Transcript Prospects & Problems Health Care Provider

Prospects and Problems
Healthcare Provider
Dr. P. Prabhakar
Chief Operating Officer
Kamineni Hospitals
Overview
 India is a low-income country with 26% of the
population living below the poverty line, and
35% of the population illiterate and with
skewed health risks.
 Private sector is the dominant sector; 50 % of
those seeking indoor care, and 60-70% of
those seeking ambulatory care, do so from
private health facilities.
Overview contd…
 Despite the higher cost, a majority of both rural
and urban Indians prefer private care because
of the perceived inferior quality of public care.
 The entire burden of cashless, prepaid private
care is shared among 500 odd private care
providers in the country, who are approved by
insurance companies for this purpose
Health system
Who provides?
Govt
Private Voluntary
Who pays?
Govt
Private
Donors
People
Entry Barriers
 In a number of cases applicants of older ages
have been refused admission to the Mediclaim
scheme due to the unnecessary conservatism
of companies since it is felt that the outgo of
these schemes will be more than the premium
collected.
 Companies are also refusing to upgrade or
increase the sum assured for older patients.
Entry Barriers contd…
 There is an excessive emphasis on
disqualification
because
of
pre-existing
conditions
and
post-claim
underwriting.
Because of these practices health insurance
has become one of the largest litigation areas
for insurers, exceeded only by motor third party
cases.
 No standardized tool available to assess the
risk before taking the policy.
Problems
 Service provider are always at a disadvantage
(only at the receiving end, patient approach the
hospital directly for any ailment)
 Patient not made aware of exclusions, fixed
package rates, non-payable expense. All these
have to be explained by the provider.
Problems contd…
 There are reports of fraud and manipulation by
clients and providers, which have implications
for the growth and development of this sector.
Monitoring systems are weak.
 There are chances that if the doctor and
patient collude, they can do more harm to the
system.
Problems contd…
 Preferred Provider Network (PPN) screening
focuses on tariffs rather than markers of
Clinical Outcomes or cost effective care.
 Policies providing a ceiling of the assured sum
and fixed tariff for procedures could result in
difficulty for the hospital to provide quality care.
Problems contd…
 But it is providers who now face the risks of not
getting reimbursements from TPAs. Besides,
once patients are admitted and if treatment
costs exceed the sum insured, providers may
not get the difference in treatment cost and the
sum-insured.
Problems contd…
 TPAs not updated about the renewal
immediately, causing unnecessary delay in
pre-auth.
 Providers also penalized for oversight of TPAs
while given preauthorization for higher amount
than the policy.
Conclusions
 Fixing of responsibilities and stringent action
can act as deterrent for all the erring sections.
 Analysis of hospital bills across providers for
similar disease patterns / diagnosis will prove
that there is no incentive for being cost
effective.
 Payment timelines should be well defined and
adhered to.
Areas for industry and government action
 Work towards creating standards for high quality
healthcare.
 Invest in training and developing healthcare
manpower.
 Work with health insurers to improve coverage.
 Create public – private partnerships in healthcare.
 Mechanism to provide incentives for providers, who
provider cost-effective care with better clinical
outcomes.
Questions remain!
 Govts offer different prices for the same services
 BPL and the RICH are in some way or the other
taken care of, what about the middle 60% of the
population
 Higher insurance penetration is sure to raise the
cost of care as evidenced in the west, this will
further make it difficult for the people who are not
insured
 Health of the citizen is a state responsibility, but
there is no one accountable and no one asking
the fundamental questions
Thank you