Served Insurance for the Poor

1. Served Insurance for the Poor HMO Model for Primary Care

2. Some Problems… • Health is not important priority in rural mindset, as compared to basic needs like food, livelihood and shelter • Insurance illiteracy- no concept of risk management • Feel that premium paid is money lost if unclaimed • Poor user experience due to exclusion criteria and unfriendly claim settlement process • No value in day to day healthcare requirements • Unknown, unseen provider difficult to trust without a local face • Recurring nature of premium payment • Compare with free services available at the govt. hospital and want everything free after buying insurance

3. Challenge… • Design a suitable product • Address the problems • Consider changing healthcare scenario & public sector initiatives • Target Voluntary enrollment and annual growth • Seek support/cost saving from collateral sources • Marketing and selling it • Well packaged with perceived value to the customer • Use parallel marketing & sales channels • Education/ awareness and sales campaign • Renewal incentives • Serving it well • At all levels • Transparency in transactions • Keep the costs low • Reduce administrative cost • Cross subsidization – Differential premiums, cross selling other products • Cost Sharing by the govt. or private donations or grants

4. PROBLEMS WITH RSBY • Little emphasis on building insurance literacy (which will build self responsibility for healthcare) - leading to poor utilization pattern and customer satisfaction • No local coverage for day to day needs like basic consultation diagnostic, drugs, Day-care procedures. Patient has to go all the way to the empanelled hospital for basics - spending on transport, loss of wages, food etc. which makes free consult meaningless. • Lack of co-payment leaves room open for moral hazard • No provision for public health measures, preventive and promotive interventions which actually reduced disease burden • Limited Coverage of 30,000 which may not extend to tertiary level care (which actually bears highest risk) • No control on the providers to follow best practices and may lead to high claim ratio • Missing the opportunity for meticulous patient record maintenance into a central database for further research and product/service refinement • The lack of gatekeeper function is major risk which insurance companies cover by hiking the premium

5. RSBY Model Govt. TPA Insurance company Hospital Network

6. CARE Model GOVT CARE consortium Insurance Company Hospitals Hospital Coordinator Brings expertise of understanding health care delivery and Insurance both & weave together a seamless service mechanism with highest possible efficiency that can be globally benchmarked Village Health Champion Network

7. RSBY Delivery only at district hospital level No focus on prevention No co-pay system No focus on early diagnosis and disease management locally No support to clinical practice guidelines (CPGL) and improving standard of care Fragmented user experience Higher risk to Insurance companies, thus they demand higher premium The coverage remains low and may not extend to tertiary level care if needed. Limited information exchange CARE Consortium Village & district level delivery mechanism Save claims rate by prevention Reduce moral hazard by co-pay Save hospitalization by treating timely and locally Control hospital bills by emphasizing CPGL with daily peer review and DRG system Build seamless user experience Negotiate better rates with back-end insurer/s Benefits of cost savings passed on to the consumer as increased coverage (up to 1.5 Lakhs) Transparency of each transaction between partners Differentiators

8. The service network • Central Call center and claims office • Hospital level coordinator with HIS/EHR interface • Mobile enabled Village Health Champion • Telemedicine 24x7 • Survey & Data Collection • Coordinate Periodic Camps • Transport facilitation • 6 Preventive interventions • Drinking water • Vector control, Toilets and Public drains • Reproductive health • Vaccination • HT/DM control • Health Education,

9. Coverage • Preventive care interventions, education and discounts on products like water filter, nutritional supplements, bed-nets, mosquito repellants, toilet construction etc. (Channel partnerships) • Eye and dental treatment at camps (Channel partnerships) • OPD- Free Consult, Free + Discounted Medications, Diagnostics • Pre hospitalization care – Guidance, First Aid, Transport • Facilitate Hospitalization for families uncovered by RSBY or Diseases uncovered by RSBY at the Govt. Hospital/ Medical College (facilitate the treatment and support with drugs or disposables etc. not available there upto an amount of … Rs.) • Post Hospitalization Medication - ensure delivery and intake • Coordinate with ongoing programs and govt. schemes • Wage Loss compensation • Death & Disability compensation • Child Survivor benefits (education/marriage) • Savings Component

10. Risk control • Biometric identity validation • Doctor does the triage and screening (Virtual Gatekeeper) • Self managed –no TPA (may involve standard Insurance agency as back-end risk career) • Strong IT based management • Easy to treat illness managed locally • Transactions done through mobile banking (for co-pay) • We clearly document what if scenarios to avoid hassles • Tertiary referrals, non-availability of service, co-pay refusal, inappropriate claim etc. • Second Insurance for epidemics

11. Premium calculation • Paid by user (co-pay) & Govt. • Family floater – Premium based on family size and composition • Based on RSBY cover • Premium for BPL subsidized by Govt. • Non BPL may pay full premium. • Expenses to be covered • Education and enrollment campaign costs • Claim processing fee , administrative charges • Premium to back-end insurer and second insurer • Other expenses for the network for an year

12. Virtuous cycle for renewal

13. Moving forward the PPP way… • We will start with building health demand, ensuring good user experience with an innovative insurance product that brings immediate benefits to the Govt. and people alike. • 2nd phase we can enter in to agreement for managing PHCs and build capacity for delivering efficient services at grassroots • 3rd Phase – we will construct hospitals of NABH standards in each town & district to increase bed capacity and link them to primary care network & tertiary care hospitals • 4th Phase – World class center of excellence for training and capacity building – Its agenda would include research, innovation and tool development for making healthcare cost-effective and equitable for Indian Masses.

14. Give us a chance to transform … THANKYOU