This report dwells upon the performance of health insurance business in the country while identifying the various factors that impact the sustainability of health insurance in the long run.
While underscoring the significance of insurance cover in the healthcare industry, which at present is largely unpenetrated and underfunded, the Report mentions that a number of constraints come in the way of building a robust and sustainable health insurance sector in the country. Some of the major problems, according to the Report, relate to unsustainably low premium in private group business due to fierce competition, lack of treatment protocols and guidelines, high prevalence of fraud, poor control over healthcare providers in terms of charging for services provided, absence of coverage of Out Patient treatment, diagnostics and medicines.
The Report further states that all these factors taken together lead to a situation wherein the stakeholders are caught in an unsustainable spiral of increasing claims ratio, and an increase in medical costs which paves way to an increase in premiums, leading to further adverse selection and risk of high incidence of frauds.
For bringing in sustainability in health insurance, this report supports the creation of a strong health insurance industry which can provide extensive coverage and support for a comprehensive integrated health care system. It advocates the creation of sustainable practices based on 4 aspects:
Role of Usual and Customary charges - to come up with standards for reimbursement to insured members for same procedure in similar geographies
Role of Medical protocols/Standard Treatment Guidelines and clinical pathways - to bring uniformity in treatment protocols
Health Insurance Fraud and its management
Outpatient health insurance approach and wellness
It was released at the 12th Health Insurance Summit on 3 August 2018 at New Delhi.