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Cashles Chaos: Making sense of it all

News Flash:  “The General Insurance Public Sector Association consisting of four major state-run insurance companies - United India, New India, Oriental Insurance and National Insurance have decided to stop cash-less hospitalization in most hospitals”

Shock and outrage are the two words that describe the reaction of most of the customers and media reports on this piece of news.  We demanded to know how insurance companies could take such a decision one fine day, and what would the customer do. 

Before creation of PPN (Preferred Provider Network  by the Public health insurance companies, media and the industry experts were congratulating the sector for the phenomenal growth. It is this decision which has caused a huge backlash from all around- ustomers, hospitals, media and other insurance experts.

Cashless Chaos: The Blame Game

Let’s understand the issue:

There have been various reports about overcharging by the hospitals and the lack of standard pricing. The TPAs as well as the hospitals have been blamed by everyone for being the perpetrators for the huge losses faced by the insurance industry in their health portfolio. And now, without as much as a warning, the public health insurers have delisted most of the hospitals from their existing network of hospitals, creating PPN.

Insurers’ Stand: Insurance industry faces losses amounting to  thousands of crores each year now. Last year the losses further skyrocketed  and for these losses the Insurance industry is blaming the lack of standardized pricing in hospitals along with the trend of hospitals to overcharge the insured patients.  GIPSA has also criticized the TPAs overall efficiency in keeping the claims down.

Hospitals’ Stand: The corporate hospitals believe that they are being unfairly targeted by the health insurance companies., They argue that the price they charge is proportional to the quality of care they provide. Since the kind of care in a 100 bed hospital with latest technology will be different from that in a 15 bed hospital, cost of healthcare in a large, private hospital is more.

TPA’s Stand: TPAs are being blamed of everything from inefficiency to not controlling fraudulent claims. There is immense amount of pressure on TPAs to bring down the claims and there is talk that the PSUs may opt for a single common TPA. Abhitabh Gupta, CEO, Paramount TPA says “ TPAs cannot be blamed for the losses primarily because, most of the PSU Insurance companies had underwritten health insurance at an extremely low cost sometimes even selling Rs. 1 policies, so it is but natural that they would suffer from losses. Further medical inflation has been increasing at a rate of 10-15 % while the premiums are not increasing at the same rate.” He says TPAs weren’t given the rights to meddle with the treatment and unless there is some change in their role, TPAs can’t do much.

Customer’s stand: Customers are caught in the crossfire between Hospitals and Health insurance companies and they feel cheated. Since Cashless facility is now limited to extremely small number of hospitals; customers have to pay the medical bills from their own pockets and then claim reimbursement.

With Brokers being the neutral catalysts in the health insurance domain, we sought theopinion of Sudhir Sarnobat, Founder of Medimanage Insurance Broking Pvt. Ltd on this issue:

Whether Health insurance companies are justified in delisting the hospitals in the middle of the policy:“The policy periods are of one year and at any point you take a decision, itwill be mid-term for some members and hence, we cannot hold insurer responsible for this. People look at benefit of insurance claim and that’s the core product which insurer is not refusing. If insurer finds issues with non-core benefits, they have the right to tinker with them.

Also, Health Insurance in India is currently in nascent stage and hence, the stable decision making would take a little time. One MUST not forget that this portfolio is loss-making and hence, under pressure to reduce losses, insurers are taking some sudden decisions as they are not too worried about consumer reactions”  

Blame game between insurance companies and hospitals

On Corporate Hospitals taking advantage of the system:I think that these corporate hospitals have taken advantage of the system and not offered negotiated rates when insurance is their single largest customer. It’s actually clash of egos and I think after 3-6 months, both Insurers as well as Hospitals will come to sense and will resolve this in an amicable manner when the industry bodies will act as mediators. I think IRDA may also step in”.

 On Grading of Hospitals: “The grading is a very common concept and it will help manage the cost of treatment well and will help in creation of centers of excellence. Why should a person go to Lilavati (Premium hospital in Mumbai) hospital for Hernia just because he has bought 5 Lakh or 10 Lakh cover. It’s a secondary care procedure and hence, should be managed in a  secondary care hospital.”

On the impact of this move on the customer: This (move) may bring the malpractices and over-billing to check. However, I would maintain that you need to have tertiary care hospitals in network as smaller hospitals do not have the facilities, infrastructure and manpower to manage complex procedures. “

On 10.3% of Service tax for Cashless Facility: “That’s not fair as its an additional burden. It’s discriminatory as it’s meant for Cashless Insurance patients only. But as it’s a decision by Union Government, the consumer forums/bodies should take it up with Government.”

On whether this move to curtail hospitals in the Network list will make Health insurance unattractive:
“It’s a need of the hour and once the insurance penetration and clout increases, hospitals will try to be compliant with Insurers’ requirements. This would bring in cost consciousness along with customer focus. The churning what we are seeing now is good for long term sustained development of the industry and hence, one should not look at this as negative or unattractive”

 

Timeline for Cashless Hospitalization issue:

July 1: GIPSA (General Insurance Public Sector Association) delists most of the Private hospitals in Delhi, Mumbai, Bangalore and Chennai from their PPN (Preferred Provider Network) list. (Of the 800 hospitals in Mumbai only 90 remained)

July 13: Insurance Company leaders and Top Corporate hospitals met to increase the number of hospitals in the list.

  • It was decided that there would different grades of hospitals depending on the quality of health care provided; there would also be a common rate card across the hospitals.
  • It was decided to revive the cashless facility on a case to case basis.

July 15: A Public notice by Public Insurance companies made it clear that Cashless Facility will only be resumed once the hospitals adhered to the conditions of the Insurance companies. 

July 18: There is news that even Private insurance companies are looking at joining the PPN Network.

 

overcharging hospitals

What is the first thing that the hospital staff asks you as you try to get your close one admitted? Along with the other questions about name, age, symptoms experienced, there is one question that they do not fail to ask, “Do you have health insurance?” The answer to this question has more implications on your final bill than you can imagine. We try to understand what goes behind if the answer to the question is yes!

The Trend:

The scenario today is that health insurance which is meant to relieve the financial burden incurred as a result of hospitalization actually has become a source of malpractice and mismanagement. 

Due to the inefficiency of the Public healthcare system, patients have increasingly started to opt for the private health care institutions their health needs. In the absence of a body controlling their rates, some of the hospitals are found to charge their patients in an ad-hoc manner. There is no rate card that will serve as a bench mark for charging customers. Thus the hospitals have the liberty to charge different rates to different patients gauging their paying power.

Malpractice by Hospitals, Doctors

The gross inefficiency does not end here, some hospitals hike up their fees when it is clear that a patient is covered under health insurance.

Sometimes the doctors hike up their fees as much by 3 times when he is charging an insured patient as the medical charges do not come under the income tax purview.

Sudhir Sarnobat, Co-founder and Director of Medimanage Insurance Broking Ltd gives insights into the way hospitals go about overcharging an insured patient,

No Choice of Room: All hospitals have separate standards for rooms viz of rooms like common, twin-sharing, deluxe and super deluxe. A patient should get to choose his /her room based on their budget and acceptability of comfort required during hospitalization.

Many of the hospitals deny the common and twin sharing class to members who have insurance under the pretext that it’s their policy. Even if the patient is not availing cashless facility, the doctors ask the patients whether they have insurance (and all patients without understanding the implication, nod in affirmative) and then direct them to a room category that is more expensive.

Different rate cards: Some small and medium hospitals maintain different tariffs which are mainly classified in three categories viz. Self-Paying, Insurance (Reimbursement) and Insurance (Cashless). The tariff is lowest for the self-paying patient and is called as base tariff. It’s loaded by 10-15% for Reimbursement Patients and then loaded by another 10-15% for cashless patients.  Some big hospitals do have similar practices but they do it in a subtle manner.

medical bills

Doctor’s Consultation charges: Small hospitals have visiting surgeons whose fees are mostly never published in standard tariff. Some of these hospitals inflate the doctor’s fees based on the patient’s status i.e. charge higher fees for those patients with health insurance. There are two management modalities followed in India, one is Full Time Consultant model where the doctors who are attached at one hospital cannot work for any other hospital. The doctor’s fees are generally fixed in such models. Second model is visiting consultants who are attached to multiple hospitals and admit their patients based on patient’s capacity to pay. Big hospitals have visiting surgeons who do not have fixed fees and hence doctors themselves decide the fees to charge.

Unnecessary Hospitalization: Some hospitals also push an insured patient for admission in the hospital (as only then insurance pays for treatment) where the same may not be needed. This is another form of exploitation of insured patients.

Unnecessary medical tests: Some hospitals go for excessive investigations when the patient is insured. They also make patient get involved in investigation chasing (due to structure of Human body, some or other parameters are going to be up or down based on various conditions). This is normally acceptable so long there is no major complaint from the patient. But in cases where doctors find insured patient’s parameters little excessive, they ask for further investigation and go for treating these parameters through medications and interventions.

With all the kind of malpractices rampant with the hospital bills, it is the insurance companies who are facing enormous losses due to both high claims ratio and fraudulent claims.

What do the TPAs say?

TPAs

Third Party Administrators are given the responsibility of accepting the claims and settling the valid ones by the Insurance Companies hence we asked, Mr. Madhavan, COO of Mediassist one of the leading TPAs about this problem. Mr. Madhavan said “there is some discrepancy in the charges between the bill of insured and uninsured but only in some hospitals.  Initially there was a lot of discrepancy in the charges but after the intervention of the TPAs we find that mostly only Tier 2 Hospitals indulge in it than the Tier 1 companies.” He believes that once the industry observed the trend and presented the hospitals with the data about the inconsistency, the hospitals agreed to follow a tariff and TPA with their consolidated data have a control over the costs.

 On where does the discrepancy creep in, Mr. Madhavan believes that it is more in cashless claims where it is a kind of emergency and there is very little time frame in passing the claims, in reimbursement claims the patient pays the bills from his pocket so he negotiates with the hospital and the additional time frame gives a good chance for the TPA to review the case. 

Effect of this trend

Short Term:

This trend of overcharging patients with health insurance coverage will affect the customer both in the long term and short term. In the short term, if he is charged for a disease for example for cataract for about Rs. 50,000 then he is left only with Rs.50, 000 cover if he has taken a 1 lakh cover. Thus an overcharged bill has a negative impact on your cover amount especially if it is a family floater or if the sum assured is less.

Long term:

Sudhir Sarnobat explains the long term effect of extorting money from the insurance cases, he says that the higher cost of treatments of insured patient means that the claims are higher; this he feels will either force the insurance company to limit the benefits or increase the premium. Both of these conditions will affect the penetration or viability of health insurance to people. He says, “The important element of success of insurance is to have the maximum population insured but that gets defeated when insurance becomes unattractive to buy. That further leads to only needy buying the insurance because they only see the benefit in buying costly and restrictive cover, who in turn go for claim which further increases claims.”

What are the TPAs/Insurance companies doing to tackle this problem?

Mr. Madhavan says “We are constantly in talks with the hospitals which are in our network; they share the tariff card with us so we know about their standard charges.” About the Doctor’s consultation fees, he says, “when we make package deals with the hospitals in our network, we not only negotiate the tariff but also fix the rate of consultation charges.”

About the further measures to be taken, he says, “there is lot that can be done to tackle this problem, TPA can convince more hospitals especially the commercial hospitals to give discounts and other measures to reduce the prices.”

On the other hand, Sudhir Sarnobat feels that the problem can be tackled through the education of the insured so that they know what are the limits to the expense for a particular disease for example, if the patient informs the hospitals that the limit on the cataract treatment in his policy is Rs. 20,000, the hospital either has to charge reasonably or the patient shifts to other hospital. The other solution that he provides is that there should be a regulatory board for hospitals like IRDA in insurance that will control the hospitals and bring some transparency in its operations.

With no near end of this problem of overcharging insured patients, the Insurance companies and the TPAs have to do their best to reduce the claims, whatever they do, it is the insured who faces the brunt.

heart diseases affecting the youngWith India close to becoming the number one destination for heart diseases, now even young Indians are falling prey to heart diseases. Longer working hours, unhealthy eating habits and major lifestyle changes are leading us towards the ominous position of being the only nation in the entire world which will contribute for about 60% of all heart diseases patients by the year 2015!

In a study conducted by Merwin Hosptial, Hyderabad it has been  found that 50% Indians suffer from their first heart attack before the age of 50 and 25% suffer from their first heart attack by the age of 40! So what really are the reasons for these alarming figures and heart diseases affecting the younger population of India?

To know more, click here…

heart diseases plaguing indiansThe sudden death of Indian origin, UK labour MP, Ashok Kumar due to an ischemic heart condition has once again put the spot light on heart diseases that are plaguing Indians! We Indians fall in the South East Asian belt which is notoriously weak hearted. For examples sake, in the year 2000, more than half of the 16.7 million heart disease related deaths occurred in South Asia alone. Another report to reiterate the fact that we as Indians are becoming more and more susceptible to heart diseases, is that India is expected to lose around 2 million people to coronary deaths by the year 2010.

What do these numbers and sudden deaths of seemingly fit Indians, as in the case of SAP CEO Ranjan Das highlight? The answer though seemingly simple is quite disturbing, these news and alarming facts point towards a trend which is seeing more and more Indians falling prey to heart diseases! Reasons being changing lifestyles and diet structures along with lack of physical activity and the genetic make-up; while not much can be done about our genes that showcase inherent lipid abnormality which greatly increases our chances of suffering from heart diseases. (However experts have added that poor lipid levels can be modified by the intake of a proper well balanced diet.) In a recent study designed by Apollo hospital and conducted by IMRB, it was found that 40% of Indians were at a high or moderate risk of a heart disease.

With the dice being so loaded against us, what do we do to prevent heart diseases? Following are some simple guidelines that will help us to prevent the occurrence of heart diseases in ourselves!

  • SMOKERS – whether of cigarettes, pipes or cigars – are more than twice at risk of a heart attack than non-smokers.

Studies have found that even one to two cigarettes a day greatly increase the risk of heart attack, stroke and other cardiovascular conditions. Non-smokers who are exposed to constant smoke also have an increased risk. If you quit smoking, the health benefits start almost immediately, and within a few years, your risk of stroke and coronary artery disease becomes similar to non-smokers’.

  • EXCESSIVE lipids (fatty substances including cholesterol and triglycerides), especially in the form of LDL cholesterol, cause the build-up of fatty deposits within your arteries, reducing or blocking the flow of blood and oxygen to your heart.There is a sharp increase in the risk of cardiovascular disease when total cholesterol levels are 240 mg/dl and above. Aim for a total cholesterol level of less than 200 mg/dl. LDL cholesterol should be less than 70 mg/dl for patients at very high risk of cardiovascular disease. For all others, LDL cholesterol should be less than 130 mg/dl.

Triglyceride is a form of fat. People with high triglycerides often have a high total cholesterol level, including high LDL (bad) cholesterol and low HDL (good) cholesterol levels. Triglyceride levels should be kept below 150 mg/dl. It is recommended that you have your cholesterol level checked as early as age 20 or earlier if you have a family history of high cholesterol. The cholesterol profile includes an evaluation of total cholesterol, HDL, LDL and triglyceride levels. HDL cholesterol takes the LDL (bad) cholesterol away from the arteries and back to the liver, where it can be passed out of the body. High levels of HDL seem to protect against cardiovascular disease.Aim for HDL levels greater than 40 mg/dl; the higher the HDL level, the better. An HDL of 60 mg/dl and above is considered protective against heart disease.

BLOOD pressure measures the pressure or force inside your arteries with each heartbeat.

High blood pressure increases the workload of the heart and kidneys, increasing the risk of heart attack, heart failure, stroke and kidney disease. Aim for a reading of 120/80 mmHg or lower (high blood pressure is 140/90 or higher). Control blood pressure through diet, exercise, weight management and, if needed, medication. DIABETES occurs when the body is unable to produce insulin or use the insulin it has. This results in elevated blood sugar levels. Those with diabetes have a higher risk of cardiovascular disease because diabetes increases other risk factors, such as high cholesterol, LDL and triglycerides; lower HDL; and high blood pressure.

Keeping diabetes under control is essential in reducing your risk. The more you weigh, the harder your heart has to work to give your body nutrients. Research shows that being overweight contributes to the onset of cardiovascular disease. Excess weight also raises blood cholesterol, triglycerides and blood pressure, lowers HDL cholesterol and increases the risk of diabetes.

  • VEGETABLES and fruit are high in vitamins, minerals and fibre – and low in calories.

Eating a variety of fruit and vegetables may help you control your weight and your blood pressure. Unrefined whole-grain food contains fibre that can help lower your blood cholesterol and help you feel full, which may help you manage your weight. Eat fish at least twice a week. Recent research shows that eating oily fish containing omega-3 fatty acids (for example, salmon, trout and herring) may help lower your risk of death from coronary artery disease.

Choose lean meat and poultry without skin and prepare them without added saturated and trans fat.

  • THE heart is like any other muscle – it needs a workout to stay strong and healthy. Exercising helps improve how well the heart pumps blood through your body. Aim for moderate exercise 30 minutes a day, on most days.

Exercise should be aerobic, involving the large muscle groups. Aerobic activities include brisk walking, cycling, swimming, jumping rope and jogging. However, consult your doctor before starting any exercise programme.

Sources: Hyderabad News, TOI.

heartFormer U.S. president Bill Clinton recently underwent surgery for a heart procedure. The 63 year old, was admitted to the New York-Presbyterian Hospital for the placement of two stents in a coronary artery! While the news came as a shock to the world, it was a routine procedure for the doctors at the hospital, as Clinton had earlier undergone a quadruple bypass surgery at the same hospital in 2004.

This news made headlines because it was the former president of the USA, who underwent a heart surgery. But did you know that the WHO (World Health Organization) has predicted that India is going to account for 60% of the entire world’s cardiac patients by this current year! The reason being, India falls under the group of South East Asian countries belt, which are notorious for having elevated levels of LDL cholesterol and triglycerides, while also suffering from a deficiency in HDL cholesterol (good cholesterol, which helps clear fatty buildups from blood vessels).

 Not only this, but we also tended to gain weight around the abdominal region thereby, greatly increasing our risk of heart disease. Other factors include low birth weight and malnutrition which increases our risk of diabetes and heart attacks in adulthood! So how does one identify the symptoms, which can lead to a heart disease? Following are 12 possible heart symptoms that one shouldn’t ignore:

12 Possible Heart Symptoms Never to Ignore

Here are a dozen symptoms that may signal heart trouble.

1. Anxiety. Heart attack can cause intense anxiety or a fear of death. Heart attack survivors often talk about having experienced a sense of "impending doom."

2. Chest discomfort. Pain in the chest is the classic symptom of heart attack, and "the No. 1 symptom that we typically look for," says Jean C. McSweeney, PhD, RN, associate dean for research at the University of Arkansas for Medical Sciences College of Nursing in Little Rock and a pioneer in research on heart symptoms in women. But not all heart attacks cause chest pain, and chest pain can stem from ailments that have nothing to do with the heart.

Heart-related chest pain is often centered under the breastbone, perhaps a little to the left of center. The pain has been likened to "an elephant sitting on the chest," but it can also be an uncomfortable sensation of pressure, squeezing, or fullness. "It's not unusual for women to describe the pain as a minor ache," McSweeney says.

Women, more so than men, can also experience a burning sensation in their chest, rather than a pressure or pain. "Sometimes people make the mistake that the pain comes from a stomach problem," says Nieca Goldberg, MD, clinical associate professor of medicine at the NYU Langone Medical Center in New York City and another expert on women's heart symptoms.

3. Cough. Persistent coughing or wheezing can be a symptom of heart failure -- a result of fluid accumulation in the lungs. In some cases, people with heart failure cough up bloody phlegm.

4. Dizziness. Heart attacks can cause lightheadedness and loss of consciousness. So can potentially dangerous heart rhythm abnormalities known as arrhythmias.

5. Fatigue. Especially among women, unusual fatigue can occur during a heart attack as well as in the days and weeks leading up to one. And feeling tired all the time may be a symptom of heart failure. Of course, you can also feel tired or fatigued for other reasons too! But it is better to clear up the reasons for feeling fatigue all the time, with your doctor.

6. Nausea or lack of appetite. It's not uncommon for people to feel sick to their stomach or throw up during a heart attack. And abdominal swelling associated with heart failure can interfere with appetite.

7. Pain in other parts of the body. In many heart attacks, pain begins in the chest and spreads to the shoulders, arms, elbows, back, neck, jaw, or abdomen. But sometimes there is no chest pain -- just pain in these other body areas. The pain might come and go. Men having a heart attack often feel pain in the left arm. In women, the pain is more likely to be felt in both arms, or between the shoulder blades.

8. Rapid or irregular pulse. Doctors say that there's nothing worrisome about an occasional skipped heartbeat. But a rapid or irregular pulse -- especially when accompanied by weakness, dizziness, or shortness of breath -- can be evidence of a heart attack, heart failure, or an arrhythmia. Left untreated, some arrhythmias can lead to stroke, heart failure, or sudden death.

9. Shortness of breath. People who feel winded at rest or with minimal exertion might have a pulmonary condition like asthma or chronic obstructive pulmonary disease (COPD). But breathlessness could also indicate a heart attack or heart failure. "Sometimes people having a heart attack don't have chest pressure or pain but feel extremely short of breath," Goldberg says. "It's like they've just run a marathon when they haven't even moved." During a heart attack, shortness of breath often accompanies chest discomfort, but it can also occur before or without chest discomfort.

10. Sweating. Breaking out in a cold sweat is a common symptom of heart attack. "You might just be sitting in a chair when all of a sudden you are really sweating like you had just worked out," Frid says.

11. Swelling. Heart failure can cause fluid to accumulate in the body. This can cause swelling (often in the feet, ankles, legs, or abdomen) as well as sudden weight gain and sometimes a loss of appetite.

12. Weakness. In the days leading up to a heart attack, as well as during one, some people experience severe, unexplained weakness

Sources: WebMD and Express Healthcare Management.

 
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