As a Brookings study indicates, catastrophic health expenses are on a rise in India. Mere price control and increased coverage ideas will not help overcome challenges. Quality, outcomes and reliability must be central to our efforts
The country has witnessed a significant increase in health insurance coverage across population groups. A recent study by Brookings India, ‘Health & Morbidity in India: Evidence and Policy Implications’ indicates that from 2004 to 2014, the number of Indians insured through some mechanism increased from 55 million to over 350 million.
The coverage went from one per cent of the population to 15 per cent in a decade. While universal health coverage through insurance remains a dream, the increased coverage is welcome. India accounts for some of the lowest health insurance coverage in the developing and low and middle-income countries cohort.
This along with low health spends as a percentage of the gross domestic product has meant that over seven per cent of the population is pushed to poverty on account of catastrophic healthcare expenditures. This is not only unpardonable but also wholly addressable.
Researchers suggest that universal health insurance, along with a strengthened primary healthcare infrastructure, is an important tool to ensure that all Indians have access to an equitable and affordable health system. However, as the Brookings study indicates, “public health insurance is not associated with lower out-of-pocket expenditure, probability of facing catastrophic health expenditures or impoverishment caused by health expenditures”.
While it would seem intuitive to assume that increased coverage should lower out-of-pocket expenses for health needs, this is not what the data alludes to. It maybe conjectured that inadequate coverage, lack of quality at institutions servicing a health insurance policy and asymmetric availability of healthcare facilities mean that out-of-pocket spending for both, inpatient and out-patient care remain high.
While health coverage itself is the target of most health insurance schemes, adequate and comprehensive coverage for a range of services and diseases has remained elusive. Curative and invasive interventions like surgeries or inpatient care is covered in most public health insurance policies. However, with the rise of non-communicable diseases, which contributes to over 60 per cent of all deaths in India, health insurance schemes seem inadequately planned to meet the disease burden.
lack of coverage for outpatient care and preexisting conditions act as impediments for obtaining a comprehensive and affordable health insurance scheme. Similarly, coverage for diagnostics and health tests remains patchy. The Brookings study indicates that the latter has been the largest contributor to health expenses in urban India.
More than comprehensive coverage, the lack of quality and outcomes remains a major cause of worry. India must move from an output-based to an outcome-based paradigm. Often, health insurance policies mandate coverage at pre-determined empanelled hospitals for its beneficiaries. These hospitals are selected adopting the ‘l1’ tendering process, where lowest bids are considered ‘superior’ and ‘cost effective’.
Therefore, cost controls, rather than optimal health outcomes, are key considerations for both payers and providers. The lack of co-relation between coverage and out-of-pocket expenses could be explained by this prevalent practice. The insured may look at options beyond the empanelled providers, mostly in the private sector, which could drive up costs to adequately cover their health needs. Therefore, the need to build quality and outcomes into the coverage regime is an imperative.
Quality, unlike numerical population coverage remains a challenge. Qualitative assessment of clinical quality and outcomes has been dealt through models like the diagnosis-related group reimbursement, pay-for-performance and outcome-based reimbursements the world over.
The need to evolve such models will be crucial. Health insurers have relied on price ceiling. However, this remains inadequate for public providers and also for high-end tertiary care. Similarly, price controls on pharmaceuticals and medical devices are the approach that Governments are opting to control costs. This too remains controversial and inadequate in ensuring overall outcomes and in reducing Disability-Reduced life Years in India.
Further, quality assurance through institutional certifications like National Accreditation Board for Hospitals & Healthcare Providers and National Accreditation Board for Testing & Calibration laboratories have been mandated by insurers for reimbursements. But these serve only as certifications; a more comprehensive evaluation system for outcomes and performance for all healthcare providers needs to be created.
Costs and coverage remain twin challenges. We must add quality and outcomes to these overarching pillars on which a 21st century health system for India is to be created.
(The writer is general manager, Operation &Public Affairs, Indraprastha Apollo Hospitals)