India's Largest Hospital Insurance Program Faces Challenges In Using Claims Data To Measure Quality.

Matthew Morton,Rajeev Sadanandan,Somil Nagpal,Sebastian Bauhoff

doi:10.1377/hlthaff.2016.0588

Abstract

The routine data generated by India’s universal coverage programs offer an important opportunity to evaluate and track the quality of health care systematically and on a large scale. We examined the potential and challenges of measuring the quality of hospital care through claims data from India’s hospital insurance program for the poor, Rashtriya Swasthya Bima Yojana (RSBY). Using data from one district in India, we illustrate how these data already provide useful insights and show that simple efforts to enhance data quality and an effort to expand the data captured could facilitate RSBY’s ability to track quality of care. The data collected by RSBY has significant potential to characterize and uncover the provision of low-quality care and help inform much-needed efforts to raise the quality of hospital care.

Highlights

Rashtriya Swasthya Bima Yojana (RSBY) was started in 2008 in the context of the challenges faced by the public sector in meeting demand for health care services and improved performance in providing care, and the concurrent rise of the private sector as a major provider of inpatient and outpatient services
We examined the potential for and challenges to measuring quality using claims data from the Rashtriya Swasthya Bima Yojana (RSBY, National Health Insurance Plan), a program for the poor in India
RSBY was started in 2008 in the context of the challenges faced by the public sector in meeting demand for health care services and improved performance in providing care, and the concurrent rise of the private sector as a major provider of inpatient and outpatient services

Summary

Introduction

RSBY was started in 2008 in the context of the challenges faced by the public sector in meeting demand for health care services and improved performance in providing care, and the concurrent rise of the private sector as a major provider of inpatient and outpatient services. RSBY was designed to address concerns that lower-income families were at risk of substantial out-of-pocket spending, especially for hospitalization in the private fee-for-service system. RSBY covers all families with incomes below the Indian poverty level and some categories of unorganized workers who generally lack access to formal social protection such as health insurance and pensions. Beneficiaries of RSBY can choose from among a network of hospitals in the public and private sectors that are contracted (empaneled) to provide covered services without the beneficiary having to pay any cost sharing. The program is “cashless” at the point of service: Providers are reimbursed according to a regulated fee schedule by competitively selected insurance companies that operate the program for the government

Results

Discussion

Conclusion