Health Insurance Schemes In India Research Articles

A typology framework for unethical medical practices under public health insurance schemes in India: Analysis of evidence over the past 12 years.

Unethical provider practices in public healthcare schemes adversely impact beneficiaries' health, result in the loss of public funds, and also bring disrepute to the schemes. There is extensive literature on the typologies of unethical practices in healthcare in developed countries. This study aims to develop a typology framework which is applicable in the Indian context. In this study, 25 media reports and research studies were analysed on unethical provider practices under public health insurance schemes in India over the past 12 years from 2010 to 2022. The reports were collated from de-empanelment orders issued by state health authorities against various erring entities, and research studies conducted on the abuse of these schemes. Based on the analysis and classification of the cases reported, an "Unethical Provider Practices" typology for healthcare fraud has been defined. Additional fraud typologies are found to be prevalent in India in addition to those captured by existing frameworks. These include patient harm, ID theft of beneficiary data to create cards for non-beneficiaries, and collusion between providers and different entities. Fraud control mechanisms leveraging technology such as AI-enabled digital apps for medical audits, biometric technology at the point of care and rigourous checks of ID documents before beneficiary cards are issued as well as having more specific legal provisions in place for healthcare fraud will enable enhanced prevention, detection and deterrence of healthcare fraud.

The genesis ofthe PM-JAY health insurance scheme inIndia: technical andpolitical elements influencing a national reform towards universal health coverage.

Many countries are using health insurance to advance progress towards universal health coverage (UHC). India launched the Pradhan Mantri Jan Arogya Yojana (PM-JAY) health insurance scheme in 2018. We examine the political economy context around PM-JAY policy formulation, by examining the perspectives of policy stakeholders shaping decisions around the reform. More specifically, we focus on early policy design at the central (national) level. We use a framework on the politics of UHC reform proposed by Fox and Reich (The politics of universal health coverage in low- and middle-income countries: A framework for evaluation and action. J. Health Polit. Policy Law 2015;40:1023-1060), to categorize the reform into phases and examine the interactions between actors, institutions, interests, ideas and ideology which shaped reform decisions. We interviewed 15 respondents in Delhi between February and April 2019, who were either closely associated with the reform process or subject experts. The ruling centre-right government introduced PM-JAY shortly before national elections, drawing upon policy legacies from prior and state insurance schemes. Empowered policy entrepreneurs within the government focused discourse around ideas of UHC and strategic purchasing, and engaged in institution building leading to the creation of the National Health Authority and State Health Agencies through policy directives, thereby expanding state infrastructural and institutional power for insurance implementation. Indian state inputs were incorporated in scheme design features like mode of implementation, benefit package and provider network, while features like the coverage amount, portability of benefits and branding strategy were more centrally driven. These balanced negotiations opened up political space for a cohesive, central narrative of the reform and facilitated adoption. Our analysis shows that the PM-JAY reform focused on bureaucratic rather than ideological elements and that technical compromises and adjustments accommodating the interests of states enabled the political success of policy formulation. Appreciating these politics, power and structural issues shaping PM-JAY institutional design will be important to understand how PM-JAY is implemented and how it advances UHC in India.

Social Health Protection and Publicly Funded Health Insurance Schemes in India: The Right Way Forward?

Social Health Protection and Publicly Funded Health Insurance Schemes in India: The Right Way Forward?

Can beneficiary information improve hospital accountability? Experimental evidence from a public health insurance scheme in India

We study the role of hospital compliance in the effectiveness of government health insurance in India. Using patient surveys, we document that participating hospitals charge unauthorized fees to poor patients eligible to receive free care. Average out-of-pocket payments (OOPP) for chronic kidney care patients are $43 per month, or 25% annual GDP per capita, and are high at both public and private hospitals. Awareness of program benefits is low despite patients having used insurance for several months. We conduct a randomized experiment to test whether phone-based information about program benefits can enable insurance beneficiaries to hold hospitals accountable and lower OOPP. The intervention effectively increases program awareness by 0.17 standard deviations but has no effect on OOPP overall. However, effects differ dramatically by hospital sector: patients at private hospital see no change in OOPP despite increased bargaining and search; monthly OOPP among patients visiting public hospitals, who are poorer and lower caste, drop by $12 (35%), because they are able to negotiate to get more of their benefits at the hospital instead of paying for them off-site. The findings suggest that patient-driven accountability can meaningfully improve public service delivery, even in the context of specialized tertiary care, but may not substitute for top-down monitoring of private agents.

Patient satisfaction on hospital care services: a study with specific reference to beneficiaries of community-based health insurance schemes in India

Patient satisfaction on hospital care services: a study with specific reference to beneficiaries of community-based health insurance schemes in India

Deficient state-supported cancer care: A source of deep concern

Deficient state-supported cancer care: A source of deep concern

Health Care Delivery and Keeping the Workplace Safe in the COVID Pandemic: Results of a Cross-Sectional Survey of Hospitals Delivering Care Under the National Health Insurance Scheme in India

Health Care Delivery and Keeping the Workplace Safe in the COVID Pandemic: Results of a Cross-Sectional Survey of Hospitals Delivering Care Under the National Health Insurance Scheme in India

Patient Satisfaction on Hospital care services: A study with specific reference to beneficiaries of Community Based Health Insurance Schemes in India

Patient Satisfaction on Hospital care services: A study with specific reference to beneficiaries of Community Based Health Insurance Schemes in India

Penetration and coverage of government-funded health insurance schemes in India

This paper presents the historical evolution, financing, depth and coverage, and implementation status of the currently promoted government-funded health insurance (GFHI) schemes across the socioeconomic stratum, districts, and states. The study uses official and large scale survey data, namely India Human Development Survey 2012, National Family and Health Survey 2016 and National Sample Survey 75th round on health 2019. The official data claim that around 109 million families are covered under existing GFHIs by 2017–18, while estimates from survey data do not substantiate it. The actual coverage reported by the households in survey is found 68.2% less than the claim made by the governments in official data. The size of coverage of GFHIs however makes them world's largest pro-poor health insurance schemes. The coverage amount ranges from Rs 30,000/family under Rashtriya Swasthya Bima Yojana to as high as Rs 3,30,000/family under Bhamashah Swasthya Bima Yojana, Rajasthan, and Rs 5,00,000/family under Pradhan Mantri Jan Aarogya Yojana. The penetration of various scheme is recorded high among non-poor and urban as compared to their other counterparts with a wide variation across states/districts, posing serious challenge for ensuring equitable access to healthcare to the general population. The contribution of insurance in financing total health expenditure is increasing, but has substantially low share, it is the households OOP (out-of-pocket) that still constitute the higher share in financing health expenditure.

Assessment of the public-private-partnerships model of a national health insurance scheme in India

A single hospital admission can deplete household resources so considerably as to induce impoverishment, especially in the Indian context of low government healthcare expenditure. Rashtriya Swasthya Bima Yojana (RSBY) was a national health insurance scheme for below-poverty-line Indian families, to provide improved access to hospitalization and greater financial protection via a public-private-partnership employing private sector implementation capacity. Study objectives were to understand governance (including regulatory) environment and contract arrangements; evaluate expansion of services to beneficiaries; and assess compliance of providers and user satisfaction. A case study approach in two districts met the need for in-depth information on scheme functioning, and RSBY implementation was examined between 2011 and 13 in Patiala (Punjab) and Yamunanagar (Haryana). Methods included 20 key stakeholder interviews, analysis of secondary datasets on beneficiaries and claims, primary data collection in 31 public and private hospitals and in greater depth in 12 hospitals, and an exit survey of 751 patients. Enrolled and non-enrolled hospitals were mapped in each district and service availability of enrolled hospitals assessed; enrollee characteristics were analysed; for the 12 hospitals, information was obtained on structural quality and process of care, and patient satisfaction and out-of-pocket payments.The Indian states and the government of India did not specify formal regulatory and implementation procedures in detail and states largely contracted out their functions to private insurance firms. Findings show regulatory weaknesses, and contractual breaches. Enrolment rates were low in both districts and more so for Patiala and there was limited access to services. There was little difference in process of care between public and private hospitals, though the structural capacity of private hospitals was better than public hospitals. RSBY helped improve accessibility and gave some degree of financial protection to patients. It also actively engaged with existing resources in the Indian health care and insurance markets.

Ayushman Bharat National Health Protection Scheme: an Ethical Analysis.

The Ayushman Bharat (Hindi for "India blessed with a long life") scheme is a government health insurance program that will cover about 100 million poor and vulnerable families in India providing up to INR 0.5 million per family per year for secondary and tertiary care hospitalization services. In addition, it also proposes to establish 150,000 health and wellness centers all over the country providing comprehensive primary health care. The beneficiaries of the hospital insurance scheme can avail health care services from both public and empanelled private health facilities. This scheme is one of the largest government-sponsored health insurance schemes in the world. Previous experience with government-financed health insurance schemes in India has shown that they are inequitable, inefficient, and do not provide financial protection. There is a lack of clarity on the budgetary provisions over the years when the utilization is likely to increase. The Ayushman Bharat scheme in its current form strengthens the "for profit" private health sector, requiring greater emphasis on its regulation. The scheme, which has primary, secondary, and tertiary care components, places a great focus on the secondary and tertiary care services and requires more investment in comprehensive primary health care. The potential problems of "profit-motivated" supplier-induced demand by private health care providers and corrupt practices are possible ethical burdens of the scheme. For the Ayushman Bharat to meet the ethical principle of justice, it should first address universal coverage of comprehensive primary health care and move on to hospital insurance in a progressive manner. The scheme should have provisions to strictly regulate secondary and tertiary care hospitalization in the private health sector to prevent misuse. It is the ethical responsibility of the government to ensure a strong and robust public health system, but the current provisioning of the Ayushman Bharat scheme does not do this and the reasons for this are explained in this paper.

Impact of Publicly Financed Health Insurance Schemes on Healthcare Utilization and Financial Risk Protection in India: A Systematic Review.

Several publicly financed health insurance schemes have been launched in India with the aim of providing universalizing health coverage (UHC). In this paper, we report the impact of publicly financed health insurance schemes on health service utilization, out-of-pocket (OOP) expenditure, financial risk protection and health status. Empirical research studies focussing on the impact or evaluation of publicly financed health insurance schemes in India were searched on PubMed, Google scholar, Ovid, Scopus, Embase and relevant websites. The studies were selected based on two stage screening PRISMA guidelines in which two researchers independently assessed the suitability and quality of the studies. The studies included in the review were divided into two groups i.e., with and without a comparison group. To assess the impact on utilization, OOP expenditure and health indicators, only the studies with a comparison group were reviewed. Out of 1265 articles screened after initial search, 43 studies were found eligible and reviewed in full text, finally yielding 14 studies which had a comparator group in their evaluation design. All the studies (n-7) focussing on utilization showed a positive effect in terms of increase in the consumption of health services with introduction of health insurance. About 70% studies (n-5) studies with a strong design and assessing financial risk protection showed no impact in reduction of OOP expenditures, while remaining 30% of evaluations (n-2), which particularly evaluated state sponsored health insurance schemes, reported a decline in OOP expenditure among the enrolled households. One study which evaluated impact on health outcome showed reduction in mortality among enrolled as compared to non-enrolled households, from conditions covered by the insurance scheme. While utilization of healthcare did improve among those enrolled in the scheme, there is no clear evidence yet to suggest that these have resulted in reduced OOP expenditures or higher financial risk protection.

Out of pocket expenditure on surgical and nonsurgical conditions in Odisha.

Background:Out of pocket expenditure (OOPE) for any illness is still a major problem in India. Several evidence is available regarding growing OOPE and its impact on household poverty. However, limited evidence is there regarding OOPE on multiple disease conditions in public hospitals.Aim:To estimate the OOPE for various hospitalized conditions at the secondary level of care in Odisha and find out various financial coping mechanisms adopted by the patients.Methods:The primary survey was done in the secondary care hospitals in the two districts of Odisha using a semi-structured interview schedule. Data were collected from 284 subjects (212 males, 72 females) in 2014 on the socioeconomic status and OOPE on multiple disease conditions. Descriptive statistics using Stata Version 11 were used to estimate the results.Results:The mean total OOPE was Indian Rupees (INR) 2107 (95% confidence interval [CI]: 1788–2426) for single episode of hospitalization out of which medical expenditure was INR 1530 (95% CI: 1238–1821) and nonmedical expenditure was INR 577 (95% CI: 501–653). The OOPE on surgical conditions was 1.7 times more than the nonsurgical conditions. Drugs and diagnostics were the major components of hospital expenditure, whereas the share of transportation expenditure was more in the nonmedical expenditure. Further, most of the patients had to face hardship financing due to limited financial protection measures.Conclusions:With the growing debate on the rolling out of universal health insurance scheme in India, this study assumes significance by providing critical information for designing public financing strategies to protect the interest of the poor in public health care institutions.

Healthcare Delivery and Stakeholder’s Satisfaction Under Social Health Insurance Schemes in India: An Evaluation of Central Government Health Scheme (CGHS) and Exservicemen Contributory Health Scheme (ECHS)

This study attempted to evaluate the working of the Central Government Health Scheme (CGHS) and Ex-servicemen Contributory Health Scheme (ECHS) by assessing patient satisfaction as well as the issues and concerns of empaneled private healthcare providers.The study is based on a primary survey of 1,204 CGHS and 640 ECHS principal beneficiaries, 100 empaneled private healthcare providers and 100 officials of the schemes across 12 Indian cities.We have found that patients are reasonably well satisfied with the healthcare services of both empaneled private healthcare providers and the dispensaries-polyclinics but are relatively more satisfied with the former than the latter. We also found that beneficiaries are willing to pay more for better quality services. Though the schemes provide comprehensive healthcare services, the beneficiaries incur some out-of pocket health expenditure while seeking healthcare. Furthermore, beneficiaries are not in favor of the recent proposal to replace the schemes with health insurance for several reasons. The empaneled private healthcare providers are dissatisfied with the terms and conditions of empanelment, especially the low tariffs for their services as compared to prevailing market rates and the delays in reimbursements from the schemes.We suggest that appropriate efforts be undertaken to enhance the quality of healthcare service provided in the dispensaries-polyclinics of the CGHS and ECHS as well as to address the issues and concerns of empaneled private healthcare providers to ensure better healthcare delivery and for a long-term, sustainable public-private partnership.

An evaluation of two health insurance schemes in India

The study aimed to find out the functioning of two community-based health insurance schemes through patients enrolled in them, at a tertiary care hospital in Karnataka, South India. Methodology: It was a cross sectional study, total of 384 patients was randomly selected from the whole lot of patients who were enrolled in the two selected community-based health insurance schemes. The study was carried out using a pretested semi structured questionnaire. About. 98% of the respondents said that they availed services 1–3 times from the scheme in 1 year; 89% of the respondents said that discount provided by the scheme was useful. Satisfaction levels of the card users were analyzed and out of 384 patients, 54.9% patients said that their scheme was good and 51.8 felt that admission and claim process was good. About 49.2% said that quality of treatment was good. It can be concluded that many users are satisfied with the health insurance they have opted and utilisation rate of the card is high.

Making health insurance work for the poor: Learning from the Self-Employed Women's Association's (SEWA) community-based health insurance scheme in India

How best to provide effective protection for the poorest against the financial risks of ill health remains an unanswered policy question. Community-based health insurance (CBHI) schemes, by pooling risks and resources, can in principal offer protection against the risk of medical expenses, and make accessible health care services that would otherwise be unaffordable. The purpose of this paper is to measure the distributional impact of a large CBHI scheme in Gujarat, India, which reimburses hospitalization costs, and to identify barriers to optimal distributional impact. The study found that the Vimo Self-employed Women's Association (SEWA) scheme is inclusive of the poorest, with 32% of rural members, and 40% of urban members, drawn from households below the 30th percentile of socio-economic status. Submission of claims for inpatient care is equitable in Ahmedabad City, but inequitable in rural areas. The financially better off in rural areas are significantly more likely to submit claims than are the poorest, and men are significantly more likely to submit claims than women. Members living in areas that have better access to health care submit more claims than those living in remote areas. A variety of factors prevent the poorest in rural and remote areas from accessing inpatient care or from submitting a claim. The study concludes that even a well-intentioned scheme may have an undesirable distributional impact, particularly if: (1) the scheme does not address the major barriers to accessing (inpatient) health care; and (2) the process of seeking reimbursement under the scheme is burdensome for the poor. Design and implementation of an equitable scheme must involve: a careful assessment of barriers to health care seeking; interventions to address the main barriers; and reimbursement requiring minimum paperwork and at the time/place of service utilization.