Emerging Health Insurance Sector – A Digital Approach for Tackling Issues and Challenges

This article first appeared in The HealthCare Radius print issue (November 2017). It has been reproduced here for the readership of this blog. 

As state and central governments strive towards making healthcare affordable, Indian healthcare is transitioning to innovate and introduce best practices using technology to provide basic healthcare access to all citizens. The sector is also having the potential to leverage technology to bring in standardization, create efficient delivery systems thus ensuring reach, growth, and profitability. With this approach, technology can be used to address problem areas across various levels of the healthcare delivery process –

The Consumer Problem

As health insurance serves a crucial healthcare need, meeting the policyholder’s expectations in terms of product and service is crucial. The current scenario, however, is far from ideal. To start with, the unavailability of unbiased information while purchasing a policy and lack of awareness about utilization guidelines, cashless policies has crippled the adoption of policies in India. Secondly, once a patient is admitted, the lack of transparency of the health insurance approval and reimbursement process leads to an unsavoury hospital experience. Thirdly, the current process of information exchange between hospitals and payers is also prone to errors, back and forth between insurance desks that result longer turnaround times, where customer service too suffers.

Link the Hospital

The volume and scale at which insurance desks in hospitals process health insurance claims daily itself justify the need for a streamlined and simplified approach to claims processing that ensures a hassle-free experience for the hospital as well as the patient. Common problems faced by hospitals include – long waiting time after the discharge in case of cashless insurance, back and forth between the insurance desk and the payer and answering continuous queries about policy approval status from relatives due to the lack of transparency in the whole process. Additionally, while hospitals are dealing with multiple insurers to process patient claims, the information exchange process is still manual, time consuming and prone to error.

Primary and Secondary Healthcare

Several experts in the industry suggest that going forward, the industry’s agenda must expand its focus to include an outpatient health insurance cover to enable the utilization of primary and secondary healthcare, synonymous to the tertiary services that are currently being provided. Fewer than 2.50 per cent of patients in any given year need hospital-based care, which implies that 97.5 per cent of all conditions would need to be dealt with at the primary-care level. (Mor & Kalita, 2014) Justifiably, there is a need to invest considerably in primary level healthcare within a framework that averts patients from hospital-based care unless required.

Since, the primary and secondary healthcare providers cater a customer base much larger than that of the hospitals, handling traffic on such a large scale would require a network of primary health facilities, that are adequately staffed, skilled and supported along with a reliable logistical support system on a strong technology framework. Certainly, given the challenge and need, upon this day and age, a technological framework that can support such a large volume of transactions for real-time response is one that is completely automated.

Addressing the issues and challenges – The role of technology

The aim must be to develop an active interdependent relationship with technology as opposed to complete dependency. This relationship will serve the needs of all stake-holders, while also improving efficiency, transparency, and delivery of resources. Similarly, across the key challenges and issues elaborated on earlier, digitalization and standardization of practices can bring about significant changes in the claims exchange process:

For the consumer and the hospital:

For a better way of delivering health insurance, a technology framework should be implemented which brings the provider and the payer into a single platform to exchange claims electronically hence enabling quicker processing of claims data. Automation in terms of providing messages and emails about claim status to the policy holder would result in transparency.

From a hospital’s perspective, electronic data gathered from the claims exchange process will help them view monthly transactions, identify trends, and streamline financial data that can be analysed on a large scale.

On a public level, health insurance data can be used to identify healthcare trends – age groups when individuals are being diagnosed with diabetes, frequency of diseases by geography, etc. With relevant data, predictive analysis is a great way to work on solutions that can benefit coming generations.

For outpatient health insurance:

Delivering primary healthcare to consumers without a digitized technology framework is difficult. A patient visiting a physician for fever cannot wait for the payer to approve eligibility and adjudication on email.

A comprehensive healthcare policy linked with a database such as AADHAR can be a way to deliver outpatient schemes. To elaborate on how it would work – the patient walks in to the clinic, produces the ADHAAR ID, the physician enters the ID for eligibility, selects the ailment from a drop-down menu, administers treatment, clicks the button, the amount is deducted from the sum insured. Similarly, the pharmacy and the diagnostic centre can also be linked on this platform where reports are shared digitally, medicines can be ordered through the platform and delivered home.

Technology also opens possibilities such as appointment scheduling, effective grievance redressal, and case record maintenance from the primary care level.  With technology, we have a better chance at reaching out to a larger populace, especially those in need. With technology, we have a better chance at simplification.

What lies ahead?

The health insurance sector should make much more progress towards becoming more electronic based. In an age where financial payments such as income tax returns filings, paying taxes, statutory documents such as Form 16, TDS deduction forms are all paperless, health insurance claim transactions still require a lot of paper. We must work towards enabling a technology platform and standard where this need is reduced significantly if not eliminated. We, as an industry must collaborate to make that happen because without the aggressive adoption of technology, best practices and creation of standards rapid progress is very difficult.