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Mission Mumbai Health Micro Health Insurance: with Micro Financing Dr R D Lele Hon. Chief Physician and Director of Nuclear Medicine, Jaslok Hospital and Research Center, Mumbai Lilavati Hospital and Research Center, Mumbai. Emeritus Professor of Medicine (for Life) and Ex Dean, Grant Medical College and Sir J. J hospital, Mumbai. Emeritus Professor, National Academy of Medical Sciences, India. Chairman Research Advisory Committee, Haffkine Institute
Current Scenario of Health Insurance in India • Employee State Insurance Act(1948) • Mandatory social insurance scheme in formal sector. • ESIS introduced in 1952. • Benefit to 33. 4 million workers with income less than Rs 6, 500 per month, along with their families. • Limit now raised to Rs. 15, 000 pm • 136 Hospitals, 1443 dispensaries • 6542 M. O. s, 2988 GPs GOVT EXPENDITURE IN HEALTH CARE 0. 9% OF GDP FAR LESS THAN WHO RECOMMENDATION – 5% OF GDP
Current Scenario of Health Insurance in India ( Contd…. ) • CGHS introduced in 1954. • • • 4. 5 million beneficiaries Railways 8 million Defense 6. 6 million Ex Servicemen 7. 5 million Public Sector (Mining, Plantation) 4 million Other Public Sector Undertakings – 8 million ESIS and CGHS cover 35 million
MEDICLAIM scheme of General Insurance Corporation introduced in 1986. Pays for in-patient services only Does not cover MTP and tubectomy, preventive care( immunisation against HBV) or OPD Group MEDICLAIM for organisations available for age 5 -80 children age between 3 m – 5 years Minimum Premium Rs 213 per annum for Rs 15000 Highest Premium Rs 17156 for Rs 500, 000
Health Insurance as an integral component of HMO pre paid managed care – urgent need for a paradigm shift. by DR R D LELE Key note address at The Asian Health Insurance Congress, September 1, 2; 2004 at Taj Mahal Hotel, Mumbai. JAPI 2004 Dec. Vol 52, 947 -950
UHI scheme for BPL families. In 2003 Govt. of India introduced Universal Health Scheme. All the four public sector non-life insurance companies offer this scheme at a premium of Rs. 365 a year from an individual or Rs. 548 for a family of 5. government provides subsidy of Rs. 100 per BPL family.
“HEALTH INSURANCE IN ITS PRESENT FORM HAS NO FUTURE IN INDIA” – Dr R D Lele, 2004 : Keynote address- Asian Health Insurance Conference 2004 - Claim Ratio 140%; 180% for Group Health Insurance. Private Health Insurance Companies lost Rs 273. 83 crores in 2007 -08, Rs 243. 98 crores in 2008 -09. State owned New India, Oriental, National and United India lost Rs 638. 27 crores in 2007 -08, Rs 1248. 73 crores in 200809. High share of group health insurance – main cause of losses. Raising premium rates and denying claims eg maternity benefits – Vicious circle with dissatisfaction to everyone. PRIVATE HEALTH INSURANCE COVERS LESS THAN 15 MILLION PEOPLE
IRDA Act 1999 stipulated a specific percentage of insurance business in rural and social sector (unorganized sector, informal sector, economically vulnerable or backward classes) in urban areas. The 1 crore poor citizens of Mumbai-Thane-Navi Mumbai fall in this category. IRDA: 2005 Guidelines to promote Micro-insurance = life micro-insurance products = general micro-insurance products-health, accident minimum Rs. 5000, max Rs. 30, 000 cover. Scope for LIC, SBI to collaborate in providing micro-finance and micro-insurance for the poor citizens of Mumbai, with the help of NGOs and self help groups.
Micro-insurance is the most effective instrument for the poor. Micro-insurance can impower the groups and through then help individual members. Integration of MFI and MI is very critical success story- SEWAEla Bhat- Ahmedabad India.
When Health is Security Ela Bhatt Times of India Jan. 24, 2012 Health Insurance has to be within the mandate of microfinance institution (MFIs) Deposit-linked life and health insurance collaboration between MFIs and health sector Income security and health security are two sides of the same coin, especially for the poor who are at the heart of MFIs. SEWA Ahmedabad : Success story
LIC-Jeevan Madhur – micro-insurance policy with a term of 5 -15 years SA minimum Rs. 5000 maximum Rs. 30, 000 TATA-AIG life: Nava Kalyan Yojana: 5 year Samapoorn Bima Yojana- 15 years protection Ayushman Yojana- single premium 10 year micro-insurance protection plan. Birla Sunlife: Bima Suraksha Super Bima Dhan Sanchay 5, 10, 15 year policy tenure. SBI Life Insurance: Grameen Shakti
IRDA Act 1999 stipulated a specific percentage of insurance business in rural and social sector (unorganized sector, informal sector, economicaly vulnerable or backward classes) in urban areas. The 1 crore poor citizens of Mumbai-Thane-Navi Mumbai fall in this category.
CHARACTERSTICS OF UNORGANIZED SECTOR WORK FORCE Poor Self-Employed Employers not identifiable Illiterate Migratory Lack of skills
New Pension System (NPS) For self-employed profession and others in the unorganized sector, to be part of Mission Mumbai Health. Pension Fund Regulatory and Development Authority PFRDA- for implementation of NPS. Elderly population growing at 3. 8% as against overall population growth of 1. 8%, hence the importance & urgency of extending NPS to the vast urban unorganized poor sector, through microfinance (MFI)and microinsurance.
Successful MFIs Grameen Bank (Bangla Desh) Bank Rakyat (Indonesia) Banco Sol (Bolivia) Community –based banks (Latin America)
Rashtriya Swasthya Bima Yojana Rs 30 per family per year from beneficiaries 75%Premium from Central Government 25% Premium from State Government Both public and privete sector providers are eligible to be part of the provider network
Acute Illness 61% of episodes 37% of costs Chronic illness 17% of episodes 32% of costs Hospitalization 11% of aggregate costs
SWASTHYA BIMA YOJANA BENEFITS Total sum insured of Rs 30, 000 per BPL family on a family floater basis Pre-existing diseases to be covered Coverage of health services related to hospitalization and services of surgical nature which can be provided on a day-care basis Cashless coverage of all eligible health services. Provision of Smart Card. Provision of pre and post hospitalization expenses. Transport allowance @ Rs. 100 per visit upto maximum of Rs 1000
Major Deficiency of RSBY Covers only hospitalisation costs – 11% of poor man’s illness expense Does not cover cost of drugs (48%), diagnostic tests(7%), and doctors’ fees(34%) of illness expense. No component of preventive care
Rajiv Gandhi Jeevandai Arogya Yojna Over 20 million poor, alloted identity cards will walk into any public or private empanelled hospital to get treatment for 972 surgical procedures with free medical treatment upto Rs. 1. 5 lacs per annum. Hospitals must keep 10% of their beds reserved for this Hospitals must adhere to the costs set up for surgery Courts have order hospitals to keep 2% of their revenue aside for subsidising poor patients with income below Rs. 50000/per year.
RGJAY now applicable to 16. 24 lakh beneficiaries (families earning less than Rs. 1 lakh/ yr. ) in Mumbai and its suburbs. Free Hospital treatment upto Rs. 1. 5 lakhs for card holders 972 medical procedures will be covered. So far 4. 5 lakhs out of 16. 24 lac beneficiaries received health cards.
My Recommendation to Government Upgrade RSBY card to my Bronze card and provide micro finance to BPL Indians. The poor do not need charity. . they need micro finance support.
Health of Urban Poor (HUP) Supported by Govt. of India Funded by USAID Maternal and child Health (MCHN) Post-partum Family Planning PPFP Post-partum Intra-uterine contraceptive device. Roel of ANMs, ASHAs, Mamtas PPIUCD Emergency Contraceptive Pi. U utilization urban / rural. Migration, poverty and Access to Health Care.
Current Experience in Health Expenditure Share of Hospitalisation 11% of aggregate health care costs Share of Consultation 33% Share of Medicines 49% Share of Diagnostic test 7% My HMO Pre Paid Care Project Covers consultations, diagnostic tests , medicines and hospitalization AND IN ADDITION PREVENTIVE CARE FOR ALL Involves trusted community representation in claim settlement and benefits package design Increases transparency Reduces administrative costs and eliminates need for TPAs
Muhammad Yunus : Grameen Bank Micro Finance: Innovation and Revolution Social Business Enterprise to maximise benefits to poor people without incurring losses, not to maximise profits. Social business is not charity to the poor but “benevolent capitalism”, as against “greed capitalism”. Micro financing and micro health insurance a success story in Bangladesh. For 60 Takas per year Bangladeshi woman gets Health Insurance.
ELA BHATT: SEWA Ahmedabad 1974 Providing micro finanace banking services to poor women employed in unorganised sector. Microfinance in India is workable. “Poor are bankable” VIMO-SEWA successful micro insurance scheme for the poor.
Micro Financing in India ICICI Bank: 16 managers each oversees work of 6 co- ordinators. 10000 SH Groups – 200000 customers at BOP Formation of SHG with 20 members in each group – loan given to SHGs, not individual. 10000 SHGs with ICICI is an ecosystem. Hindustan Liver Limited(HLL) with Shakti. Ammas ITC with Sanchalaks in the E-Choupals.
Micro Finance Loans Government: Rs 24, 000 crores NABARD (National Bank for Agricultural and Rural Development) SIDBI ( Small Industries Development Bank of India) Rashtriya Mahik Kosh (RMK) SHG Bank Linkage (SBL) Joint Liability Approach
Non Government: Micro Finance Institutes(MFI s): Rs 11734 crores 85% of MFIs are non profit, account for 25% of loans, serving 38% of borrowers Average Loans Rs 2500 – Rs 10000 38%> Rs 10000 Total active borrowers - 2. 26 crores 90% women, majority small scale self employed, only a few daily labourers. Bharat Micro Finance Report: March 2009. 7. 66 crore micro finance accounts. Loans Rs 35900 crores.
Community Health Insurance Projects (CHI) in India NGO/CBO Membership based Large ( >1 million): Yeshaswini – Bangalore Vimo. SEWA - Ahmedabad Arogya-Shree - AP Medium (about 50000) Karuna Trust, ACCORD Small (5 -20000) KKVS DHAN Hallo Foundation- Andur. Dr. Shashikant Ahankari
Pilot Description – Rural Maharashtra Partnered with an NGO, working in ~1200 villages in rural Maharashtra on women empowerment through various initiatives like SHG formation, livelihood promotion, etc. Designed a comprehensive health scheme targeted at people in rural Maharashtra Launched in 12 villages of Latur district in April 2009, followed by 40 villages of Solapur in Oct 2009; and then another 80 in Osmanabad in January 2010 Scheme launched and supported by marketing events in the villages NGO employed part time sales agents in each village and sales co-ordinators to supervise them ~5, 000 lives enrolled across ~120 villages Created a network of 20 health service providers across clinics, pharmacies, labs, nursing homes and hospitals Managing network and claims processing on an ongoing basis to ensure hassle free service Community health workers launched to provide health services at village level
Pilot Description – Bangalore Slums Partnered with an NGO working for 3 years to form a collective of unorganised sector workers (e. g. electricians, housemaids, drivers, plumbers) NGO had ~22, 000 members across Bangalore Designed a comprehensive health scheme for members of NGO Launched the health scheme in slums of north-east Bangalore in July 2009 Sales staff of the NGO promoted the scheme ~1000 lives enrolled till Jan 31, 2010 Created a network of ~20 health service providers - clinics, pharmacies, labs, nursing homes and tertiary hospitals - in Bangalore Managing network and claims processing on an ongoing basis to ensure hassle free service Each admission and discharge facilitated by a network facilitator
CURRENT SCENARIO… 80% of Health care expenditure comes from private pockets – rich as well as poor Out of pocket expenditure on health care. . Rural and urban poor: OPD- Rs 144 person per year IPD- Rs 3202 person per year Illness is the common cause of indebtedness. 30 crore Indians living on less than a dollar a day. Less than 5 percent of them have access to mirofinance.
Current Scenario in Dharavi The poor in Dharavi pay 600 to 1000 percent interest to local money lenders. Vegetable vendors borrow at even 10% a day A micro finance bank with access to this market can do good business by offering credit at 25 percent. Is this Excessive? ? The BOP customer finds the cost of credit down from 600% to 25% a boon.
Continued… 85 % of households in Dharavi own a TV set. 75% own a pressure cooker and blender. 56% own a gas stove. 21% have telephone Feasibility Study in Dharavi Dr R D Lele, January 2006 1360 families surveyed
Continued… Dharavi family spends on an average ( per year) Rs 1116 for doctors fee: upto Rs 2500. Rs 1753 for medicine: upto Rs 5000. Rs 814 for medical tests: upto Rs 2000. Major illness and hospitalisation makes them bankrupt Majority agree to pay Rs 2500 as premium which gives: Life Insurance to bread winners Accidental cover and health insurance for the entire family Preventive and curative care by an assigned family physician
C K Pralhad : Fortune at the bottom of pyramid “Stop thinking of the poor as a burden on society requiring charity and subsidies to be permanently doled out by state, and start recognising them as resilient and creative entrepreneurs and value conscious customers. ”
Hindustan Times, 7 th April, 2010
Salient Features of My Mission Financing and delivery of health care through per capita pre-payment, so that the physician organization has a budget for the care it will provide and an incentive to use the resources wisely. Maintenance of continuous healing relationship of the family physician (FP) with the voluntarily enrolled population ( 1 FP for 500 – 1000 families ), to provide promotive, preventive and curative care to 3000 to 6000 individuals for which the FP will be handsomely remunerated ~ 1 lakh per month.
Physicians and multi-disciplinary specialist teams can design and execute best care processes, in a most cost-effective manner. Hospital facilities, complex diagnostic equipment and laboratory investigations can be deployed on a regional basis where it can be used with greatest efficiency and economy, backed by insurance cover.
Electronic patient record (EPR) which provides an accurate and comprehensive picture of each patient. EPR avoids unnecessary duplication of tests, facilitates collaboration and coordination of care among specialties, and allows monitoring of compliance with the practice guidelines to ensure high quality of care. Computerized prescription in the patient’s own language, gives detailed instructions about how to take the drugs and alerts for adverse reactions. It eliminates medication errors and transforms the care process.
Over-use and mis-use of tests and procedures, so common currently, is strongly discouraged while early detection and prevention and early treatment and chronic disease management are strongly encouraged. There is great emphasis on patient education and information. Patients are encouraged to come in early and have their symptoms checked so that any potential illness can be treated sooner and at much less cost. Emphasis on prevention reduces the need for inpatient hospital care especially for Diabetes. Hypertension, congestive Heart Failure and Asthma. The medical peer group, not an insurance company, determines the clinical policies, which technologies and procedures will be employed and covered under the pre-payment, and health insurance.
The medical peer group develop the drug formulary themselves. The drug selection is based on its therapeutic efficacy, safety and cost. Physicians have the freedom to over-ride the formulary to prescribe what they believe is medically necessary in a particular case. This approach is most effective in cost control. In the current fee-for service scenario of medical practice, new single source patent protected drugs are aggressively promoted by drug manufacturers with little head-to head comparison with older, effective and often less expensive drugs. HMOs use evidence-based approach to promote drugs of choice.
Impact of preventive care of life style illness will be measurable by the drastic reduction in critical illness claims which are a major cause of losses made by health insurance companies at present. Time for paradigm shift.
HMO managed care will not only ensure the elimination of the widely prevalent gender discrimination against females, it will actually put major emphasis on the care of the mother and the female child and adolescent girl eg nutrition, menstrual hygiene, sanitary napkins, prevention of iron deficiency, sex education and prevention of STD / HIV, emergency contraception and family life education, women’s reproductive health and promotion of breast-feeding. Care of the pregnant women will ensure that no baby is born with a birth weight less than 2. 5 kg.
Action Plan for city of Mumbai Annual Income Annual Premium Bronz Card 40000 -100, 000 Rs 2500 Silver Card Over 100, 000 Rs 5000 Gold Card Over 200, 000 Rs 7500 Platinum Card Over 500, 000 Rs 10000 Micro Finance for Bronz Card holders For bronz card holders • Life Insurance for bread winner • Accident cover and Health Insurance cover for entire family of five • No exclusions • Preventive and curative care by assigned family physician
Unique features Preventive dental care Preventive mental care. Accident Prevention Blood Doner directory automated with SMS
Thyrocare Dr. A. Velumani Ph. D an active partner in Mission Mumbai Health, committed to provide all essential laboratory tests at an affordable cost to the poor citizens of Mumbai. 350 essential generic drugs provided at low cost through bulk-buying The benefit of low cost will be passed on to patients.
Components of a health system Consumer adoption & awareness Financially selfsustaining Manage provider network Consumer support services Front line – CHWs and OMs Financial structuring Doctor Healthcare Quality Control Consumer awareness Basic insurance risk mgmt Hospital / Nursing Home Consumer data mgmt Prevention -promotive techniques Reinsurance Diagnostic Lab Cash flow mgmt Feedback on quality of service Tight operational control Drugs and Pharmacy mgmt Claims mgmt
HMO tie up with…… Life Insurance and Health Insurance Companies. Family Physicians and Specialists Laboratories and Diagnostic Centres. Drug Companies – bulk buying at discounted rates Nursing Homes and Hospitals are urged to expand their roles as HMOs and provide pre paid preventive care through assigned family physicians. Electronic Health Record for each member of family of 5 -6. Computerised prescription for patients HMO: Health Care Management: Preventive Care Through PCP Curative Care Drugs Diagnostic Tests – Hospitalisation and Rehabilitation
Illustrative product / scheme design Customer benefits Coverage 30%+ reduction in total healthcare costs • Access to quality healthcare (hospitals, nursing homes, doctors, drugs, labs) • Protection from “health shocks”, both hospitalisation as well as OPD • Preventive health measures / education reducing disease incidence over time • 1. Hospitalisation / Surgeries • Cashless treatment at empanelled hospitals upto a limit of Rs 30, 000 • Co-pay for every hospitalisation of Rs 50 -200 • Few exclusions – HIV / AIDS, war, nuclear explosion 2. Outpatient care • 1 free annual health checkup for entire family after 3 months of enrolment • First aid and basic health services (e. g. BP measurement) from a community health worker (CHW) • Consultation at empanelled doctors at Rs 15 per visit (50% discount to market) • Quality, generic drugs at 30 -50% discount to market rates • Common diagnostic tests at 30 -50% discount to market rates 3. Disease prevention and health improvement measures Only family enrolment, no individual enrolment allowed • Annual premium of Rs 850 for a family of 5 • Pricing 55
Taiwan Model I visited Taiwan on 9 - 13 th May 2010 to see at first hand the National Health Insurance of Taiwan working successfully since 2004. All 23 million citizens of Taiwan have universal health insurance. Each citizen has electronic health record, computerised prescription and links to clinics and hospitals. Taiwan Health Insurance is making losses since preventive Health Care is not integrated with Health Insurance. Mumbai, Thane and New Bombay together have a population of 23 million. We can do better than Taiwan in this respect by combining preventive Health care with Health Insurance.
IRDA- comprehensive micro-insurance guidelines incorporating product, distribution, administration, regulation, etc. to promote health insurance among the poorer sections of society. Mission Mumbai Health will implement the same objective.
Future of Health Care in India NGO partnership with State Governments is the only way to provide Micro Insurance through Micro Financing to the BPL (37 crore) and APL (70 crore) Indians. Todays Health care is only illness care. Promotion of positive health and prevention of illness are the primary aims of the physicians. This message is known to India for over 5000 years. (Charaka and Sushruta)
AVIVA: example of corporate social responsibility (CSR) - LIC-CSR activities: 20 th October 2006 - Golden Jubilee Foundation Relief of poverty or distress Advancement of education Medical relief Advancement of any other object of general public utility.
For the 70 lakh poor citizens of Mumbai, micro finance budget of Rs 15000 crores is required At 25% interest, it is a viable social business venture. MISSION MUMBAI HEALTH IS NOT MISSION IMPOSSIBLE Impossible can easily be broken down into possibilities as a cooperative effort involving : Ø Jayant Banthia, Ex-Chief Secretary, Govt. of Maharashtra Ø Municipal corporation of Greater Mumbai (Sitaram Kunte) Ø Rotary club of Bombay Ø SNEHA (Dr. Almeida Fernandes) Ø Kevim Bhatnagar – Pension specialist Ø Arogya Bharati