Transcript Slide 1
Seminar On Micro Insurance Presented by : APV Reddy CEO Family Health Plan Ltd. 15th Oct 2005 Healthcare Spending Other sources Employers 1.2% 0.8%ESI 1.4% Govt. 20.7% Municipalities 0.5% External Aid 0.5% Out of pocket 75.2% Over 75% out of pocket payment..…Indicator of potential for Health Insurance Source: Peter Berman 1996 • 2% of APL Indian fall into BPL every year due to Health care indebtedness - Express Healthcare Management 2004 • Health care expenditure is the second cause for Rural Indebtedness - NCAER • 24 % of Hospitalized Indian are pushed into indebtedness due to Healthcare expenditure - World Bank How does the Health Insurance Industry looks today Around 9% population is covered…… Traditional Insurance (Mediclaim) 1% ESIS & CGHS 3% Railways 1% Social /Mandatory Insurance 4% NGO/CBHI (Self funded) 1% How does the Health Insurance Industry looks today • • • • • • • • • • ESIS CGHS Railways Defence Employees Ex Servicemen Mining & Plantations State Sponsored Schemes Employer Reimbursement schemes Community Based H S Health Segment of Life Inc 253 43 80 66 75 40 5 140 30 2 • • Health Ins PSU Health Ins Pvt Cos 100 30 • TOTAL 864 Lakhs Market place Indian Population 30% BPL 70% APL 50% lower Middle class Public Hospitals /Trust Low cost Hospitals 40% Upper Middle class Moderate cost, high tech 10% Elite class High cost, high tech, Frills Economic levels are major drivers in the Health care industry Indian Population – Rural Vs Urban Urban -27 % Rural -73 % So far…… emphasis of organized health insurance has been in Urban areas for multiple reasons Urban India- Segmentation Above Poverty Line COVERED URBAN Above Poverty Line 270 mn UNCOVERED BPL UNCOVERED Source: Census India Mediclaim CGHS ESIS PSUs State Govt. Defense Self Employed Employed but not covered Urban Poor 90 mn lives 90 mn lives 90 mn lives Rural India - Segmentation Organized 60% ( 430 mn) 360 mn Farmers Above Poverty line 530 mn Unorganized 170 mn RURAL 730 mn Organized Below Poverty Line 130 mn 200 mn Unorganized 70 mn Source: Census India What India needs for a achieving a significant Health Insurance coverage Innovative Product •Community based products •Social Insurance •Coverage for Out-patient •Integration of Inpatient & Out-patient What India needs for a achieving a significant Health Insurance coverage Claims Management Medical Pre-authorization Call Centre Cashless Network MIS Photo ID Card TPA Healthcare Spectrum Preventive care Vaccination Check-ups Heath camps Consultation Out-patient care Investigations Pharmacy Medical In-patient care Surgical All the existing Models cater to the In-patient requirement only Suggested Plan •Govt has to play a role in social & preventive medicine •Govt. hospitals capable of handling medical treatment •Surgical treatments are expensive •Lack of surgeons in Rural Hospitals Medical Surgical Number of cases 58% 42% Expenditure 23% 77% Hence Health Insurance cover for…… Surgical treatment Relevant Medical treatment Suggested medium Co-operative Societies Banks/ NABARD Co-operative Banks 30% rural Indians avail Banking services ( 41.6 million families) Almost 100 % villages are covered under co-operative fold 67% of rural household are members of Co-operative institutions 7% of the Farmers have Kisan credit card Over 35,000 branches of 560 banks located in 563 districts in 30 states Source:NABARD.microfinance.2004 Provider of healthcare services Govt. Hospitals Private Hospitals Public Private partnership Nursing Homes Network of hospitals - both private and government across the country to facilitate delivery of treatment to the rural poor at their door step…… Yeshasvini - Features 1600 Surgical procedures 100 % Cashless treatment In Top Quality Hospitals Free Outpatient Consultation Standard rates at Private Hospitals Largely Discounted Lab Tests Easy Access User friendly Membership for Registered member of State Co-operative society for minimum 6 months Dependant family members Age limit- Upto 80 yrs Product features Cost of Medicines & consumables during hospital stay Cost of Operation Theater ,Anaesthesia, Surgeons fee Professional charge: Consultant fee, Nursing fee Accommodation Entities involved Govt. of Karnataka Implement Administer Network Hospitals FHPL Dept. of Co-operative Implementation of the Scheme Trust Dept of Co-op Family Health Plan Ltd (FHPL) Governing Body Fund maintenance & Disbursement Periodic review Member identification Membership protocol- collection of Fee Feed Back Administration Claim processing Services to member Reporting – MIS Periodic review Provider of healthcare services Cashless treatment Special discounted tariff for medical treatment Network hospitals Preferential treatment Free Out-patient consultation Discounted Lab charges Exclusive front desk counter 2003-2004: -114 Hospitals 2004-2005:- 137 Hospitals Hospitals spread across 30 Location All hospitals follow single rate list for defined surgical procedure STATISTICS Yeshasvini Co-operative Farmers Health Care Trust Jun 03 - May 04 Numbers No of Mems Enrolled Value Rs. 1,601,152 Jun 04 - May 05 Numbers Value Rs. NO’s Value Rs. 2,021,661 Contribution collected 96,909,491 119,755,440 Govt Contribution 45,000,000 35,788,000 3,743,622 4,880,368 Interest Total for 2 years Cont frm CO OP soc 6,296,177 Contrbution from SBM 300,000 Total Amt Collected 145,653,113 167,019,985 312,673,098 Claim Status Claims Settled Bills Pend for pyment Total 8,996 105,385,417 13,632 162,317,166 12 97,000 1,232 16,971,603 9,008 105,482,417 14,864 179,288,769 0.56 Free OPD Treatment 35,814 23,872 0.74 50,171 85,985 284,771,186 Facts & Figures Year 1 Year 2 Year 3 ( 4 months) Sensitization 6 months News paper/ TV/ Radio Jingles 2 months News paper/ TV/ Radio Jingles 2 months News paper/ TV/ Radio Jingles Enrollment drive 6 months 2 months 4 months ID cards Not issued Partly issued Partly issued Number of hospitals 114 137 Group size 16 lakh 21 lakh 14 lakh Membership fee Govt Rs.60/- PA ( 9.6Cr) Rs.30/- PA (4.5 Cr) Rs.60/- (11.9 Cr) (Total 4.56 Cr) Rs.120/- (16.9 Cr) Nil Rs.3.45 Cr Govt. +48 L (interest) + 62.9L( Co-op) +3L ( SBM) Total Corpus Rs.14.19 Cr Rs.16.5 Cr 16.9 Cr Renewal rate Not applicable 35% 43% Claims settled 9008 14864 1937 ( Pre-auth) Total claim payout Rs.10.53 Cr 17.9 Cr 3.39 Cr( Pre-auth value) Avg Claim value 11689/- 12042/- Incidence 0.56% 0.74% Free OPD 35814 50171 9356 Success factor •Strong Govt. initiative & support •Large identifiable groups •Defined & extensive network of hospitals •Largely discounted rates at Private hospitals •Effective administration by TPA Thank you