Transcript Health Insurance in Maharashtra through Rashtriya Swasthya

Moving Towards Universal Coverage in India Rashtriya Swasthya Bima Yojana (RSBY)
Dr. Nishant Jain
www.rsby.gov.in
07.07.2015
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Role of the Government in Health Insurance
 Very Low penetration of Health Insurance (Less than 100 million
people covered with health insurance till 2007)
 Objectives of Government Funded Health Insurance
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Gradual Shift From Supply Side Financing to Demand Side Financing
Strengthening Public Health Care by bringing competition and incentives
Providing Power of Choice to the Beneficiaries in terms of treatment
Reduce OOPE on health care
 A health insurance scheme (RSBY) was designed keeping in
mind the characteristics of the beneficiaries
 RSBY was designed as a “Business Model” for a social sector
initiative
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Birth of RSBY
 Why RSBY designed such a way?
 Design a scheme based on the characteristics of the target segment
 Poor, Largely illiterate, Often migrant in nature
 It was doubly risky as none of the Govt. funded smart card
initiative or health insurance had worked well in India in the past
 Scheme was not forced on the State Governments it was
marketed to them and it took lot of time and effort
 It was decided to start the scheme in few districts in few States
but the larger picture was kept in mind
 Financial planning was done not only for the first stage but
projections were prepared for the full scaled up model
www.rsby.gov.in
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 Benefits
What is RSBY
 Cover for Hospitalisation Expenses of Rs. 30,000/- (US$ 650 ) per family
per annum on a family floater basis (Upto five family members)
 1020 pre-defined surgical packages including Maternity & Newborn Care
 Cover for Day Care Surgeries
 All Pre-existing Diseases to be covered
 1 day pre and 5 day post hospitalisation Expenses
 Transportation costs (Rs.100 per visit) with overall limit of Rs.1000 (US$
22)
 Sources of funding for program
 Rs. 30 (US$ 0.65) per family per year from Beneficiaries
 75% of Premium from Central Government
 25% of Premium from State Government
 Both Public and Private providers can be empanelled
 Beneficiary can get cashless treatment in empanelled hospital
www.rsby.gov.in
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www.rsby.gov.in
4. Selection through tendering
Government
of India
State Nodal
Agency
9. Submission of data and bill
Insurance
Company
10. Payment to Insurer
Beneficiary
Data
FKO
Health Care
Call
Centre
Awareness
Health
Camps
BPL
Beneficiaries
6. Issuance of
FKO Card
District
Kiosk
8. Download of FKO
Data at DKM server
Providers
DKM
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Key transfer
Verification by FKO by
fingerprint and smart card
FKO
Card
RSBY
Card
Data of Beneficiary family
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Enrollment Station
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Stakeholders and their Roles
Oversight of scheme
X
State
Nodal
Agency
X
Financing of scheme
Setting parameters (benefits package, empanelment
criteria, BPL criteria, etc.)
Hardware specifications (e.g. systems, Smart Card, etc.)
Contract management with Insurer
X
X
X
X
Central
Government
X
X
Accreditation/Empanelment of providers
X
Enrollment of Beneficiaries
X
Claims processing and payment
X
X
X
Outreach, Marketing to beneficiaries (Pre enrollment)
Awareness Building of beneficiaries (Post enrollment)
Service delivery of Health Care
X
X
X
X
X
X
X
Monitoring state-level utilization and other patient
information
X
Monitoring national RSBY information
X
Training
X
www.rsby.gov.in
Insurer
NGOs/
Providers
Other
of Care
Partners
X
X
X
X
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40 rue de Lille
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Current Status of RSBY Implementation in India
 Cards issued – App. 32.3 million
 People enrolled – App. 110 million
 Number of People benefitted till
now – App. 4 million
 Number of Hospitals Empanelled
– App. 10,100
 States where Service delivery has
started – Twenty Five
 Number of Insurance Companies
Involved – Fourteen
www.rsby.gov.in
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PREMIUM TRENDS in RSBY
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Conversion Ratio
100.00%
86.87%
90.00%
83.38%
78.63%
80.00%
71.27%
67.59%
70.00%
60.00%
56.27%
53.02%
55.86%
50.32%
50.00%
43.24%
40.00%
53.59%
56.09%
52.87%
47.46%
47.44%
43.83%
35.25%
45.74%
38.01%
33.07%
30.00%
20.00%
11.11%
14.05%
10.00%
0.00%
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High for
all the
districts
Conversion Ratio
100.00%
Large
variations
across districts
HP
Less variation
across Districts
90.00%
Kerala
Kerala
HP
HP
CG
80.00%
HP
HP
HP
70.00%
HP
Bihar
Bihar
Bihar
Bihar
Bihar
60.00%
Bihar
Bihar
Bihar
Bihar
Bihar
50.00%
Bihar
Bihar
Bihar
CG
HP
Nagaland
Kerala
Orissa
CG
CG
CG
CG
OrissaOrissa
Orissa
Kerala
CG CG CG
CG CG
CG
Bihar
CG
Kerala
Kerala
Kerala
Kerala
Kerala
Bihar
40.00%
Tripura
Tripura
Nagaland
HP
Bihar
Bihar
Bihar
Bihar Bihar Bihar
Bihar Bihar
Bihar
Nagaland
CG
Orissa
Orissa
Kerala
Kerala
Kerala
Kerala
Kerala
30.00%
20.00%
CG
10.00%
0.00%
0
10
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20
30
40
50
60
70
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80
Hospitalisation Ratio
 Access to hospitals have4.5
increased for RSBY
4
3.5
beneficiaries
3
 Districts which have
2.5
finished two years have 2
1.5
higher hospitalisation
1
 There is huge variations 0.5
across different States 0
www.rsby.gov.in
Hospitalisation Ratio
3.83
3.01
295 Districts 1st year
95 Districts 1st Year
1.92
295 Districts 1st
year
95 District 2nd Year
95 Districts 1st
Year
95 District 2nd
Year
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Hospitalisation Ratio
Hospitalisation Ratio for 295 Districts which have finished 1 Year
6.00
5.00
5.21
4.00
3.63
3.34
3.00
2.82
2.79
2.62
2.69
2.26
2.00
1.77
1.70
1.35
1.00
0.99
0.92
0.09
0.11
0.93
0.98
0.98
0.69
0.76
0.42
0.08
0.00
www.rsby.gov.in
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295 Districts where One Year
Completed
95 Districts where Two Years
Completed
Round 1
Balance With
Ins Co.
12%
Burnout Ratio for 295 Districts
Balance with
Insurance
Company
27%
Expenditure
by Insurance
Company
88%
Round 2
Expenditure
by Insurance
Company
73%
-25.98
125.98
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Hospitalization (Round1) vs. Enrolment (Round 2)
Category of Enrolment
change
No. of
Districts
Average
Hospitalizati
on
Increased
7
3.12%
3.40%
9%
Increased significantly
46
3.92%
2.26%
59%
Decreased
7
3.20%
2.37%
9%
Decreased Significantly
7
2.40%
1.93%
9%
Remains good
11
2.72%
2.40%
14%
Median
Percentage
districts
• Hospitalization in Round 1 is correlated with Enrolment in Round 2.
• The average hospitalization for districts where enrolment increased significantly
is 63% more than that of districts where enrolment decreased significantly
• Districts with large BPL population and above 2.7% hospitalization in round 2
should be ready for a higher or maintained enrolment in round 3.
• Districts with hospitalization less than 2% have to be made more aware if
higher enrolment is desired in the next round.
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Male - Female Distribution
Male- Female Enrollment
Male Female Hospitalization
100%
100%
90%
90%
80%
39%
45%
80%
70%
70%
60%
60%
50%
50%
40%
40%
30%
61%
55%
30%
20%
20%
10%
10%
0%
41%
44%
59%
55%
0%
Round 1
Male Enrollment Ratio
www.rsby.gov.in
Round 2
Round 1
Male Hospitalization Ratio
Round 2
Female Hospitalization Ratio
Female Enrollment Ratio
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Success So Far – Improving Access
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Improvement in access to Healthcare for targeted segment
In the worst naxalite affected areas also RSBY has been
able to provide benefits to people
There is a marked improvement in utilisation by women in
the scheme (more than 60% usage by women in northern States)
Out of pocket expenditure for health is coming down (Six
times lesser OOPE for RSBY beneficiaries than non-RSBY)
State Governments are improving their BPL list because
RSBY is bringing out the discrepancy
Able to provide social identity to people
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
Success So Far
Competition between Public and Private Hospitals
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Increase in capacity of private hospitals
Setting up of Hospitals by Private sector in remote areas
Use of IT ensure that Insurance Company and Government
gets data daily from the Hospitals
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Incentives for staff of public hospitals from Insurance money
Hospital retains the insurance money in the hospital and can be
used for the hospital by the hospital.
This data is analysed for patterns/ spikes and strong action taken
against errant hospitals
Cashless & paperless transaction for people
paperless claim process for hospitals
www.rsby.gov.in
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
Success So Far
Using Smart Card and Biometric technology successfully
for a social sector scheme at this large scale and thereby
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Portability of Smart Card across India
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Reducing Frauds/ errors
Improving targeting and
Stopping leakages
Migrant workers are now able to get benefit anywhere in India
(Split card)
Unique IDs are given to each RSBY empanelled hospital
Almost Real time data available from all over India
Standardised Templates and documents at Central level
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Satisfaction Level of Beneficiaries from RSBY
Himachal
Excellent
Very Good
Gujarat
Not Satisfied
Satisfied with the scheme
Not satisfied with the scheme
4%
17%
26%
Chhattisgarh
70%
Not satisfied
19%
Average
3%
Not Satisfied
with scheme,
23%
Haryana
Very Good/
Good
60%
Kerala Average
Good
5%
Satisfied with
Scheme, 77%
www.rsby.gov.in
83%
Excellent
18%
4%
Very
good
26%
Excellent
65%
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Survey Results – Gujarat
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More than 80% of beneficiaries had to spend less than one
hour at the enrollment station
92% of the beneficiaries told that RSBY staff at help desk was
polite and helpful
89.7% of beneficiaries that were enrolled but had not used
the scheme said that they will enroll next year.
98.3% of beneficiaries that had used the RSBY card said they
will enroll next year also.
83%of respondents said that they will recommend the same
hospital to their relatives where they received treatment
under RSBY.
88.9% of respondents who used RSBY said their out of
pocket expenditure on health came down because of RSBY
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07.07.2015
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Survey Results – Himachal Pradesh
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86% of enrolled beneficiaries were aware of RSBY
90% of the beneficiaries who were sick used RSBY card for
availing treatment
85% of people went to hospitals through referrals
Only 43% of hospitals had separate help desk for RSBY and in
other cases it was combined with existing reception
97% of the respondents reported that staff at the help desk
was polite and helpful
Only in 5% of cases transport allowance was provided
88% of respondents reported that they were provided food
at the hospitals
89% said that they will avail the facility in the same hospital
again
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07.07.2015
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Survey Results – Chhattisgarh
 98% of the respondents view that behaviour of staff at
help desk is polite.
 77.8% of respondents who were hospitalised were
provided free food during hospitalisation;
 95.1% of hospitals had separate RSBY help desk and 97% of
the respondents reported that staff at the help desk was
polite and helpful
 Only in 67.2% of cases transport allowance was provided
 88% of respondents reported that they were provided food at
the hospitals
 The home delivery was reduced by 35% amongst
respondents
www.rsby.gov.in
07.07.2015
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Challenges
 Beneficiary Data Preparation
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Improving the quality of data
Building on the previous year enrolled data for next year
Updating the BPL data
Preparing data for new categories
 Improving Enrollment
 Informing and motivating families to come and enroll
 Improving average family size
 Which intermediaries to engage for this purpose
 Capacity building.
 Designing different capacity building materials for different
stakeholders
 Organising separate training workshops for different stakeholders
www.rsby.gov.in
07.07.2015
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Challenges
 Information dissemination
 Designing and Implementing effective communication strategies
 Ensuring that beneficiaries are enrolled and know how to use the
benefits of RSBY
 Collecting feedback from beneficiaries
 Coordination with PACS Programme of DFID in Selected States
 Early Detection/ Prevention of fraud.
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Closely monitoring the hospital’s performance and trends
Identify early hospitals engaged in malpractices
Strict action against errant hospitals
Incentivising better performing hospitals
www.rsby.gov.in
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Future Plan
 RSBY is being extended to many other categories which
will be partially or fully sibsidised
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NREGS Beneficiaries
Building and Construction Workers
Railway Porters
Postmen
Domestic Workers
Street Vendors
Beedi Workers
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Extension and Expansion of RSBY
Tertiary Care
Private Insurance
RSBY
Fully Subsidised
Other Occupational
Groups e.g Taxi
drivers
B&
C
Wor
kers
Dom
estic
Wor
kers
Str
eet
Ve
ndo
rs
NRE
GS
Work
ers
Curative Continuum
RSBY
Partially Subsidised/
Non-Subsidised
Government Employees
Secondary Care
Primary Care/ Outpatient
Below Poverty Line
(30%)
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07.07.2015
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
Future Focus Areas for RSBY
For expenditures beyond Rs. 30,000 different State
Governments are linking with other funds/ schemes
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Improving the quality of service at the hospitals
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RSBY provides them a platform to transparently deliver this
Government of India has designed an Quality management system
Evolving a robust back-end data base management
Capacity Building at each levels for all the stakeholders
Cover OPD linked with RSBY (Experiments going on)
Store Health data on the smart card with proper security
Use the Smart Card for other targeted interventions and
provide subsidies like Life Insurance, Food Subsidy
www.rsby.gov.in
07.07.2015
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Future of RSBY Smart Card…….?
Common Storage Area
- Family demographic details
- Biometric details of RSBY family
RSBY
related
data
www.rsby.gov.in
Health
Card
related
data
PDS Data
Life and MNREGS
disability
Data
data
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Thank You
[email protected]
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07.07.2015
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