have done proper financial planning for retired life, thanks again to help and guidance from Vishwas.

And then, this happened in January this year. I will probably never forget even the date – 10th of January. My son had taken his annual vacation and with family was boarding a transatlantic flight. From the airport he had called. It was late evening in India. My wife and I spoke to him, our daughter-in-law and the grand daughter. Half an hour after the call, my wife suddenly started complaining of breathlessness and discomfort. I took her to our family doctor. All it took him was two minutes of testing her to advise me that she needs to be admitted and may require an emergency surgery. I rushed her to the hospital. She was rushed to the ICU. About 15 minutes later, the hospital informed me that she is stabilized, but would need the surgery immediately. And they politely demanded I make a deposit of Rs. 1 Lakh. Obviously I did not have that kind of liquid cash in my bank account.

I did, of course, have a Health insurance, covering both of us, also taken through Vishwas. I tried contacting my TPA. I was told their cashless approval can happen only by Monday morning. My son was on board the flight – not reachable for hours to come. I tried reaching Vishwas. He was not reachable even after several attempts. That is when I realized that it was during that period of the year when he goes on his annual pilgrimage, and does not carry his mobile. My desperation was growing into despair. Finally, I spoke to my family doctor, who spoke to doctors known to him, who in turn spoke to doctors in that hospital. And by the time the hospital agreed to prepare my wife for surgery, it was Sunday morning.

Well, the surgery was a success, and my wife has recovered well. But, even today when I think of that traumatic Saturday night, I shudder.

By about March end, Vishwas came home to collect the installments on my Life insurance policies. I told him about my experience. He was very thoughtful when he left my house that day.

The next I met him was in June. He had dropped in for some coffee, and to remind me about my Health Insurance renewal due in July. Only this time, he did not ask for the cheque!!

‘What happened to Bhabhiji was a learning for me’ he said. ‘I recommend you Renew your Health insurance policy through a good broker.’

‘What? You do not want to handle this renewal??’ I was puzzled.

‘Like I told you, Bhabhiji’s hospitalization made me realize one thing. Health insurance is not like other insurances. If your car meets with an accident, and, because I am not available you have to contact the insurance company directly and their sending a surveyor takes a day or two more, heavens will not fall. You will be upset, yes, but, it will not be a life and death situation; with health insurance, it can be a life and death situation.

The day Bhabhiji got admitted unfortunately I was not available, but even if I was available, except probably helping you with whatever liquid cash I have, I could not have done anything better. And, I cannot go around lending my cash to everyone!

In your case, your doctor was able to help you, and so, at least by the next day the surgery was performed. This will not be the case with everybody, and the patient who meets with an emergency on a Saturday night may have to wait till Monday!!

You are not just a client, but also a good friend; so, even after that incident, you continue to patronize me. I cannot expect this to happen with all my clients.

So, if I remain greedy for the commission I get on the health insurance, incidences like this can result in my losing my client – and the client’s total portfolio!!

So, from that day on, I have been advising all my clients to get their health insurance renewed through a broker. Only, I advise them to be choosy about the broker and to go to that broker who is dedicated to health insurance instead of doing all and sundry business, that broker who has contacts not alone with insurance companies and TPAs but also with hospitals and nursing homes.’

If what Vishwas said so far surprised me, what he said next made me spill my coffee.

He said with a smile on his face ‘You won’t believe this but, when my Health Insurance came up for renewal in April, I got it renewed through such a broker.’

That day when I was listening to him, I was surprised. But since then, every time I think of this, I realize it made good business sense for him to do what he is doing. Typical of Vishwas.. full of business sense!!

Quacks in IndiaRoadside Unqualified Doctors thrive in India reports CNN India. This is actually not surprising. We have all witnessed unqualified on-the-job-trained so-called compounders while travelling to or through villages and small towns.

Where does this problem of unqualified doctors sprout from?

Apart from people traditionally depending on magic and supernatural as the last resort, the larger problem goes like this:

Bright students from interiors and rural areas with an ambition to become doctors travel to study in large cities due to lack of such education facilities in most of these locations. They get used to the lifestyle, the expenses and the works, and continue to practice in the “sheher”. It’s largely similar to an IITian going to US for further studies and settling down there. No wonder we notice more than 50% of the Talented Engineers blogging on the Google Blog being Indians.

Thriving of such unorganized 'services' also thrives on the simple demand-supply system. The no. of Doctors produced in India as compared to the demand and population is extremely low. Further, doctors have naturally and conventionally moved to lucrative urban areas in India and abroad, leaving rural areas without enough doctors.

So lower production of doctors coupled with migration of doctors to urban areas, is a larger problem, which affects rural healthcare.

Here goes the reproduction of the CNN Report.

New Delhi, India (CNN) -- Sitting on an iron bench along a busy street, Chaman Lal sticks his fingers into a mug full of a greasy concoction and then applies the dark-red brew to areas where his patients complain of pain.

Lal -- who does not have a license to practice medicine, but claims to be a successful bone doctor and traditional healer -- says this potion of 18 herbs is a cure-all. His large signboard, placed along the roadside, claims he can even treat paralysis.

"I have a special potion for polio as well. Although I don't get polio cases these days, but it can be cured with that potion and oil massage," Lal said as he rubbed the broken ankle of a young man with the potion.

Part of India's massive informal economy, these street-side medicine men and women are called quacks by the medical association here -- but they say they are traditional healers. They cater to a huge market of poor people who cannot afford costly private health care. The number of such practitioners is unknown.

"There's no firm estimate, but I can say that for every 100,000 qualified doctors in our country, there are 200,000 quacks," said Ashok Adhao, president of the Indian Medical Association. "The practice is condemnable."

Lal runs his clinic like many others practicing his craft: on the road. He doesn't have a nurse, disinfectants, a chair or a table, but people with broken limbs, ruptured muscles, cervical pain and back problems line up to be treated by him.

"I had multiple fractures five years ago. He cured me. I am back again for his treatment after suffering a fall that injured my ribs," said Balkar Singh, who was waiting for Lal to see him.

Lal pays some 3,000 rupees or US$60 a month in rent to a flat owner whose front yard he uses to run his open-air clinic. He earns about that much in one day from his patients -- a decent income in India.

"We are five brothers. We are all in the same occupation that we inherited from our father, forefathers," Lal said.

"I trust him," Amit Vij said of Lal, who was treating his broken ankle.

Practicing medicine without a license is a crime in India. Health authorities say they act against such practitioners.

"There are strict quality controls for health care in place and law takes its course (when violators are found)," said health ministry spokesman Dhiraj Singh.

Yet, unlicensed doctors thrive in the country primarily due to a lack of enforcement, said Adhao, of the medical association.

People are also likely driven to seek out such treatment due to over-crowded and short-staffed state-run hospitals, and costly care at corporate health care centers, Adhao added.

India's per capita income is about $750 a year, according to government figures for 2008-2009, or about $2 a day.

The average cost of a hospital visit in India is not clear, but the country's vice president, M. Hamid Ansari, said in a speech last year: "Though many such private hospitals have been provided government land at concessional rates and favorable customs and tax treatment, there are questions regarding their commitment to provide free or concessional treatment to poor patients."

In another Delhi neighborhood, numerous tents have been set up on footpaths, streets and under bridges where micro-clinics offer so-called "cures" for a variety of sexual conditions, mostly with their own herbal version of Viagra.

Banners hanging over the tents promise guaranteed treatment on cash and credit.

Inside are vials and jars full of powder, salts and herbs placed in order around images of Hindu gods and goddesses.

"We do face problems when police and municipal officers come. But we manage it" by paying bribes, said Shiv Kumar, a caretaker of a sexual disorder-treatment clinic.

Rajiv Singh, a clinic owner lying on a cot outside and under a bridge of New Delhi's prestigious Metro rail, said if his business starts to fall off, he will simply break camp and look for another location with potential new clients. Here, such a move is not a big deal.

He also said the work he and others like him are doing is effective.

"We are treating people for centuries now. Our treatment is there since ages," he said.

http://www.cnn.com/2009/WORLD/asiapcf/10/27/india.doctors.roadside/index.html

 

New Delhi, India (CNN) -- Sitting on an iron bench along a busy street, Chaman Lal sticks his fingers into a mug full of a greasy concoction and then applies the dark-red brew to areas where his patients complain of pain.

Lal -- who does not have a license to practice medicine, but claims to be a successful bone doctor and traditional healer -- says this potion of 18 herbs is a cure-all. His large signboard, placed along the roadside, claims he can even treat paralysis.

"I have a special potion for polio as well. Although I don't get polio cases these days, but it can be cured with that potion and oil massage," Lal said as he rubbed the broken ankle of a young man with the potion.

Part of India's massive informal economy, these street-side medicine men and women are called quacks by the medical association here -- but they say they are traditional healers. They cater to a huge market of poor people who cannot afford costly private health care. The number of such practitioners is unknown.

"There's no firm estimate, but I can say that for every 100,000 qualified doctors in our country, there are 200,000 quacks," said Ashok Adhao, president of the Indian Medical Association. "The practice is condemnable."

Lal runs his clinic like many others practicing his craft: on the road. He doesn't have a nurse, disinfectants, a chair or a table, but people with broken limbs, ruptured muscles, cervical pain and back problems line up to be treated by him.

"I had multiple fractures five years ago. He cured me. I am back again for his treatment after suffering a fall that injured my ribs," said Balkar Singh, who was waiting for Lal to see him.

Lal pays some 3,000 rupees or US$60 a month in rent to a flat owner whose front yard he uses to run his open-air clinic. He earns about that much in one day from his patients -- a decent income in India.

"We are five brothers. We are all in the same occupation that we inherited from our father, forefathers," Lal said.

"I trust him," Amit Vij said of Lal, who was treating his broken ankle.

Practicing medicine without a license is a crime in India. Health authorities say they act against such practitioners.

"There are strict quality controls for health care in place and law takes its course (when violators are found)," said health ministry spokesman Dhiraj Singh.

Yet, unlicensed doctors thrive in the country primarily due to a lack of enforcement, said Adhao, of the medical association.

People are also likely driven to seek out such treatment due to over-crowded and short-staffed state-run hospitals, and costly care at corporate health care centers, Adhao added.

India's per capita income is about $750 a year, according to government figures for 2008-2009, or about $2 a day.

The average cost of a hospital visit in India is not clear, but the country's vice president, M. Hamid Ansari, said in a speech last year: "Though many such private hospitals have been provided government land at concessional rates and favorable customs and tax treatment, there are questions regarding their commitment to provide free or concessional treatment to poor patients."

In another Delhi neighborhood, numerous tents have been set up on footpaths, streets and under bridges where micro-clinics offer so-called "cures" for a variety of sexual conditions, mostly with their own herbal version of Viagra.

Banners hanging over the tents promise guaranteed treatment on cash and credit.

Inside are vials and jars full of powder, salts and herbs placed in order around images of Hindu gods and goddesses.

"We do face problems when police and municipal officers come. But we manage it" by paying bribes, said Shiv Kumar, a caretaker of a sexual disorder-treatment clinic.

Rajiv Singh, a clinic owner lying on a cot outside and under a bridge of New Delhi's prestigious Metro rail, said if his business starts to fall off, he will simply break camp and look for another location with potential new clients. Here, such a move is not a big deal.

He also said the work he and others like him are doing is effective.

"We are treating people for centuries now. Our treatment is there since ages," he said.

 
Medimanage Health India Corporate Blog | Health India Blog | Health Insurance India Blog