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Process Evaluation Report: Chief Minister's Comprehensive Health Insurance

Scheme, Tamil Nadu

Technical Report · June 2017

DOI: 10.13140/RG.2.2.33648.46084

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PROCESS EVALUATION REPORT

Chief Minister’s Comprehensive Health Insurance Scheme, Tamil Nadu

JUNE 2017

PROCESS EVALUATION REPORT

Chief Minister’s Comprehensive Health Insurance Scheme,

Tamil NaduJUNE 2017

Authors Anup Karan, Arpita Chakraborty, Hema Matela, Swati Srivastava and Sakthivel Selvaraj from PHFI, New

Delhi Elna James Kattoor, Lakshmi Ramakrishnan, Tirumaal Arumugam, Umakant Dash, and V.R.

Muraleedharan from IIT, Madras Girija Vaidyanathan from Sarvahita Health Research Association, Chennai

Contributors Rajesh M from IIT, Madras

Suggested CitationKaran, A., Chakraborty, A., Matela, H., Srivastava, S., Selvaraj, S., Kattoor, E. J., Ramakrishnan, L., Arumugam, T., Dash, U., Muraleedharan, V.R., Vaidyanathan, G. (2017). Process Evaluation Report of Chief Minister’s Comprehensive Health Insurance Scheme, Tamil Nadu. New Delhi, India: Public Health Foundation of India

© Public Health Foundation of India. All rights reserved.June 2017

PubliC HeAltH FoundAtion oF indiADelhi-NCRPlot No. 47, Sector 44, Institutional AreaGurgaon, Haryana 122002www.phfi.org

Possible inaccuracies and errors are unintentional and the sole responsibility of the authors.

Design and printed by 3P Solutions (www.3psolutionsindia.com)

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FoReWoRd 7

ACknoWledgement 8

liSt oF AbbReviAtionS 10

exeCutive SummARy 13

1. intRoduCtion 18

1.1 CMCHIS: salient features 19 1.1.1 Eligibility 20 1.1.2 Cashless hospitalization and coverage 20 1.1.3 Follow-up treatments 21 1.1.4 Diagnostic procedures 21 1.2 Operational aspect of the scheme 22 1.2.1 Institutional framework 22 1.2.2 Selection process for insurance agency 23 1.2.3 Selection process for the TPA 23 1.2.4 Empanelment of network hospitals 24 1.3 Methodology 24 1.3.1 Qualitative information 24 1.3.2 Quantitative information 25 1.4 Structure of the report 25

2. AWAReneSS geneRAtion PRogRAm 26

2.1 Types of IEC activities taken up 27 2.2 Outreach programs 30 2.3 Expenditure on IEC 33 2.4 Awareness level among the card-holders 34 2.5 Discussion and Conclusion 35

3. enRolment PRoCeSS 37

3.1 Phases of enrolment 37 3.2 Enrolment through kiosk 39 3.3 Enrolmentthroughfields 41

ContentS

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3.4 Coverage of population under the scheme 41 3.5 Experience of the households with the enrolment process 43 3.6 Discussion and conclusion 45

4. PRovideR netWoRk, utilizAtion oF HeAltH CARe And ClAim PRoCeSS 46

4.1 Empanelment of Providers 46 4.1.1 Procedure for empanelment - selection criteria and grading 46 4.1.2 Growth and distribution of empaneled facilities 48 4.2 Patterns of claims (utilization) 49 4.2.1 Overall pattern 49 4.2.2 Government vs.private hospitals 50 4.2.3 District-wise utilization 51 4.2.4 Gender-wise utilization 52 4.2.5 Age-wise utilization 54 4.2.6 Types of treatment: surgeries vs. therapies 55 4.2.7 Utilizationofspecificpackages[excludingreservedpackages for government providers] 56 4.2.8 Reimbursement for treatment 59 4.2.9 Utilization by procedures reserved for public facilities 66 4.3 Claim experience 67 4.3.1 Claim process 67 4.3.2 Turn-around time to settle claims 69 4.4 Discussion and conclusion 71

5. PuRCHASing oF HeAltHCARe And PRovideR PAyment meCHAniSmS 73

5.1 Organization of Chief Ministers Comprehensive Health Insurance Scheme 75 5.2 Purchasing of Healthcare Services 77 5.2.1 Purchasing in CMCHIS 77 5.2.2 Strategic purchasing 83 5.2.3 Purchasing in other Indian social health insurance schemes 86 5.3 Provider payment mechanisms 88 5.3.1 Provider payment mechanisms and incentives in CMCHIS 88 5.3.2 Refund – an incentive to make claims 89 5.3.3 Penalties for providersfor non-adherence to guidelines 90 5.3.4 Provider payment features across Indian social health insurance schemes 90 5.4 Claim ratio under the CMCHIS Scheme 91 5.5 Discussion and conclusion 92

6. monitoRing meCHAniSm 94

6.1 Overall monitoring of the scheme by TNHSP 94 6.2 Monitoring mechanism involved in overall functioning of the scheme 95 6.2.1 Fresh enrolment 95 6.2.2 Distribution of CMCHIS Card 96 6.2.3 Health camps 97 6.2.4 Database Management 97 6.2.5 Hospital Empanelment and De-empanelment 97 6.2.6 Financial Audit of empaneled hospitals 97 6.3 Monitoring during hospitalization 98 6.3.1 During admission 98 6.3.2 During hospitalization 99 6.4 Post-hospitalization – claim settlement 100 6.5 Purchasing of consumables and implants 101 6.6 Discussion and conclusion 101

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7. ConCluding obSeRvAtionS 104

ReFeRenCeS 106

AnnexuReS

Annexure 3.1: District-wise Distribution of Hospital Network across Tamil Nadu under the CMCHIS Scheme, 2015-16 108

Annexure 4.1: Grading Criteria under CMCHIS for Multi-specialty Hospitals 109Annexure 4.2: District-wise Number of Active Hospitals Empaneled under the CMCHIS Scheme –

2012-13 to 2015-16 110Annexure 4.3: Number of Scheme Utilization by Districts – 2012-13 to 2015-16 112Annexure 4.4: District-wise Number of Scheme Utilization by Male and Female in Government and

Private Hospitals, 2015-16 114Annexure 4.5: Percentage Share of Utilization by Female across Package Categories 115Annexure 4.6: Number of Claims by Various Age-Groups across Package Categories, 2015-16 116Annexure 4.7: Package-wise Median Final Approved Amount (Reimbursed) per Claim from

2012-13 to 2015-16 - Government, Private and Total 118Annexure 4.8: District-wise Average per Claim Reimbursement in Government and Private

Hospitals by Gender, 2015-16 (in INR) 120Annexure 4.9: Key Indicators by Package Categories Reserved for Government Facilities 121Annexure 4.10: Percentage of Final Approved to Claim Amount by Packages across

Government and Private Facilities 122Annexure 4.11: Average Claim and Approved Amount for Highly Utilized Packages by Type of

Facility: 2012-13 to 2015-16 124Annexure 5.1: Claim and Burnout Ratios under CMCHIS as per Financial Year, 2012-13 to 2015-16 125Annexure 6.1: Institutional Structure for Monitoring under CMCHIS 126

LIST OF FIGURES

Figure 1.1: Institutional Framework of CMCHIS 23Figure 2.1: Process Flow of Developing IEC Materials 27Figure 2.2: Booklet on the CMCHIS Scheme 28Figure 2.3: Board about the CMCHIS Scheme 29Figure 2.4: Poster Containing Information on Health Camps Conducted by Hospitals

under CMCHIS 31Figure 3.1: DifferentModesofEnrolmentinCMCHIS 38Figure 3.2: Enrolment and Smart Card Distribution to Eligible Families under CMCHIS

(12.9 million families) 39Figure 3.3: Cumulative Enrolment through District Kiosks – 2012-2015 40Figure 3.4: TPA-wise Number of Enrolled Households at District Kiosks 40Figure 3.5: District-wise Distribution of Percentage Enrolled in CMCHIS to Total

Population in 2015 42Figure 4.1: Number of Empaneled Hospitals across Districts - by Government and Private,

2015-16 48Figure 4.2: District-wise Distribution of Empaneled Hospitals under CMCHIS, 2015-16 49Figure 4.3: District-wise Average Number of Claims per Empaneled Hospital - Government and

Private, 2015-16 52Figure 4.4: Male and Female Distribution of Utilization: 2012-13 to 2015-16 53Figure 4.5: Percentage Distribution of Utilization by Age Groups, 2012-13 to 2015-16 54Figure 4.6: Cardiothoracic Surgeries - Age-wise Number of Claims, 2012-13 to 2015-16 55Figure 4.7: Percentage Distribution of Claims by Type of Treatment across Government and

Private Hospitals, 2012-13 to 2015-16 56Figure 4.8: Utilization per Procedural/Surgical Categories in Government and Private 58

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Facilities (2012-13 to 2015-16)Figure 4.9: Total Claim Amount Paid (Reimbursement) to Government and Private

Hospitals: 2012-13 to 2015-16 59Figure 4.10: Average Reimbursement of Treatment during 2012-13 to 2015-16 - by Government,

Private and Total (in INR) 60Figure 4.11: District-wise Average per Claim Reimbursement in Government and Private Hospitals,

2015-16 (in INR) 61Figure 4.12: Claim Settlement Process under the CMCHIS Scheme 69Figure 4.13: Percentage Distribution of Claims by Turn-Around Time (TAT) by Type of

Facility – 2012-13 to 2015-16 70Figure 5.1: Health Financing Functions 74Figure 5.2: Organogram of the CMCHIS on the Purchaser-Provider Backdrop 75Figure 5.3: Actors, Institutions and Their Responsibilities in the CMCHIS 76Figure 5.4: Principal-Agent Relationship in CMCHIS 83Figure 5.5: Claims and Premiums under CMCHIS: 2012-13 to 2015-16* 92Figure 6.1: Overall Monitoring of the Scheme by TNHSP 95Figure 6.2: The Monitoring System during Scheme Enrolment 96Figure 6.3: Hospital Monitoring System under the CMCHIS Scheme 98Figure 6.4: Monitoring Process during Hospitalization under the CMCHIS Scheme 99Figure 6.5: Monitoring Process during Post-Hospitalization (Claim Settlement) under the

CMCHIS Scheme 100

LIST OF TABLES

Table 2.1: Distribution of Health Camps and Mega Camps by Districts and TPAs 32Table 2.2: IEC Expenditure by Year (in INR Crore) 33Table 2.3: Awareness about Key CMCHIS Features among the Enrolled Households

(% of Correct Responses by Households) 34Table 3.1: Key Indicators - Card-Holders Experience with the Enrolment Process 43Table 4.1: Distribution of Empaneled (Public and Private) Hospitals across Grades

(as of August 2016) 47Table 4.2: Share of Government and Private Hospitals in Claims – 2012-13 to 2015-16 51Table 4.3: Average and Median Reimbursement by Type of Treatment during

2012-13 to 2015-16 - to Government and Private Hospitals (in INR) 61Table 4.4: Package-wise Average per Claim Reimbursement during 2012-13 to 2015-16 -

Government, Private and Total 63Table 4.5: Share in Number of Claims and Cost of Selected Highly Utilized Procedures under

CMCHIS in 2015-16 65Table 4.6: Key Indicators of the Procedures Reserved for Government Facilities 67Table 4.7: Average Pre-authorization, Claim Bill Amount and Final Approved Amount

during 2012-13 to 2015-16 - Government, Private & Total 68Table 5.1: Selected Mean Surgical Episode Expenditures by Ailment Categories from NSSO and

CMCHIS Package Rates, Tamil Nadu (INR) 82Table 5.2: Strategic Purchasing Features across Indian Social Health Insurance Schemes 87Table 5.3: Claims Ratio and Burnout Ratio, 2012-13 to 2015-16* 91

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ACknoWledgement

This report is an outcome of a collaborative work between the Public Health Foundation of India (PHFI, Delhi), Indian Institute of Technology (IIT, Madras), Sarvahita Health Research Association, Chennai and Tamil Nadu Health System Project (TNHSP).

Thereporthasbenefitedimmenselyfromcontributionsmadebyseveralofficialsfrom the Department of Health and Family Welfare. Foremost among them is Dr. J. Radhakrishnan, I.A.S., Principal Secretary, Health and Family Welfare, Government ofTamilNadu,whosecriticalcommentsonouranalysisandfindingshelpedusreviseandrefinemanyofourobservations.WethankDr.P.SenthilKumar,SpecialSecretary, Health and Family Welfare, for the special interest he has shown in this study. We are grateful to Shri Shambu Kallolikar, I.A.S., former Project Director, Tamil Nadu Health Systems Project (TNHSP), and Shri M.S. Shanmugam, I.A.S., former Project Director, TNHSP, for their support and encouragement in the initial stage of this study. We owe a special thanks to Shri. P. Umanath, I.A.S., Director, Rehabilitation and Welfare of Non-Resident Tamils, for sharing his deep knowledge of the various government sponsored insurance schemes in India and details of the current scheme.

We would like to place on record our deep sense of gratitude to Dr. Darez Ahmed, I.A.S, Mission Director, National Health Mission (Tamil Nadu), Dr. T. S. Selvavinayagam, Additional Director of Public Health, Government of Tamil Nadu, for their valuable and critical inputs on the study, and for their constant encouragement and unstinted support, both administrative and technical, to take this important work to its logical conclusion. We would like to thank Dr. Ravi Babu Sivaraj, Joint Director (CMCHIS, TNHSP) for his support. We owe a lot to Dr. Satish Raghavan V, Deputy Director, TNHSP, Dr. K. Vinay Kumar, Deputy Director, NHM-TN,Dr.SunilGavaskarParthasarathy,MedicalOfficer,CMCHIS,andDr.BabuShanmugam, Medical Officer, TNHSP, for their constructive comments on thereport and for their support in numerous ways during the entire study period.

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We wish to also gratefully acknowledge the critical inputs from Dr.K.Kolandaswamy, Director of Public Health and Preventive Medicine, Government of Tamil Nadu, at various stages of this study.

WeareextremelygratefultotheOfficialsoftheUnitedIndianInsuranceCompanyLtd., (UIIC, Chennai) and their associated Third Party Administrators, namely MDIndia Health Care, Vidal Health, and Medi Assist, for sharing the entire data set related to this study, and also for sharing their insights in the interpretation of various claims related issues.

Our sincere thanks to representatives of various private and public hospitals empaneled under CMCHIS and the participants of the household survey and focus group discussions, for sharing their experiences, views and impressions on the Scheme.

Thanks are also due to other colleagues of the Healthcare Financing Unit in PHFI who directly or indirectly helped in the preparation of the report.

The preliminary findings of this study have been presented at various foraincluding the Indian Institute of Technology, Madras; the Tata Institute of Social Sciences, Mumbai; the Post-Graduate Institute of Medical Education and Research, Chandigarh and others. We would like to thank the participants of these fora for their inputs and contributions in the preparation of the Process Evaluation Report of Chief Minister’s Comprehensive Health Insurance Scheme in Tamil Nadu.

The AUTHORSPublic Health Foundation of India,

Delhi NCRIndian Institute of Technology – Madras, Chennai

Sarvahita Health Research Association, Chennai

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liSt oF AbbReviAtionS

BPL Below Poverty Line

BSA Balance Sum Assured

CMCHIS Chief Minister’s Comprehensive Health Insurance Scheme

CPC Central Purchase Committee

DPO DistrictProjectOfficer

DRG Diagnosis Related Group

DRO DistrictRevenueOfficer

EDC Empanelment and Disciplinary Committee

ENT Ear Nose Throat

FFS Fee-for-Service

FGD Focus Group Discussion

FM Frequency Modulation

GDP Gross Domestic Product

GO Government Order

GoTN Government of Tamil Nadu

GSHIS Government-Sponsored Health Insurance Scheme

HMIS Health Management Information System

ICD InternationalClassificationofDiseases

IEC Information Education Communication

INR Indian Rupee

IP In-patient

IPHS Indian Public Health Standards

IRDA Insurance Regulatory and Development Authority of India

JCI Joint Commission International

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JD Joint Director

KII Key Informant Interview

LED Light-Emitting Diode

LO LiaisonOfficer

MCI Medical Council of India

MD Mission Director

MDI MD India

MoLE Ministry of Labour and Employment

MoM Minutes of Meeting

MoU Memorandum of Understanding

MRD Medical Record Departments

MSP Madras Security Prints

NABH National Accreditation Board of Hospitals and Healthcare Providers

NHM National Health Mission

NICU Neo-Natal Intensive Care Unit

NSSO National Sample Survey Organization

OBGY Obstetrics and Gynecology

OP Out-patient

PICU Pediatric Intensive Care Unit

PTCA Percutaneous Transluminal Coronary Angioplasty

RGJAY Rajeev Gandhi Jeevandayee Arogya Yojana

RI Revenue Inspector

SMS Short Message Service

RSBY Rashtriya Swasthya Bima Yojana

TAT Turn-Around Time

TN Tamil Nadu

TNHSP Tamil Nadu Health Systems Project

TPA Third Party Administrator

UHC Universal Health Coverage

UID UniqueIdentificationNumber

UIIC United India Insurance Company

USFDA United States Food and Drug Administration

VAO VillageAdministrativeOfficer

WHO World Health Organization

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exeCutive SummARy

introductionThe concept of government-sponsored health insurance schemes has emerged withtheaimofprovidingfinancialcovertopoorhouseholdsduringcatastrophichealth shocks. In Tamil Nadu, the Chief Minister’s Comprehensive Health Insurance Scheme (CMCHIS) was launched in 2011 to provide “quality medical care for identified specialty services requiring hospitalization for surgeries and medicalprocedure”. The main objective of the scheme is to enable access to health care for the lower income sections of the society. The enrolment is limited to families whose annual income is less than INR 72,000. This report traces the progress of the CMCHIS in TN (Tamil Nadu) till about mid-2016.

The scheme is implemented by the state government through the Project Director, Tamil Nadu Health Systems Project (TNHSP). The CMCHIS enables families to derive amaximumbenefitofINR4lakhover4years,withanannuallimitofINR1lakh,andaprovisiontogetbenefituptoINR1.5lakhforcertainspecifiedprocedures.Thebenefitisonafloaterbasis.

Awareness generation ProgramCMCHIS implementation also included various Information, Education and Communication (IEC) activities, primarily to increase awareness of the scheme. United India Insurance Company (UIIC) was mandated to implement the awareness generation and IEC activities in consultation with TNHSP. Health camps (held every month by empaneled hospitals) are an important outreach and awareness generation activity for increasing the coverage to remote/interior areas. UIIC officials reported that from2012 tilldateabout INR9crorehasbeenspentonawareness-generation programs.

A household survey was conducted in 10 sample districts of Tamil Nadu to assess the awareness level of the enrolled households. Out of the 2773 enrolled household covered in the household survey, almost three-fourth (74%) were continuing from the earlier state sponsored health insurance scheme sponsored by the Tamil Nadu Government. Among the remaining 26% households, enrolled newly in the CMCHIS scheme, half of them reported to have undergone any kind of IEC activity. Close to one-thirdofthem(31%)cametoknowabouttheschemefromthestaffmembersofPanchayatoffice/VillageAdministratorOfficer(VAO).

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However, over all awareness among the newly enrolled households regarding eligibility for the scheme is low, because 61% of the household had reported that they were not aware of the eligibility conditions. Regarding availability of the benefitsunderthescheme,only12%wereawarethattheycouldgettreatmentunder the scheme in both empaneled public and private hospitals. Awareness aboutpost-hospitalizationbenefitsforselectedprocedureswasparticularlylow.

enrolment ProcessThe Government of Tamil Nadu provided the basic details of the eligible persons and family members to be covered under the scheme. The details for a total of 1.34 crore families (including 1.29 crore from the previous scheme) were provided to UIIC immediately after the contract was awarded. The process of enrolling the eligiblebeneficiarieswasdoneby theTPAwith thehelpof thevendor (MadrasSecurity Prints (MSP), Eagle Prints). A new smart card – a health insurance identity card with a microprocessor chip, containing biometrics and photograph of all family members – was generated using the existing data on eligible families; a uniqueidentifier(UID)wasgeneratedandlinkedtotherationcard.

The scheme has a good population coverage. Around 56% of the total state population is covered under the scheme.

Provider network, utilization and Claim Process

Provider network With increased program coverage an adequate network of health service is required to meet the increased demand. Hence a total of 771 hospitals, 155 government and 616 private, are presently empaneled under the scheme. Other than the hospitals situated in the state (753), 18 other hospitals from the neighboring states of Karnataka, Kerala, Andhra Pradesh and Pondicherry have been empaneled. The hospitals are categorized into eight categories: six (A1-A6) for multispecialty hospitals, and two (S1-S2) for single specialty hospitals.

Many hospitals were also de-empaneled because of their poor performance and various complaints against them. Over the years, a total of 279 hospitals were de-empaneled from the network of CMCHIS, out of which 67 hospitals voluntarily dropped out of the scheme.

Utilization of healthcareOver the year, the overall claims (by bothmen and female beneficiaries) havegrown by 38.2% (from 255,673 in 2012-13 to 353,525 in 2015-16). In absolute terms,theclaimsbymaleandfemalebeneficiarieshaveincreasedby50.0%and20.4%, respectively, over the same years. The rate of increase in claims by males is

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greaterthanthatbyfemales.Asaresult,theshareoffemalebeneficiariestothetotal has fallen from 39.7% (in 2012-13) to 34.6% (in 2015-16).

Overall, utilization of private facilities is higher, which is in line with the high representation of private facilities in the hospital network. However, as against 22% share of public hospitals in the total number of hospitals, their share of total utilization was about 42% in 2015-16. Even if we exclude the procedures reserved for public facilities, the share of public hospitals in total utilization was about 37% in 2015-16.

The total number of claims in private and public facilities has gone up considerably. As a result the number of claims by Surgeries and Therapies show a quantum jump over the years. However, the share of Therapies in both public and private facilitieshasgoneupmoresignificantlythanSurgeriesovertheyears:from58.8%in public institutions and 60.9% in private institutions (in 2012-13) to 68.8% and 66.2%, respectively, in 2015-16.

In 2012-13, Medical Oncology was the highest utilized package (33,237 cases, 16.4%) but over the years the share of Nephrology has increased. The higher utilized packages in public hospitals as compared to the private ones are mainly NICU (Neo-Natal Intensive Care Unit) and PICU (Pediatric Intensive Care Unit). On the other hand, Nephrology, Knee & Hip Replacement, Ophthalmology surgery, Cardiothoracic surgery and OBGY (Obstetrics and Gynecology) are more utilized packages in private hospitals.

The scheme is utilized the most by individuals between the ages of 40 and 60 years. The utilization is lowest among the children between the ages of 2 and 5 years.

Claim experienceClaimprocessinvolvestwoprocesses:pre-authorizationandfinalclaimsettlement.

� OncetheCMCHISbeneficiarygetsadmittedtoahospital,thehospitalsubmitsprescribed documents through TPA (Third Party Administrator) for pre-authorization.Afterthepre-authorizationapproval,thebeneficiaryundergoesthe approved surgical/medical procedure.

� All the necessary claim documents need to be uploaded online at the time of discharge from the hospital. After the approval of the claim, e-payment is made to the hospital by UIIC.

The entire process of claims submission to e-payment (Electronic Payment) is expectedbe completedwithin sevendays from thedateoffinal submissionofclaims. While the claim settlement process is increasingly being improved, there is still scope for reducing the total turn-around time, particularly from the firstsubmissiontofinalsubmissionofdocuments.

The total amount paid through claims increased from INR 537 crore in 2012-13 to INR 708 crore in 2014-15. It dropped by INR 37 crore in 2015-16, amounting to a total claim of INR 671 crore.

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The average claimed amount (amount claimed per utilization) was less for the government facilities compared to the private ones for the four years under study. For government facilities, it is decreasing over time, whereas for private ones it is more or less the same amount over the past four years.

Purchasing of Healthcare and Provider Payment mechanismsLike other health insurance schemes in India, the CMCHIS follows a contractual system to purchase care from providers. The contracted insurer via third-party administratorsfulfillstheroleofpayersandpurchaseshealthservicesfromserviceproviders empaneled under the scheme.

� Organization of Chief Minister’s Comprehensive Health Insurance Scheme The government has involved an insurer to provide a basic package of services

from facilities empaneled under the scheme. The agencies involved are funding entity (TNHSP), Purchaser (United India Insurance Corporation) and three TPAs in the state (Vidal, MD India and Medi Assist). UIIC implements the scheme through the TPAs who oversee provider payments and contracts.

� Purchasing of Healthcare Services Under CMCHIS, the package cost for each procedure has been standardized

andfixed,usingapaymentmethodbasedonFee-for-Service(FFS)andcase-based payments through Diagnosis-Related Groups (DRGs). Package rates werefixedex ante through a consultative process involving TNHSP and other stakeholders.

Provider payment mechanisms CMCHIS appointed a sole purchaser (UIIC) to operationalize payments to

providers through three third-party administrators (TPAs). Government hospitals under the scheme operate with a mixed payment system, with elements of both ex ante and budget-based payment methods. This is linked to a six-tier gradation of service providers. Health care providers are paid for each case (treatment, diagnostic test, or post-operative procedures) treated. ProviderscanclaimpaymentunderacombinationofuptofiveDRGs,follow-up services and diagnostics for one patient.

Claim Ratio under the CMCHIS Scheme One of the indicators used to ascertain the viability of payment mechanisms

by the purchaser is the claim ratio. Claim ratio is the total amount paid to providers as a percentage to total premium amount. The trend in the approved claims and premium collected by insurers across 2012-16 in the CMCHIS is the following:

� Premiumscollectedremainedmoreorlessthesameduringthefirstthreeyears of the scheme and then increased almost by INR 100 crore to 755 crores in 2015-16.

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� Approved claim amounts have steadily increased over the years from approximately INR 537 crores in 2012-13 to INR 684 crores in 2015-16.

� The claim ratio increased from 74% in 2012-13 to 107% in 2015-16. Combining all four years, the claim ratio was around 98% and burnout ratio was 109%.

monitoring mechanism � The Project Director exercises overall regulation of the project activities. The ProgramOfficersareentrustedwiththedutiesofimplementation,inspectionand supervision of the functions of various programs implemented.

� The overall monitoring of the scheme is done primarily through two sources: (1) meeting of stakeholders conducted by TNHSP, and (2) the grievance cell, operated through the toll-free number.

� The monitoring process during hospitalization and post-hospitalization process is well documented and to a large extent well in place. The scheme needs better procedures to validate the eligibility of beneficiary in case ofemergency.

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1. intRoduCtion

Publicly funded health insurance scheme, specially targeted to the poor and other vulnerable sections of population, is considered an important mechanism in the pursuit of Universal Health Coverage (UHC) (WHO, 2010).Manydeveloping countries have used tax revenues to finance health insurance schemesand extend subsidized health insurance to their respective poor population. Prominent examples include Mexico,China,Columbia,thePhilippines,VietnamandThailand(Wagstaff&Lindelow,2008).

Indiajoinedthisgroupofcountries,bylaunchingthefirsteverfullysubsidisedstate-levelhealthinsurancescheme labelled ‘Rajiv Aarogyasri,’ in the year 2007, in the state of Andhra Pradesh. Following this, ‘Rashtriya Swasthya Bima Yojana’ (RSBY) was launched by the Indian Ministry of Labour and Employment (MoLE) in the year 2008. A few other Indian states such as Tamil Nadu, Maharashtra, Karnataka, Himachal Pradesh and Kerala also took proactive initiatives in this direction. All these publicly funded health insurance schemes aim to improve access to quality healthcare by the poor and other vulnerable sections of the population and providethemfinancialriskprotection(MoLE,2008).

Tamil Nadu’s Chief Minister’s Comprehensive Health Insurance Scheme (CMCHIS), launched in the year 2012 isaneffortinthisdirectionbythepresentStateGovernmentofTamilNadu.Theschemeaimstoprovidefinancialriskprotectiontopoorandothervulnerablepopulationofthestateagainstexpensivetherapeuticand surgical health conditions (http://www.cmchistn.com/index.php). The scheme’s name contains the word ‘comprehensive’signifyingtheloftybenefitprovisionsintheschemecoveringapproximately60%ofthestate population for more than 1,000 health conditions on a ‘cashless’ (no over-the-counter payment) basis.

Theschemehasprogressedsignificantlyoverthepastfouryearsintermsofthefollowing:

� geographic coverage � number of enrollees across districts, � numberofmaleandfemalebeneficiaries, � engagement of private and public health providers, � coverage of high-cost procedures,

As of date, more than 1.6 crore (16 million) families (approximately 43 million lives) from across all the districts of the state are enrolled in the scheme, being entitled to utilize healthcare services from about 770 hospitals located within the state and the neighboring states of Karnataka and Kerala (http://www.cmchistn.com/features_ta.php, accessed on 10 August, 2016). The Government of Tamil Nadu spends approximately INR 750 crore (http://www.tnbudget.tn.gov.in/demands/d19.pdf) a year towards premium to the insurance company and other monitoring mechanisms, which constitutes up to 9% of the total health budget of the state.

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Duringthelastfouryearsofitsimplementation,theschemehassignificantlyevolvedintermsofoverallgovernanceandmanagementofthescheme.Thisisreflectedinthedesignandimplementationofstrategicpolicy guidelines with regards to the following:

� enrolment processes, � payment methods, � empanelment of providers, � regulatory measures to ensure compliance of providers � awarenesscreationamongpotentialbeneficiariestoimproveeffectivecoverageofthescheme.

Overall, the scheme has gained a positive public image and credibility in terms of what it can do to reduce thedis-comfortsofsevereillnessesandfinancialburdenonmillionsofpeople,particularlytheeconomicallyvulnerable sections of the society.

Needless to say, there is enormous scope to further strengthen the overall functioning and performance of the scheme. This report provides an analysis of the functioning and progress of the scheme over the past fouryears(2012-16),itattemptstothrowlightonspecificconstraintsorissuesthatneedtobeaddressed,and also suggest someways forward for policymakers to enhance the reach and effectiveness of thescheme in the years to come. Lessons of CHCHIS would certainly help in building the healthcare system of thestate,encompassingboththeprivateandpublichealthcareproviders,andinfulfillingthebasictenetsof universal health coverage in Tamil Nadu in the years to come.

Section 1.1 in the present chapter provides salient features of the scheme (eligibility conditions for enrollees, cashless payment method, follow up treatments, diagnostic procedures).

Section 1.2 provides details of Operational Framework of the Scheme, including selection process for insurance agency, Third-Party Administrators (TPAs) and empanelment of providers.

Section 1.3 presents the overall methodology followed for this study.

The over-arching purpose of this study is to throw light on the factors that have enhanced or hindered the effectivenessofthescheme,andsuggestwaysinwhichitseffectivenesscanbestrengthenedinthenearfuture.

1.1. CmCHiS: salient featuresThe scheme aims to ensure access to treatment for a number of severe and life-threatening ailments through a network of public and private hospitals. This is a cashless scheme implying ailing persons covered in the scheme are not required to pay any amount over the counter at the time of availing hospital services. Till date, around 16 million households amounting to approximately 43 million population of the state, have been issued health cards under the scheme.

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1.1.1. eligibilityTheeligibilitycriteriondefinedforavailingthebenefitsoftheschemeis“anyfamilywhoseannualincomeisINR72,000orless”ascertifiedbytheVillageAdministrativeOfficer(VAO),membersofunorganizedlabourwelfare boards, and the spouse, children and dependent parents of such members in urban and rural areas. AllGovernmentservants,civilpensioners,EmployeeStateInsurancebeneficiariesandfamilieshavinganannual income of more than INR 72,000 are not eligible under this scheme. The term eligible family includes the eligible member and his or her family, which includes

1. the legal spouse,2. children of the eligible person till they get employed or married or attain the age of 25 years,

whichever is earlier, and who are dependent on the eligible person, and3. dependent parents of the eligible person.

Chapter3presentsdetailsofhoweligiblemembersareidentifiedandenrolledintheScheme:

Box 1.1: Eligibility of Family Members to Enroll under CMCHIS

If any person, in any of the categories (1), (2) or (3), is enlisted in the family ration card, then it shallbepresumedthatthepersonisamemberofthefamily,andnofurtherconfirmationwouldbe required. If any member of the family of an eligible person is eligible to have his/her name included in the family of an another eligible person, he/she would be eligible to have his/her name included in one health insurance identity card only and claim assistance under one card only. Once the children of the family head get employed or married or attain the age of 25 years, whichever is earlier, they should obtain fresh smart cards after establishing their eligibility with proof of the coverageintheFamilyRationCardandtheSmartCardaswellasIncomeCertificatefromtheVAO.

Source: http://www.cmchistn.com/eligibility_en.php

1.1.2. Cashless hospitalization and coverageTheschemeenables theenrolled families toderiveamaximumbenefitof INR4 lakhover4years (INR1 lakh in each year); it has a provision to avail benefits up to INR1.5 lakh for certainprocedures (likerenal transplantation, cochlear implant surgery etc.).1Thebenefitisonafloaterbasis2 and can be availed individually or collectively by members of the family during the policy year with no restriction on the number oftimesthebenefitsareavailed.Theunutilizedentitlementwilllapseattheendofeverypolicyyear.This

1 For details of procedures with a coverage of 1.5 lakhs per annum, please see Annexure D of the Tender document (http://cmchistn.com/tender_document.pdf)2Familyfloaterplansarehealthinsuranceplansthatcoverallmembersofafamilytogetheronasharedbasisandwithnoindividual

limit for each member.

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3 http://www.cmchistn.com/features.html4 http://www.ndtv.com/india-news/tamil-nadu-jayalalithaa-launches-new-health-insurance-scheme-461039

implies that utilization of the scheme by any member of the family anytime during any year of this 4-year-term will be deducted from the cap and the balance for the year continues to remain for further use by the same or other family members.

Coverage of Treatments:

Theschemepresentlycoverstheexpensesincurredfor1,016tertiarycareproceduresunder36differentspecialties.3 Certain tests prior to and after surgeries are also covered under the scheme.4 Certain conditions such as amputation under orthopedic trauma, poly trauma, mastoidectomy, tympanoplasty under Ear Nose Throat (ENT) etc (56 packages in total) are reserved to be treated only in government hospitals. Special Wards (named as Amma Ward) have been created in public institutions empaneled under this scheme. The proceduresunder the schemehavebeenclassifiedunderdifferent categories.Outof1,016procedurescovered under the scheme, some procedures are covered up to INR 1 lakh; some up to INR 1.25 lakh and high-end procedures and critical procedures covered up to INR 1.5 lakh per year (see the Tender document for details, http://cmchistn.com/tender_document.pdf).

1.1.3. Follow-up treatmentsTheschemealsoprovides113follow-upcoverageinpost-hospitalizationforcertainspecificproceduressuch as total thyroidectomy, portocaval anastomosis, operation of adrenal glands bilateral, and splenorenal anastomosis. The scheme provides disease-specific package for follow-ups, consultation, investigation,drugs etc. for a period of one year. Follow-up treatment is entirely cashless to the patient and starts on the 6th day after discharge from hospital and continues for one year. The package amount for the follow-up is apportionedtofourquartersforoperationalconvenience.Moreamountisallocatedforthefirstquarterasfrequency of visits and investigation is likely to be more in this quarter. The approval for the treatment is given for one quarter at a time. At the time of discharge, the patent is informed of the importance of follow up consultations.

1.1.4. Diagnostic proceduresThere are 23 diagnostic procedures, included in the 1,016 procedures, covered under this scheme. Each ofthesediagnosticprocedureshaveapre-fixedreimbursementrate.Thisisinadditiontothediagnostictests included in the general package for hospitalization. Only those patients referred through government institutions or screening camps are eligible under such diagnostic tests.

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1.2. operational aspect of the scheme

1.2.1. Institutional frameworkTheschemeis implementedbythestategovernmentthroughtheofficeofProjectDirector,TamilNaduHealth Systems Project (TNHSP), located in Chennai. The Scheme at present functions under the Mission Director (MD), State Health Mission. The Misson Director of the National Health Mission (NHM, TN State) exercisesoverallregulationoftheinsurancescheme.Variousprogramofficersareinplaceformonitoringandeffectiveimplementationoftheschemeacrossthestate.

The United India Insurance Company (UIIC) is entrusted with the responsibility for enrolment of eligible households, empanelment of hospitals and service delivery through empaneled hospitals. UIIC through third-partyadministrators(TPAs)fulfillstheresponsibilityofday-to-dayoperationsandmonitoringofthescheme.At thedistrict-level,UIIC/TPAshavea teamofprogramvigilanceofficers,whoareengaged inimplementing and monitoring the scheme.

TheTPAshavedeputedLiaisonOfficers(LOs)ateachempanelledhospitalforsmoothfunctioningofthescheme.TheLOisthefirstpointofcontactforthepatientsatanempanelledhospital.He/shehelpspatientsinenrollingandincompletingformalitieswiththeproviderstoavailbenefitsofthescheme.Theschemealso has a 24/7 functioning Call Centre to address queries and to help eligible patients smoothly go through the enrolment processes (Figure 1.1).

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Figure 1.1: Institutional Framework of CMCHIS

LiaisonOfficerat empaneled

hospitalsCall center Monitoring and

surveillance teams

TNHSP / MD / NHM

Tamil Nadu Government

Software application for preauthorization and

claim- processing

Enrolment, Issue and distribution of smart cards

TPA 1 (VIDAL)District administration

TPA 2(MD INDIA)

TPA 3(MEDI ASSIST)

VENDOR(Remedinet)

VENDOR(MS PRINT)

Lead Insurance Company (UIIC)

1.2.2 Selection process for insurance agency AtenderwasfloatedbytheGovernmentofTamilNaduin2011.Throughacompetitivebiddingprocess,UIIC was chosen to be the insurer of the CMCHIS as they had quoted the lowest premium at INR 497 per family in the year 2012.

1.2.3 Selection process for the TPA TPAs were recruited by the UIIC. According to the Insurance Regulatory and Development Authority of India (IRDA) Regulations, 2001, health insurance companies (here UIIC) can engage TPAs for processing healthinsuranceclaimsanddistributinginsurancecards.UIICfloatedatendertorecruitTPAsand29TPAsparticipated in the tender, in which three TPAs were selected. These were:

� Vidal, � MDI India and � Medi Assist.

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1.2.4. Empanelment of network hospitalsIn the initial phase, in 2012, UIIC invited applications online from hospitals across all 32 districts of the state, who wished to get empaneled under the scheme. A team of doctors (appointed by TPAs) scrutinized the applications and inspected the facilities, collected relevant information and documents and submitted a consolidated report to UIIC. As per guidelines of this scheme, both private and government hospitals can be empaneled with the approval of the Empanelment and Disciplinary Committee. There is also a provision of de-empaneling the empaneled hospitals if they do not comply with the laid-down criteria of quality and standard. Any de-empanelment is done through the Empanelment and Disciplinary Committee. De-empanelment happens if a hospital is found to be engaged in any fraudulent activities, or for low performance over a period of time or conducted no health camp, for more than a year.

More details on recruitment of the insurance agency, TPAs and empanelment of hospitals are presented and discussed in Chapters 4 and 5.

1.3. methodologyThe study followed a mixed-methodology by using both qualitative and quantitative data. Data was collected from both primary and secondary sources during the period of May 2015 - May 2016.

1.3.1. Qualitative informationVarious scheme-related information, such as the following, was collected from the CMCHIS website, various Government Orders (GOs), tender documents, and several Minutes of Meetings (MoMs):

� key features of the CMCHIS, � eligibility criteria, � empanelment of hospitals, � selection process of insurance agency and TPAs

Apart from these secondary sources, qualitative information was also collected from primary sources. Key Informant Interviews (KIIs) were conducted with representatives of the following:

� TNHSP, � UIIC, � TPAs (three), � DistrictProjectOfficers(DPOs), � LiaisonOfficers(LOsarelocatedatthenetworkhospitals)and � Public and private empaneled hospitals (five randomly selected from the list of the network

hospitals). In addition, Focus Group Discussions (FGDs) were conducted in 10 randomly selected districts consisting of 10-12 individuals, both enrolled and non-enrolled (roughly around 50:50) under the scheme. The FGDs also included participants, who have utilized the scheme.

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1.3.2. Quantitative informationAdministrative data on the enrolment, network hospitals, premium amount paid by government to the insurance agency, and claims paid to various providers, district-wise, procedure- wise and gender-wise, were collected from the TNHSP and the UIIC.

In addition, a primary survey was conducted on 5,503 households, both from the rural and urban areas, from the same 10 randomly selected districts on the basis of cluster analysis in Tamil Nadu. Out of the 5,503 households, 2,773 were enrolled in the CMCHIS scheme. Household survey questionnaire covered socio-economic and demographic factors, health profile of the household in near past and associatedexpendituresandfinancialmechanisms.

Information on the utilization of in-patient care and corresponding expenditure pattern for Tamil Nadu was estimated using the 71st round of household survey data, conducted by the National Sample Survey in 2014 (Health and Morbidity Round).

1.4. Structure of the reportChapter 2 discusses awareness generation of the scheme and Chapter 3 contains details of the enrolment process. Chapter 4 presents a detailed analysis of the utilization of the scheme, including the process of empanelment of providers and distribution of claims amount, by district, private and public facilities, gender and major categories of procedures/treatments.

Chapter5addressestheissuesrelatedto“strategicpurchasing”andthescopeformakingitmoreeffectivein the future. Current challenges being faced with regard to payment methods adopted for providers are also analyzed in this chapter.

Effectivemonitoringisparamountforsustainingtheoveralleffectivenessofthisscheme.Monitoringcoversa range of activities, including conduct of health camps, enrolment of patients, empanelment and de-empanelment of providers, claims payment, discharge reports and post-hospitalization. These are discussed in Chapter 6.

OverallconcludingobservationsandbroadpolicysuggestionstoenhancetheeffectivenessoftheSchemesare presented in Chapter 7.

5 The 10 randomly selected districts were Thiruvallur, Krishnagiri, Salem, Coimbatore, Dindigul, Cuddalore, Perambalur, Pudukottai, Kanniyakumari and Nagapattinam. These districts were selected based on cluster analysis of districts using various district-level socio-economic, demographic and infrastructural indicators.

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2. AWAReneSS geneRAtion PRogRAm

Information, education and communication (IEC) activities play a pivotal role in public health programs forgeneratingawarenessthroughdifferentcommunicationstrategiesandhelpcreatedemandforhealthservices and bring about behavioral changes. Awareness generation combines strategies, approaches and methods that enable individuals, families, and communities to play active roles in achieving, protecting and sustaining their own health. Channels for IEC can include interpersonal communication (such as counselling sessions or community meetings and events) or mass media communication (such as radio, television, newspaper, brochures, leaflets, posters, audio/visual materials). Successful IEC activities canfacilitate connecting people to the programs or reaching coverage targets and increasing adoption of healthy behaviors or appropriate actions for health problems, contributing toward the impact of public health programs (Das & Leino, 2011). One of the successful campaigns in India is the Pulse Polio campaign where IEC strategies played a key role in increasing coverage of polio vaccination and eradiation of polio (UNICEF, 2003). A study of the Rashtriya Swasthya Bima Yojana (RSBY), a Government of India’s ambitious health insurance program for the below-poverty-line population, suggests that the households, who had recently been reached by IEC were more likely to enroll in the scheme (Das & Leino, 2011).

CMCHIS implementation also included various IEC activities, primarily to increase awareness of the scheme. Additionally the IEC campaign is intended to provide the details of coverage under the scheme, to facilitate better understanding of implementation of scheme by the empaneled hospitals, along with increasing the visibility about the scheme. Since the year 2012, UIIC was mandated to implement the awareness generation and IEC activities in consultation with TNHSP.6 At the time of awarding the implementation to UIIC, 1% to 1.5% of budget was allocated to IEC.

Observations based on review of various scheme related government documents, visits to beneficiaryhouseholds by the study team members and qualitative information collected during discussions with UIIC andTNHSPofficialsindicatedthatthedevelopmentoftheIECprogramwasthroughadynamicprocessandone thatevolvedover time.Once the implementationof theschemewas initiated,UIICofficials inconsultation with TNHSP designed IEC activities, based on their past experience over various phases (of enrolment) of the scheme (Figure 2.1). At UIIC, even though there was no separate team for IEC, the publicity department of UIIC was indirectly involved in implementing the awareness generation process. An IEC officer,appointedbyTNHSP,andaretiredDistrictRevenueOfficer(DRO)coordinatedandmonitoredallthe IEC related activities. Most of the IEC materials were printed in both Tamil and English, depending on the requirement. IEC tools developed were common for public and private hospitals.

6 Basedoninterviewswithofficials.

27

Figure 2.1: Process Flow of Developing IEC Materials

TNHSP

UIIC

Publicity Department,

UIIC

IEC Officer, UIIC

Retd. District Revenue Officer

(DRO), UIIC

Generation of IEC Materials

Appr

oval

of I

EC

Mat

eria

l by

TNHS

P

2.1. types of ieC activities taken up � Newspaper advertisements on CMCHIS usually had a full-page coverage, in all major state level and districtlevelnewspapers(bothinEnglishandTamil).UIICofficialsreportedthatsofarsuchadvertisementshave appeared three times, costing about INR 3 crores.

� All details of CMCHIS (such as the tender documents, user manuals) have been printed and provided to district collectorates and other concerned district level administrators, to enable clarity in procedures to be followed by them.

� Stalls are arranged in exhibitions and trade fairs. During all the trade fair exhibitions, light-emitting diode (LED) boards were exhibited to make the display attractive and UIIC reported that they had spent about INR 0.1 crore (INR 10 lakh) toward this activity each time. UIIC reported carrying out this activity four times over the last four years.

� UIICofficialsinformedthatvarioustypesofposters,brochures,booklets(seeFigure2.2)andpamphletswere printed. Each district received a total of 30,000 copies over time.

� TPAs organize a regional meeting every six months especially with VAO, panchayat members and RIs. The meeting is attended by other stakeholders also (such as the residents and enrollees of the scheme) to discuss strategies for awareness generation and organization of health camps. Initially this meeting was organized at block level.

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Figure 2.2: Booklet on the CMCHIS Scheme

� Large hoardings are erected across the state. UIIC reported that 2,500 hoardings have been displayed across Tamil Nadu. Other than these, small hoardings are also being displayed. Hoardings are also placedinallthegovernmentandtalukofficesacrossalldistrictsinthestate(Figure2.3).

29

Figure 2.3: Board about the CMCHIS Scheme

� Booksofdifferent typesarealsoprinted, includingasmallbookofguidelinesandpocketbookforpatients, list of diagnostic centers. Nearly a crore copies of the small book of guidelines have been distributed while 5,000 to 10,000 of other, such as a book listing the diagnostic centers, are distributed in each district.

� Name boards about the scheme are displayed in both public and private network hospitals.

Other IEC activities are the monthly meetings conducted at block and hospital levels along with district-levelofficialsand/orempaneledhospitals.Thesemeetingsareconductedtohelpthedistrictandhospitalofficialstounderstandtheschemeandtoprovideanyupdatesonguidelinesforimplementingthescheme.

30

In the past, a few times, advertisement on the scheme was also done through TV (Television) and FM (FrequencyModulation)radiosignal,butdetailsoftheseeffortsarenotavailable.

Box 2.1: Key IEC Materials Used in CMCHIS for Awareness Generation

2.2. outreach programs EachempaneledhospitalcarriedoutdifferentIECandawarenessgenerationactivitiesasperthemandateof the scheme.

Healthcampsconductedbyempaneledhospitalswereanimportanteffortforoutreachandincreasingthecoverage to remote or interior areas in each district (see Figure 2.4 for a sample poster for health camps). Health camps were conducted every month by all the scheme- empaneled hospitals to do outreach and awareness.

Duringthesehealthcampsthehospitalswenttodifferentareasintheiroutreachtoorganizehealthcheckupandtoscreenandidentifyeligiblebeneficiaries,whowerenotalreadyenrolled.However,nodocumentationwas available to review on exactly how these camps were conducted and the type of screening done during thecamps.UIICofficialsreportedthatthesehealthcampswereconductedmainlybyprivatehospitals.Onlyabout 10% of the total camps were done by government hospitals. Private hospitals were mandated to providereportsonnumberofcamps,numberofbeneficiariesreachedandscreened.Howevergovernmenthospitals were not required to provide such reports.

Other types of specialized health camps were also conducted. These were referred to as mega health camps and were organized by TPAs in each district. In the mega camps, three or four hospitals in each district come together to participate.

• Newspaperadvertisements

• Nameboards/hoardingsinpublicandprivatehospitals

• Stallsinvarioustrade-fairs

• Hoardingsingovernmenttalukoffices

• Posters,broachersandpamphlets

• Announcementthroughtelevisionandradio

• Healthcampsorganizedbypublicandprivatehospitals

• Ammacamps/megacampsorganizedannually

31

Figure 2.4: Poster Containing Information on Health Camps Conducted by Hospitals under CMCHIS

The budget for these was reported to be INR 15,000 per camp, and this fund was provided to the TPA by UIIC. These mega camps are being implemented since March 2012 and presently are being conducted at a frequency of one camp per district per month. These mega camps generally get much publicity and important persons such as members of legislative assembly (MLAs), ministers and district collectors visit the camps. In addition to these, Amma camps are organized at a grand scale once a year, close to the birthday of the Chief Minister. Table 2.1 provides the district-wise cumulative number of health camps and mega camps conducted in the state (Till 2015). Overall the largest number of hospital-based camps and mega camps were conducted in Vidal and MDI districts. There were no overarching patterns that could be

32

established in the proportion of health camps conducted by district. Districts with the largest share of health camps are Coimbatore (10%) and Erode (10%) which are under MDI; and this was followed by Madurai (7%) and Kanyakumari (6%), which are under Vidal. The share of health camps in Chennai, under Medi-Assist, wasabout5%ofthetotalcampsconducted.Thedistributionofmegacampsdifferedfromhospital-basedhealth camps. The share of mega camps was higher in Dharmapuri (10%) under MDI, and in districts such as Karur (8%) and Kanyakumari (8%) under Vidal.

Table 2.1: Distribution of Health Camps and Mega Camps by Districts and TPAs

TPA DISTRICT Health camps Mega Camps

Number Percentage Number Percentage

Vidal Cuddalore 368 2.1 8 0.8

Dindigul 735 4.3 7 0.7

Kanyakumari 1,094 6.3 74 7.8

Karur 284 1.6 77 8.1

Madurai 1,222 7.1 37 3.9

Nagapattinam 114 0.7 21 2.2

Pudukkottai 202 1.2 6 0.6

Ramanathapuram 214 1.2 13 1.4

Sivagangai 356 2.1 10 1.1

Tanjore 327 1.9 36 3.8

Thiruvarur 795 4.6 67 7.1

Trichy 522 3.0 13 1.4

Tirunelveli 107 0.6 19 2.0

Tuticorin 171 1.0 8 0.8

Total-Vidal 6,513 37.7 396 41.7

MDI Coimbatore 1,772 10.3 13 1.4

Dharmapuri 271 1.6 99 10.4

Erode 1,840 10.6 61 6.4

Krishnagiri 178 1.0 22 2.3

Nilgiris 851 4.9 28 3.0

Salem 183 1.1 22 2.3

Tiruppur 1046 6.1 16 1.7

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TPA DISTRICT Health camps Mega Camps

Vellore 254 1.5 59 6.2

Total – MDI 6,396 37.0 320 33.7

Medi Assist Ariyalur 109 0.6 12 1.3

Chennai 892 5.2 0 0.0

Kancheepuram 527 3.1 40 4.2

Namakkal 783 4.5 36 3.8

Number Percentage Number Percentage

Perambalur 133 0.8 14 1.5

Theni 456 2.6 2 0.2

Thiruvallur 420 2.4 52 5.5

Thiruvannamalai 202 1.2 33 3.5

TPA DISTRICT Health camps Mega Camps

Villupuram 382 2.2 40 4.2

Virudhunagar 475 2.8 5 0.5

Total-Medi Assist 4,381 25.3 234 24.6

Total - Tamil Nadu 17,290 100% 950 100%

Source: CMCHIS administrative data

2.3 expenditure on ieC Between2012and2015about INR6.65crorewas spenton IEC.UIICofficialsalso reported thatgoingforward there could be some changes in the IEC and awareness program activities. Currently UIIC is in discussion to place an advertisement about CMCHIS scheme on postcards and to broadcast radio jingles about the scheme. Table 2.2 provides the year-wise details of the expenditure under IEC.

Table 2.2: IEC Expenditure by Year (in INR Crore)

Details 2011-12 2012-13 2013-14 2014-15

Publicity done by UIIC- head-quar-ters including newspapers and boards

1.10 0.16 4.76

Staff at the 39th All-India Trade Fair 0.02

34

TV Advertisements 0.0022

IEC Training Expenses for Govern-ment representatives / Regional and hospital meetings in all districts

0.54 0.07

Total 1.10 0.18 5.30 0.07

Source: CMCHIS administrative data

2.4. Awareness level among the card-holdersOut of the 2,773 enrolled households covered in the household survey, almost three-fourths (74%) were continuing from the earlier health insurance scheme sponsored by the Tamil Nadu government, (Table 2.3). Among the remaining 26% households, enrolled newly in the CMCHIS scheme, half of them reported to have undergone some kind of IEC activity. Close to one-third of them (31%) came to know about the scheme from the staff members of Panchayat office / VAO office. Only 34% of the cardholders (both the newly enrolled in CMCHIS and the earlier ones continuing from the pre-CMCHI scheme) were aware of the eligibility criteria for family members who could be covered under the scheme. Only 30% were aware that they could get treatment under the scheme in only empaneled public and private hospitals. Only 40% of the respondents knew that only selected disease conditions were covered under the scheme and only 31% knew that only selected diagnostic procedures were covered. Awareness about post-hospitalization benefit for selected procedures was particularly low (only 7%).

Table 2.3: Awareness about Key CMCHIS Features among the Enrolled Households (% of Correct Responses by Households)

Responses by the Cardholders % of Cardholders

Percentage of households continuing from the pre-2012 scheme 74.4

Percentage of households enrolled newly in the CMCHIS 25.6

Out of the 26% households newly enrolled in CMCHIS

Undergone any form of IEC activity 49.9

ReceivedinformationfrommembersofPanchayat/VAOoffice 31.0

Reported that BPL families can be enrolled 28.2

Reported that families with annual income up to INR 72,000 can be enrolled 3.7

Out of all the households enrolled in CMCHIS*

Earning children in the household cannot be covered 34.0

35

Responses by the Cardholders % of Cardholders

Children, whose name is not on the ration card, cannot be covered 41.3

Coverage under the scheme for 4 years 16.9

Scheme can be availed in both empaneled public & private hospitals 30.0

Benefitisavailableforselectedkindofdiseases 39.9

Benefitisavailableforselectedkindofdiagnosticprocedures 31.2

Benefitisavailableforcertainpost-hospitalizationprocedures 6.6

*Percentage of households that responded “Yes” to the following questions; Source: Estimated from the household survey data

The FGD7 in community revealed that in some of the villages, although enrolment was done, people were unawareoftheutilityofthecard.Itwasobservedthatpeoplewerenotabletodifferentiatebetweenmanyidentity cards and CMCHIS card. For example, Palethan (name changed), aged 60, when he was asked to show the CMCHIS card, he opened a bag and took out a bulk of cards including voter identity card, farmer card, Aadhar card, driving license, old insurance scheme card and also CMCHIS card. He said, “I have many cards and do not know which card you are asking for.” Vimala (name changed) underwent a surgery two years ago and had incurred an expense of around INR 2 lakh. She had to sell her farm land to meet the expenses. When the study team asked her to show all the cards she has, only then she realized that she was enrolled in the CMCHIS scheme. Jasemine (name changed) said:

I went to the hospital to get admitted for a surgery. When the treating doctor asked if I have the card, then only I came to know about the usage and benefits of it.

On the other hand, in some other village people were aware that the CMCHIS card could be used for free hospitalization but did not know which were the empaneled hospitals and what were the procedures covered under the scheme.

EventhoughJyothi(namechanged)knewthatthey’llgetbenefitfromthecardforherhusband’sillness,shewas not aware of the hospital where she could utilize it.

2.5. discussion and conclusionWhile all the activities related to awareness generation and IEC were implemented by UIIC and the respective TPAineachdistrict,TNHSPofficialswerecloselyinvolvedin:

� the planning of these activities, � designing the content and � ensuring distribution of the materials.

7 BFor details of FGDs, please refer to the methodology section (Section 1.3, Chapter 1).

36

No other entities or organizations (such as NGOs) is reported to be involved in the planning and or implementation of the IEC activities.

Based on the available information about IEC and awareness generation programs, some broad observations can be made. A large number of IEC activities were taken up over the four-year period of the scheme’s implementation. However, there is no adequate documentation or reports available on the IEC activities. Becauseof inadequatedocumentation, it isdifficulttounderstandwhatbroadstrategiesorapproacheswere considered for implementing IEC activities. It was not clear if any targeted approaches were used for IEC activities, to increase awareness in the poorer districts or areas or other hard-to-reach and remote areas. Based on the discussion with key informants from empaneled hospitals, it could be deduced that there were no standard guidelines or targets set for the hospitals for coverage of hard-to-reach or poorer sections of population through the outreach/health camps.

Lowawarenesslevelamongthecard-holdersisalsoreflectedintheresponsesofthehouseholdsduringthe primary survey. Very few households could report correct answers regarding the duration of scheme benefits,coverageoftheschemeandhospitals,wheretheycanavailthefacilities.

Thefollowingcouldbeconsideredforincreasingtheeffectivenessoftheoutreachactivities:

� a strong IEC plan/strategy, � involvement of local organizations � involvement of the village/ward representatives (such as panchayat members), � better documentation, � greater participation of NGOs and civil society in IEC.

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3. enRolment PRoCeSS

Enrolmentistheprocessofauthenticatingtheidentityofthebeneficiaries,verificationoftheireligibilityandregisteringthemtoaccesstheservicesunderthescheme.Theprocessofenrolmentofbeneficiariesin the scheme plays a vital role in the successful implementation of a scheme. The process of systematic enrolment of population is seen as one of the key factors for transition of existing social health insurance towards universal health coverage (Carrin & James, 2005; Sun, 2011). Some of the factors that are known to facilitate successful enrolment include the following:

� simple eligibility requirements, � innovative outreach mechanisms and � use of smart technologies.

Inthischapter,wedescribetheenrolmentprocessinCMCHISthatisfollowedbytheUIIC,anddifficultiesencounteredbythebeneficiariesandothersinvolvedintheprocess.

3.1. Phases of enrolmentDuring2012and2013(whichisofficiallyreferredtoasphase1and2,respectively),0.14millionhouseholdswere enrolled. As a result, the total number of enrollees increased to 13.04 million households (which includes 12.9 million households enrolled before 2012) (Figure 3.1). Enrolment was based on various identity cards such as Voter Card, Driving License, Old Age Pension Card, Sri Lanka Refugee Card. Eligible families wereidentifiedwiththehelpofVAOs,villagecounselorsand/orwardmembers.TheprocessofenrollingtheeligiblebeneficiarieswasdonebytheTPAwiththehelpofthevendors(MadrasSecurityPrints(MSP)andEaglePrints).MSPprintedthesmartcardsanduponverificationbyTNHSP,thecardsweredistributedtothebeneficiaries,throughvariousways,includingcampbasedapproach,throughVAO,ward/counseloretc.

38

Figure 3.1: Different Modes of Enrolment in CMCHIS

� Used the database from previous scheme for enrolement.

� Around 13.4 million elegibles were enrolled through Phase I & II

� Set up in every District collectorate.

� 291,623 entrollees are enrolled till July 2015.

� Conducted between Feb-Aug 2014

� 2 million are enrolled during this process

GOVERNMENT OF TAMILNADU

chIEF MINIsTER’scOMpREhENsIVE hEALTh INsURANcE schEME

PhaseI & Ii

DistrictKisosk

FieldEntrolment

The 32 districts were divided among the following three TPAs for the process of enrolment:

� Vidal Health (14 districts) � Medi Assist (10 districts) � MD India (8 districts) 8

Phase II of enrolment started in 2013. During this time, enrolment process was also initiated by going directly to all villages in all blocks as well as all corporations and municipalities in urban areas. Figure 3.2 gives the phase-wise details of the enrolment and smart card distribution.

8 Please refer to Table 2.1 for details on the districts under each TPA.

39

Figure 3.2: Enrolment and Smart Card Distribution to Eligible Families under CMCHIS (12.9 million families)

During Phase I and Phase II (2012-13), a total of 12,988,793 smart cards were printed; of these, 12,903,786 were distributed to families as by the time of distribution, few families had migrated to other places or were notavailable.Howeveramongthefamilieswhohadreceivedthecards,TNHSPfinallyapproved12,881,404families,afterindependentconfirmationofeligibility.41%ofthecardsweredistributedbyVidal,whereasMedi Assist and MDI had distributed about 31% and 28%, respectively.

3.2. enrolment through kiosk In 2012, kiosks were set up in each of the district collectorates to facilitate enrollment of eligible households (but not card holders) in an ongoing manner. Families who wanted to be enrolled could approach the district kiosk with a ration card and a letter from the VAO certifying that the annual family income of the household was less than INR 72,000. In addition, families (non-card holders) who visited the empaneled hospitals for treatment could also enroll through these district kiosks. In case of non-enrolled but eligible beneficiaries,theLOfacilitatestheprocessofeligibilityverificationandhelpsthefamilytogetthesmartcard through the district kiosk.

Inthebeginning,thekioskwasanofflinesetup.In2014thiswaschangedintoafullyonlinesystemandenrolment was done on the spot and cards were issued immediately, as printers and all required equipment were made available at district level. Year-wise enrolment through Kiosk is given in Figure 3.3. Cumulatively,

Source: TPA data dashboard

40

enrolment through kiosk has gone up from 36057 households in year 2012 to 291,623 households in year 2015 (the orange bar showing new enrolment through district kiosks).

Figure 3.3: Cumulative Enrolment through District Kiosks – 2012-2015

36057

105886

225026

291623

0

50000

100000

150000

200000

250000

300000

350000

2012 2013 2014 2015

Nu

mb

er

of

En

rolle

d

69829

119140

66597

Note:Year-wiseenrolledareshowninyellowbarsandredlineshowscumulativeenrolmentfigure;Source:TPAdatadashboard.

The trend in enrolment over the four years under each TPA through district kiosks is presented in Figure 3.4.

Figure 3.4: TPA-wise Number of Enrolled Households at District Kiosks

Source: TPA data dashboard

41

Ongoing enrolment was done by each TPA in their respective districts through the kiosks. The pattern of enrolment varied by TPA and by districts. In some districts a higher proportion were enrolled during Phase I and II, such as in many of the districts covered by Vidal TPA; in some districts, such as Chennai, Madurai, Coimbatore, Tiruppur, and Namakkal, a larger share was enrolled through the district kiosks. In other districts, like Thiruvalluvar, Kanchipuram, Salem, Erode and Dharamapuri, most enrollments were donethroughfieldenrolment.

Box 3.1: Process of enrolment through district kiosk

The process of enrollment at the district kiosk is as follows: The LOs present at the kiosk verify the rationcardandincomecertificateissuedbytheVAO.Aphotoofanyoneofthemembersofthefamily (over 18 years) is taken at the kiosk. The data is then sent for printing the card. The card can becollectedbyorhandedovertothebeneficiary,whichtakesonanaverage15-20days.

For eligible non-card holder who visits a hospital for treatment: If the specialist doctor decides to admit the patient, the patient is directed to the helpdesk (based on the treating doctors’ assessment of their economic condition). The LO in the helpdesk in turn facilitates the process of enrolment through district kiosk.

For eligible non-card holders through health camps: During the monthly health camps organized by the empaneled hospitals, eligible non-card holder households are directed to the district kiosks for enrolment.

3.3 EnrolmentthroughfieldsToenrollpeoplelivingindifficult-to-reachareas,TPAsorganizedspecialenrolmentcampsduringFebruaryto August 2014. With the guidance of the District Collector and the panchayat president, a team of District ProgramOfficer,DistrictCoordinatorandrepresentativesfromthevendorreachedthein-accessiblevillagesfor enrolment. Around 23 lakh9 families were enrolled through this process.

3.4. Coverage of population under the schemeInformation on the average family size of the enrolled is not available in the public domain. Therefore estimating the total number of enrolled individuals and enrolment rate (percentage of population enrolled) tilldateacrossthestateandbydistrictcouldnotbeaccuratelyestimated.TNHSPofficialshadreportedthat a sample of the enrolled families was reviewed and an estimate of the family size (number of person from a family enrolled) was derived to be 2.7. Since the older children (older than 25 years) and elderly were 9 Based on information shared by the TPAs.

42

enrolledasseparatefamilies,itispossiblethatthisfigureisacloserestimateoftheaveragefamilysizeofenrolled. Using this average family size and households enrolled in the scheme, the number of enrolled individualbeneficiariescanbeestimatedtobe42.9million(1.68millionfamiliesmultipliedbyestimatedaverage family size of 2.7), representing about 60% of Tamil Nadu’s total population. This is an increase by almost 9 percentage points from pre-2012 level.

Percentage of population covered under the CMCHIS scheme also varies widely across districts in the state. Figure 3.5 provides the geographical spread of the percentage of population enrolled in the scheme across the districts. Karur has the highest percentage of population enrolled in the scheme (76%), closely followed by Erode (75%), Dharampuri (71%) and Pudukottai (71%) (see Annexure 3.1 for details). On the contrary Chennai (40%) and Thuthukudi (49%) are among the lowest in terms of coverage. Districts with around half the population coverage are Tirunelveli, Kanchipuram, Thiruvallur and Coimbatore. In the districts of Ariyalur, Theni, Thiruvarur and Perambalur, more than 65% of the population are enrolled in CMCHIS.

Figure 3.5: District-wise Distribution of Percentage Enrolled in CMCHIS to Total Population in 2015

ThiruvallurChennai

Kancheepuram

Villupuram

Cuddalore

Nagapattinam

NagapattinamThiruvarur

Thanjivur

Pudukottai

Sivaganga

Ramanathapuram

TuticorinThirunalvelic

Kanyakumari

Virudhnagar

Theni Madurai

Dindigul

Karur Trichy

PerambalurAriyalur

Salem

NamakkalErodeNilgiris

CoimbatoreTirupur

Vellore

Thiruvannamalai

Dharampuri

Krishnagiri

Figure 3.5

Source: Author’s representation based on information obtained from the TPAs

43

3.5. experience of the households with the enrolment processAs mentioned in the methodology section, the survey of 2,773 enrolled households undertaken to study the impact of CMCHIS also probed the experiences of the enrolment process (Table 3.1). Of these 2,773 enrolled households, around 90% of the family members were covered under CMCHIS. Among the enrolled family, the average family size enrolled was 3.2. Male members account for 53% of the total enrolled members in the scheme. Children (0-5 years) and aged (above 60 years) constitute around 2.2% and 7.6%, respectively of total enrolment, whereas around 54% of the enrolled are between the ages of 20 and 50. Around one-third of the enrolled were the earning members of the family, while more than one-fourth were students.

Most of the newly enrolled households (94.5%) were enrolled through the enrolment camps and very few throughdistrictkiosks.VAOofficebearersandpanchayatmembersplayedanimportantroleinorganizingthe camps and informing people about it. 74% of the respondents reported that they got to know about thecampfromthestaffofVAOandpanchayatoffice.

On an average, the households were informed about the camps six days in advance. Around 90% of the total card-holders reached the place of enrolment on their own. This could be because the enrolment camps were organized quite close to their residence (average distance was 1.5 kilometers and average travel time was 15 minutes). However after reaching the camp, the card-holders, on an average, had to wait for40minutes.Inalmost3/4thofthecases,thedocumentverificationofficersaskedforaGreenRationCardasaproofoftheireligibilityandinmostcases(61.9%),theyconfirmedthefamilymembers’namewiththeir own list.

Though,91%reportedthatphotographsweretakenforallthemembers,fewerthanhalfsaidfingerprintsof all family members were taken. However, almost 80% of the households reported that they received the smart cards after more than a month of their enrolment in the scheme. Around one-third of the respondents informedthattheVAOorpanchayatstaffdeliveredthecardatthehousehold.However,veryfewreportedreceiving the list of empaneled hospitals and the procedures that are covered under the scheme.

Table 3.1: Key Indicators - Card-Holders Experience with the Enrolment Process

Indicators

Place of Enrolment for the household (% of household)

District kiosk 1.9

Enrolment camp 94.5

Others 3.6

Source of information about place of Enrolment (% of household)

10 Farmer, non-farm worker, salaried, self-employed etc.

44

Indicators

Posters / Wall paintings 15.6

Loudspeaker announcement 9.0

HealthStaff 17.5

VAOOffice/PanchayatStaff 74.1

Average number of days before enrolment households were informed about the place 5.7

People reached the place of enrolment on their own (%) 89.8

Average distance to enrolment camp (in km) 1.5

Average travel time to enrolment camp (in minutes) 15.0

Average waiting time in enrolment camp to meet the concerned person (in minutes) 40.0

Documents asked to show

Green Ration Card 73.5

Average time taken to verify the documents (in minutes) 13.0

VerificationoftheNamesofFamilyMemberswithInsuranceAgency'sList

CheckedonlyHeadofHousehold'sName(%) 25.8

CheckedAllFamilyMembers'Names(%) 61.9

Households,wherefingerprintsofallmembersweretakenduringenrolment(%) 46.5

Households, where photographs of all members were taken during enrolment (%) 90.8

Households that received the smart card after more than a month of enrolment (%) 78.5

Mode of delivering the card to the households (%)

Collected from enrolment camp 20.2

DeliveredathomebyVAO/Panchayatoffice 35.1

List of procedures covered under the scheme was given (%) 18.0

List of empaneled hospitals under the scheme was given (%) 31.7

Officersatenrolmentcampinformedabouttheprocesstousethecard(%) 24.3

Source: Estimated from the household survey data

During FGD, participants also reported receiving the cards late or not receiving. Vasudev (name changed) said:

Panchayat office organized a camp for taking photograph of the family head and submission of the application, half of the families have still not received the card. I am the councilor of the panchayat for this village. But my family has not received the card. We have been approaching the government. But yet to receive the card.

45

Fewinstanceswerereportedwheretheenrolmentprocessatthedistrictcollectorofficegotdelayedandthe patient had to pay for the treatment from his own pocket. The distance from the village to district headquarters was found to be an important reason for non-enrollment. In many instances, patients, though eligible, could not make use of the scheme as they were unable to travel to the district kiosk. A FGD participantreportedthatgettingenrolledthroughdistrictcollectorateofficethroughpersonaleffortswasnot easy. An eligible person reported:

Ivisitedthecollectorofficefivetimes.ButIcouldnotgetafavorableresponsefromtheofficials.Duringthelastvisit,theyaskedmetobringallthefamilymemberstothecollectorateofficewhichwasimpossibleandfinallyIhadtogiveupmyefforts.

One of the enrolled, Parthasarathy (name changed) reported:

I have given my ration card details, income certificate and copy of Aadhaar card and now I have come to collect my card. It has been two months.”

3.6. discussion and conclusionWith more than 15 million families enrolled in the scheme, the scheme has a total coverage of about 60% of the total state population. The scheme is demand driven, in the sense that those eligible but not yet enrolledcouldgetenrolledbyproducingvalidcertificatesoftheireligibilityanytimeintheyear.Yet,duringtheFDGs,wecameacrosseligiblebeneficiaries lamentingaboutbarriers intheenrollmentprocess.Thiscould be primarily because of the time taken at the kiosks or the inconvenience of taking all the family members to the kiosks.

Though the enrolment is high, it was observed from the results of household survey and FGDs that very few received the information brochure comprising the list of empaneled hospitals and the procedures covered under the scheme.

We are unable to throw much light on the distribution of socio-demographic characteristics of the enrollees across districts, due to lack of data. Also it is not possible with available data to carry out any analysis of the impact of the enrolment strategies within and across districts.

Itcouldbebeneficialfortheschemetodrawamorecomprehensiveselectioncriteriaalongwithperiodicrevision and assessment of the present income level of the household. More information spread through television and radio advertisements about the benefits and availability of the schemes may increaseutilization under the scheme for the target population.

46

4. PRovideR netWoRk, utilizAtion oF HeAltH CARe And ClAim PRoCeSS

CMCHIS has empaneled a large network of private and public hospitals from across the state, and to some extent from the neighboring states as well. This chapter presents details of these empaneled providers, the extent to which they have been utilized for various treatments, an assessment of the claims processes and the overall performance of the providers.

4.1. empanelment of providersOver the years, the number of providers empaneled under the CMCHIS has increased considerably because of the following reasons:

� increasing number of enrollees from across the state, � significantincreaseintheutilizationofhealthcareandclaimsmadeovertheyears, � consciouseffortstoimproveaccessibilityofservices,andofferenrolleesawiderbasketofproviders

to choose from. Details of enrollees and utilization of procedures/services are discussed in Section 4.2.

4.1.1. Procedure for empanelment - selection criteria and grading There were 771 hospitals empaneled under the CMCHIS (as of August 2016), of which, 155 are government facilities and 616 are private facilities. Almost all the government hospitals that provide tertiary care are empaneledunderthescheme,reflectingeffortstoenhancethepublicimageofgovernmentfacilitiesandreadiness of the government to compete with private providers in attracting patients.

The private facilities that empaneled under scheme until 2012 were automatically empaneled in the CMCHIS. These facilities signed a MoU with the TNHSP after the CMCHIS scheme was launched in 2011.

The scheme follows a grading system for the empanelment of providers which is based on hospital’s physical and human infrastructure, details of the specialties and diagnostic services available and various accreditations. Grading falls into eight categories varying from A1 to A6 (for multispecialty hospitals) and S1 and S2 for single specialty hospitals, with the A1 being the highest category (see Box 4.1). All government facilities empaneled in the scheme are graded as A1 (Table 4.1).

However, among private hospitals, only 7.5% are graded as A1, 11.0% as A2, 24.8% as A3 and 23.2% as A4. It should be noted that overall, private and public facilities together, 201 (26.1%) of all empaneled facilities (771) come under A1 category. And 296 of all facilities (about 40%) all of which are private, come under A3 and A4 categories (Table 4.1).

47

Table 4.1: Distribution of Empaneled (Public and Private) Hospitals across Grades (as of August 2016)

GradesNumber of Hospitals % of Hospitals

Government Private Total Government Private TotalA1 155 46 201 100.0 7.5 26.1A2 68 68 11.0 8.8A3 153 153 24.8 19.8A4 143 143 23.2 18.5A5 64 64 10.4 8.3A6 21 21 2.7 2.7S1 71 71 11.5 9.2S2 50 50 8.1 6.5Total 155 616 771 100.0 100.0 100.0

Source: Estimated from CMCHIS administrative data

Box 4.1: Process of Empanelment by Private Facilities under CMCHIS

For fresh empanelment, the scheme follows an online procedure for private providers. The interested facilities needed to fill an online form, which includes information on the hospital’sphysical and human infrastructure, details of the specialties and diagnostic services available and various accreditations. A team of doctors from TPA along with expert doctors from TNHSP visit the facilitiesforverification.Basedontheirverification,pointsareassignedagainsteachcriteria(seeAnnexure 4.1 for details and http://cmchistn.com/hospitalList1.php). The applicant facility is graded based on the accumulated points by each criteria.

For example, a hospital with the bed capacity of <=30 gets 1 point; with 30-100 beds, gets 2 points and hospitals with >100 beds, 3 points. Similarly, the facility gets one point each for pathological lab, bio-chemical lab, micro lab etc. Points are also associated with various accreditations and safety certificates suchasNationalAccreditationBoardofHospitalsandHealthcareProviders (NABH),Joint Commission International (JCI), and Indian Public Health Standards (IPHS).

Altogether, a multispecialty hospital can get up to a total of 51 points and a single specialty hospital up to 20. For multi-specialty hospitals grades assigned vary from A1-A6 (A1:>41, A2: 31-40, A3: 21-30, A4: 16-20, A5: 11-15, A6:<10); and for single specialty hospitals, grading are S1 or S2 (S1: 15-20 points,andS2:<15points).Basedongrades,paymentsfordifferentservices/procedureshavebeenfixedbytheinsurancecompany.Thepackageratesaregradedfromhighest(A1/S1)tolowest(A6/S2) (http://cmchistn.com/hospitalList1.php).

48

4.1.2. Growth and distribution of empaneled facilities

Government hospitals constitute about 20% of all empaneled facilities (155 out of 771 providers as of August 2016). Over the period of four years of the scheme, the hospital network has increased from 637 in 2012 to 771 (including 18 hospitals located outside the state) by August 2016, which is about 21% increase in the total number of empaneled facilities over the last four years. This increase is net increase in the empaneled facilities, after accounting for the number of de-empaneled facilities during the period. Many hospitals were de-empaneled because of their poor performance and various complaints against them. Over the years, a total of 279 hospitals were de-empaneled from the network of CMCHIS, out of which 67 hospitals voluntarily dropped out of the scheme. However, many of them were re-empaneled later on. The last two years of the scheme witnessed comparatively more number of hospitals getting de-empaneled. Figure 4.1 shows district-wise distribution of government and private hospitals in the state in 2015-16.

Figure 4.1: Number of Empaneled Hospitals across Districts - by Government and Private, 2015-16

01020304050607080

Ariya

lur

Chen

nai

Coim

bato

reCu

ddal

ore

Dhar

ampu

riDi

ndig

ulEr

ode

Kanc

heep

uram

Kany

akum

ari

Karu

rKr

ishna

giri

Mad

urai

Nag

apat

tinam

Nam

akka

lN

ilgiri

sPe

ram

balu

rePu

duko

ttai

Ram

anat

hapu

ram

Sale

mSi

vaga

ngai

Than

java

urTh

eni

Thiru

vallu

rTh

iruva

nnam

alai

Thiru

varu

rTi

rune

lveli

Tiru

pur

Trich

yTu

ticor

inVe

llore

Villu

pura

mVi

rudh

anag

ar

Source: Estimated from scheme administrative data

Government Private

Out of 771 empaneled facilities, Chennai has the highest number of facilities (78, 10.1% of total empaneled facilities). This is followed by Coimbatore (74). Other districts that have more than 30 empaneled hospitals under the scheme are Salem (47), Madurai (46), Erode (40) Kancheepuram (40), Trichy (41) and Kanyakumari (33).

The districts with fewer number of empaneled (less than 10) hospitals are Pudukottai (7), Tuticorin (9), Thiruvarur (8), Nagapattinam (8), Perambalur (7) and Ariyalur (6) and Cuddalore (6) – these 7 districts have a low presence of private providers compared to many other districts of the state (see Figure 4.2 below).

Besides, the scheme also empaneled 18 hospitals located outside the state to enhance access to the empaneled facilities by the cardholders, particularly those residing in the bordering districts of the state.

Source: Estimated from scheme administrative data

49

These empaneled hospitals are located in Andhra Pradesh, Karnataka, Kerala and Puducherry. Annexure 4.2 provides the district-wise details of empaneled hospitals over the years.

Figure 4.2: District-wise Distribution of Empaneled Hospitals under CMCHIS, 2015-16

ThiruvallurChennai

Kancheepuram

Villupuram

Cuddalore

Nagapattinam

NagapattinamThiruvarur

Thanjivur

Pudukottai

Sivaganga

Ramanathapuram

TuticorinThirunalvelic

Kanyakumari

Virudhnagar

Theni Madurai

Dindigul

Karur Trichy

PerambalurAriyalur

Salem

NamakkalErodeNilgiris

CoimbatoreTirupur

Vellore

Thiruvannamalai

Dharampuri

Krishnagiri

Figure 4.2

Source: Estimated from scheme administrative data

4.2. Patterns of claims (utilization)

4.2.1. Overall patternAs noted earlier (in Chapter 3), enrolment has increased from 12.9 million at the beginning of the scheme in 2012-13 to 15.7 million families in 2015-16, an increase of around 22%. Over the same period, the number ofclaimsmadeundertheschemehasalsoincreasedsignificantly,from0.255millionin2012-13to0.353million in 2015-16, nearly 38% increase (see Table 4.2 below). In 2015-16, the TPAs introduced guidelines for government hospitals to upload all supporting documents (such as bills and reports) against any claim.

50

This was earlier applicable only for private facilities. During KIIs, TPA representatives shared their views that setting up of the required instruments to scan and upload documents and train the people in government hospitalsindifferentdistricts,consumedconsiderabletime.Thiswasoneofthereasonsforthemarginalfallinthenumberofclaimsduring2015-16,mainlyinthefirsthalfoftheyear.Inthesecondhalf,theclaimspicked up again. However,theoverallincreaseinutilizationcouldbeattributedtotheeffortsmadetoexpandthecoverageoftheschemeandincreaseawarenessofthebenefitsofthescheme,particularlythroughthehealthcamps.

Box 4.2: Utilization Rate under CMCHIS

By 2015, around 15.7 million households, consisting approximately 43 million individuals were enrolled in the CMCHIS scheme. As per the CMCHIS claim data, a total of 363,352 claims were made in 2014-15. Hence the utilization rate (number of claims/total number of persons enrolled) comes at 0.85%. In 2015-16, number of claims made under CMCHIS were 353,525, resulting in the utilization rate of 0.83%. There is yet another way to show this utilization rate of the scheme.

The analysis of the National Sample Survey (NSS) data of the 71st round on Health (conducted in January-June 2014), reveals that in Tamil Nadu, overall 5.8% of the population used any type of in-patient (IP) services in a year. If we apply this IP proportion (5.8%) to the 43 million individuals enrolled in the scheme, we can expect about 2,494,000 IPs per year among the enrolled under the scheme.Theactualbeneficiariesare353.525fortheyear2015-16.Thismeanstheutilizationrateoftheschemeis14%(353,525beneficiariesdividedby2,494,000expectedIPsamongtheenrolled),which is noteworthy.

4.2.2. Government vs. private hospitalsTotal number of claims in both private and public hospitals has increased over the year (Table 4.2). Total claims in public hospitals increased by 62.2% from 91,275 in 2012-13 to 1,48,127 in 2015-16, while the claims in private hospitals increased by 24.9%, from 1,64,398 in 2012-13 to 2,05,398 in 2015-16. As a result, the overall share of public hospitals in the total claims has gone up from 35.7% in 2012-13 to 41.9% in 2015-16. Even if we exclude the 56 procedures reserved for public facilities, the share of public hospitals in total utilization has increased from 30.8% in 2012-13 to 37.4% in 2015-16.

51

Table 4.2: Share of Government and Private Hospitals in Claims - 2012-13 to 2015-16

All Packages

Year No. of claims % of claims

Government Private Total Government Private2012-13 91,275 1,64,398 2,55,673 35.7 64.32013-14 1,35,387 2,00,562 3,35,949 40.3 59.72014-15 1,56,605 2,06,747 3,63,352 43.1 56.92015-16 1,48,127 2,05,398 3,53,525 41.9 58.1

Excluding packages reserved for government hospitals2012-13 73,317 1,64,726 2,38,043 30.8 69.22013-14 1,10,111 2,00,061 3,10,172 35.5 64.52014-15 1,29,102 2,06,228 3,35,330 38.5 61.52015-16 1,22,728 2,05,421 3,28,149 37.4 62.6

Source: Estimated from scheme administrative data

4.2.3. District-wise utilizationDistricts of Chennai, Tiruchirappali, Salem, Erode, Kancheepuram, Madurai are among the very high num-ber of claims from government facilities, in absolute terms. Since we do not have district-wise number of enrolled individuals – we have only number of enrolled households district-wise – we are unable to make anydefinitivestatementonthedistrict-wiseproportionofenrolleesmakingclaims.Butwecanlookattheaverage number of claims per government and private facilities (See Figure 4.3 below and Annexure 4.3 for number of claims by government and private hospitals by district over the years). Most districts show a higher average number of claim per government hospital than for private hospitals. For instance, average number of claims per government facility was as high as 3,545 in Chennai followed by 2,451 in Madurai. Average number of claims per private facility was mostly less than 500 in all districts except in Kancheepuraam, Madurai and Sivagangai (little over 500).

11Allfiguresareforrespectivefinancialyear.

52

Figure 4.3: District-wise Average Number of Claims per Empaneled Hospital - Government and Private, 2015-16

0

500

1000

1500

2000

2500

3000

3500

4000

Ariya

lur

Chen

nai

Coim

bato

reCu

ddal

ore

Dhar

map

uri

Dind

igul

Erod

eKa

nche

epur

amKa

nyak

umar

iKa

rur

Krish

nagi

riM

adur

aiN

agap

attin

amN

amak

kal

Nilg

iris

Pera

mba

lure

Pudu

kotta

iRa

man

atha

pura

mSa

lem

Siva

gang

aiTh

anja

vaur

Then

iTh

iruva

llur

Thiru

vann

amal

aiTh

iruva

rur

Tiru

nelve

liTi

rupu

rTr

ichy

Tutic

orin

Vello

reVi

llupu

ram

Viru

dhan

agar

Tota

l

Source: Estimated from scheme administrative data

Government Private

4.2.4. Gender-wise utilizationWe have already noted that the overall claims have grown by 38.2% (from 255,673 in 2012-13 to 353,525 in2015-16).Inabsoluteterms,theclaimsbymaleandfemalebeneficiarieshaveincreasedby50.0%and20.4%, respectively, over the same years. The rate of increase in claims by males is greater than that of females.Asaresult,theshareoffemalebeneficiariestothetotalclaimshasfallenfrom39.7%(in2012-13)to34.6% (in 2015-16) (Figure 4.4 and Annexure 4.4). To throw more light on this distribution of claims by male/female enrollees, we need to undertake a more detailed analysis of claims by procedures, supplemented by a detailed qualitative household study on health-seeking behavior of the eligible population. We suggest a more detailed study of this sort for a better understanding of presence of any gender-sensitive issues that the scheme should address in the future.

Source: Estimated from scheme administrative data

53

Figure 4.4: Male and Female Distribution of Utilization: 2012-13 - 2015-16

Source: Estimated from scheme administrative data

Box 4.3: Utilization of Packages by Male and Female

Among the procedures covered under CMCHIS, female-share was higher for radiation oncology, medical oncology and surgical oncology (see Annexure 4.5). Proportion of female utilization was very less compared to their male counterparts for procedures like interventional radiology, vascular surgeries, hepatology, pediatric surgeries and poly trauma. Utilisation of the procedures like chest surgery (0.01% for both male and female), endocrinology (0.05%), transplantation (0.02-0.03%) and STEMI (0.01-0.05%) was considerably lower than other procedures, both for male and female.

-

-

-

- -

-

-

-

54

4.2.5. Age-wise utilizationThe scheme is utilized the most by individuals between the ages of 40 and 60 years and this is consistent over the years (Figure 4.5). The utilization is lowest among children between the ages 2 and 5 years. Except for the age-group of 6-19 and 20-30, the trend in utilization over the years has been more or less the same. Utilization among infants (age less than 1 year) has significantly increased over the years.

Figure 4.5: Percentage Distribution of Utilization by Age Groups, 2012-13 to 2015-16

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2012-13 2013-14 2014-15 2015-16

Perc

enta

ge S

hare

of U

tiliz

atio

n

Source: Estimated from scheme administrative data

>60

51-60

41-50

31-40

20-30

6-19

2-5

Infant

In 2015-16, elderly enrollees (aged 60 and above) utilized the scheme considerably well for treat-ments such as total knee and hip replacement (55% of total claims, 4,066 out of total 7,337 claims), neurological services (43%, 3,388 out of 7,866), ENT treatments (33% , 6,705 out of 17,509) (see Annexure 4.6).

Infants accounted for a substantial portion of chest surgery, in particular: it increased from 17% in2014-15to41%in2015-16,asignificantgrowthtobenoted.Figure4.5showsasignificantnumber of claims by those under the age of 10 for cardiothoracic surgeries. However, cardiotho-racic surgeries claims is the highest among the persons in the age group of 40 to 60 in all the four reference years (Figure 4.6).

Source: Estimated from scheme administrative data

55

Figure 4.6: Cardiothoracic Surgeries - Age-wise Number of Claims, 2012-13 to 2015-16

0

200

400

600

800

1000

1200

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100

Num

ber o

f cla

ims

Age in Years

Source: Estimated from scheme administrative data

2012-13 2013-14 2014-15 2015-16

4.2.6. Types of treatment: surgeries vs. therapies

As the total number of claims in private and public facilities has gone up considerably, the number of claims disaggregated by surgeries and therapies also show a quantum jump over the years (Figure 4.7). However, theshareoftherapiesinbothpublicandprivatefacilitieshasgoneupmoresignificantlythansurgeriesover the years: from 58.8% in public institutions and 60.9% in private institutions (in 2012-13) to 68.8% and 62.2%, respectively, in 2015-16.

Source: Estimated from scheme administrative data

56

Figure 4.7: Percentage Distribution of Claims by Type of Treatment across Government and Private Hospitals, 2012-13 to 2015-16

41.2 39.1 34.4 36.3 31.7 35.1 31.2 33.8

58.8 60.9 65.6 63.7 68.3 64.9 68.8 66.2

0%

20%

40%

60%

80%

100%

govt pvt govt pvt govt pvt govt pvt

2012-13 2013-14 2014-15 2015-16

% o

f Util

izat

ion

Source: Estimated from scheme administrative data Surgery Therapy

4.2.7. Utilization of specific packages (excluding reserved packages for government providers)

In 2012-13, medical oncology was the highest utilized package (33,237 cases, 16.4%) (Figure 4.8). It was followed by ENT and nephrology. In 2014-15, nephrology had the highest share at 17.6% (59,003 cases), its share increasing over the years. This was followed by medical oncology with 15.6% (52,974 cases). In 2015-16, nephrology further increased to 68,917 cases with a share of 19.5% of total claims. This was followed by medical oncology with 12.8% (45,294 cases among 0.35 million), its share decreasing from previous year.

The share of private sector within each package, represented by the orange color in the bar in Figure 4.8, was the highest in nephrology, it was around 90% in both 2014-15 (53,122 cases out of 59,003) and 2015-16 (61,388 cases out of 68,917). The other packages with high share of private sector are knee and hip replacement, ophthalmology surgery, cardiothoracic surgery, genito-urinary surgery and OBGY.

On the other hand, most of the cases under neo-natology (94%) and pediatric intensive care (91%) go to the government sector (represented by blue in the bar).

The procedures among the least used packages were pulmonology (0.5%), surgical gastroenterology (0.48%), gastroenterology (0.58%), vascular surgeries (1.21%) and orthopedic trauma (3.47%), in both private and public facilities.

Source: Estimated from scheme administrative data

57

In recent times, the cases under dialysis have almost doubled. Also the cases under neo-natal ICU (NICU) andpediatricICU(PICU)havegoneupsubstantially.Thistoohasresultedintosignificantincreaseintheoverall utilization number.

Box 4.4: Highly Utilized Packages under CMCHIS

The claims made under nephrology, medical oncology, cardiothoracic surgery, genito-urinary surgery, ENT and ophthalmology surgery account for 52% of total claims in 2015-16 and they exhibit similar pattern over the years.

There seems a clear systematic pattern of the diseases that are being treated by the empaneled facilities: the more utilized packages in public hospitals as compared to the private ones are mainly NICU and PICU. On the other hand, nephrology, knee & hip replacement, ophthalmology surgery, cardiothoracicsurgeryandOBGYaremoreutilizedpackagesinprivatehospitals(seefigure4.8).

58

Figure 4.8: Utilization per Procedural/Surgical Categories in Government and Private Facilities (2012-13 to 2015-16)

Note: X-axis shows the absolute number of claims made; Source: Estimated from scheme administrative data.

59

4.2.8. Reimbursement for treatment

Total amount paid out: public vs private

The total amount paid through claims increased from INR 537 crore in 2012-13 to INR 708 crore in 2014-15 (Figure 4.9). However, it dropped by INR 37 crore in 2015-16, amounting to a total claim of INR 671. The percentage share of government hospitals in the total claim amount has increased marginally over the period of time (28.6% in 2012-13 to 31% in 2015-16). However, as noted earlier, the share of government hospitals in total number of claims increased from about 35% to 42% over the years (please refer back to Table 4.2).

Figure 4.9: Total Claim Amount Paid (Reimbursement) to Government and Private Hospitals: 2012-13 to 2015-16

175232 260 237

362

432448

434

537

664708

671

0

100

200

300

400

500

600

700

800

2012-13 2013-14 2014-15 2015-16

Tota

l Am

ount

Pai

d in

Cla

ims (

INR

Cror

e)

Source: Estimated from scheme administrative data

Government Private Total

Average and median amount paid: public vs private

The average amount reimbursed for various procedures in government facilities has fallen from INR 19,745 in2012-13toINR16,313in2015-16(Figure4.10).Thecorrespondingfiguresforprivatefacilitiesarehigher– INR 22,133 in 2012-13, and INR 21,332 in 2015-16.

Source: Estimated from scheme administrative data

60

ThemedianamountapprovedforbeneficiariesfrombothprivateandgovernmentfacilitieshasfallenfromINR 12,500, and INR 15,000 (respectively in 2012-13) to INR 8,400 and INR 12,500, respectively in 2015-16. Median values for therapies and surgeries are shown in Table 4.3 below and median values for packages over the years are shown in Annexure 4.7.

Figure 4.10: Average Reimbursement of Treatment during 2012-13 to 2015-16 - by Government, Private and Total (in INR)

1974522133 21276

17054

21626 19992

16408

2171019670

16313

2133219239

0

5000

10000

15000

20000

25000

Government Private Total

Aver

age

Cost

(IN

R)

Source: Estimated from scheme administrative data

2012-13 2013-14 2014-15 2015-16

Average and median amount paid: surgery vs therapies

The average approved amount (reimbursed to facilities) for surgeries in both private and government facilities has been far higher than that for therapies (Table 4.3).

For surgeries in private facilities, it has increased substantially from INR 37,919 in 2012-14 to INR 42,001 in 2015-16, while it has remained more or less the same for public facilities at just below INR 25,000.

For therapies, the average reimbursement to public facilities has fallen over the years (from INR 15,301 in 2012-13 to INR 12,520 in 2015-16), yet remained slightly higher than that of private facilities.

Source: Estimated from scheme administrative data

61

Table 4.3: Average and Median Reimbursement by Type of Treatment during 2012-13 to 2015-16 - to Government and Private Hospitals (in INR)

2012-13 2013-14 2014-15 2015-16Average Reimbursement

GovernmentSurgery 24,861 24,063 24,997 24,982Therapy 15,301 13,414 12,671 12,521

PrivateSurgery 37,919 39,553 41,707 42,001Therapy 11,907 11,475 11,142 11,235

Median Reimbursement

GovernmentSurgery 20,000 20,000 20,000 20,000Therapy 15,000 11,400 10,000 11,400

PrivateSurgery 24,000 25,000 28,000 30,000Therapy 8,000 8,000 8,000 8,000

Source: Estimated from Scheme Administrative Data

Following the same trend, in most of the districts in Tamil Nadu, the average approved amount per claim is higher in private hospitals than in government ones (Figure 4.11). In Chennai, Coimbatore, Dindigul, Namakkal, Thiruvallur and Tuticorin, the average amount approved is 54-184% higher in private facilities than in government ones.

On the other hand, the average approved amount is higher in government hospitals than in the private ones in Ariyalur, Madurai, Theni, Thiruvannamalai, Thiruvarur, Villupuram and Virudhnagar.

The average per claim reimbursement formale and female beneficiaries in each district is provided inAnnexure 4.8.

Figure 4.11: District-wise Average per Claim Reimbursement in Government and Private Hospitals, 2015-16 (in INR)

05000

100001500020000250003000035000

Ariya

lur

Chen

nai

Coim

bato

reCu

ddal

ore

Dhar

map

uri

Dind

igul

Erod

eKa

nche

epur

amKa

nyak

umar

iKa

rur

Krish

nagi

riM

adur

aiN

agap

attin

amN

amak

kal

Nilg

iris

Pera

mba

lur

Pudu

kkot

tai

Ram

anat

hapu

ram

Sale

mSi

vaga

ngai

Than

javu

rTh

eni

Thiru

vallu

rTh

ooth

ukud

iTi

ruch

irapp

alli

Tiru

nelve

liTi

rupu

rTi

ruva

nnam

alai

Tiru

varu

rVe

llore

Vilu

ppur

amVi

rudu

naga

r

Aver

age

reim

burs

emen

t (in

INR)

Source: Estimated from scheme administrative data

Government Private

Source: Estimated from scheme administrative data

62

Amount paid: package wise (public vs. private)

In 2015-16, for 18 broad packages the average reimbursement was higher in private facilities than in public facilities, up from 14 packages in 2012-13 (Table 4.4). The noteworthy packages are:

� interventional radiology, � neonatology, � cardiology, � cardiothoracic surgery � surgical oncology, and � pediatric surgery.

However, government hospitals charged higher rates than private hospitals for knee and hip replacement, neurosurgery, pediatrics, vascular surgery, genito-urinary surgery, chest surgery, surgical gastro-enterology andnephrology,asper2015-16.Onepossibleexplanationforthedifferencecouldbethatallthegovernmenthospitals were graded A1 and hence receive the highest package rates. Among the private facilities, most of the claims under these categories were treated by A2 or A3 graded private hospitals, which receive lower package rates.

63

Tabl

e 4.

4: P

acka

ge-w

ise

Aver

age

per C

laim

Rei

mbu

rsem

ent d

urin

g 20

12-1

3 to

201

5-16

- G

over

nmen

t, Pr

ivat

e an

d To

tal

Pack

age

cate

gory

2012

-13

2013

-14

2014

-15

2015

-16

Gov

t.Pr

ivat

eTo

tal

Gov

t.Pr

ivat

eTo

tal

Gov

t.Pr

ivat

eTo

tal

Gov

t.Pr

ivat

eTo

tal

Card

iolo

gy21

,632

27,0

6623

,908

19,7

1430

,331

23,1

5520

,428

35,1

1523

,857

22,7

4534

,959

25,4

80

Card

ioth

orac

ic su

rger

y71

,195

82,9

0481

,577

67,5

7982

,084

80,3

1471

,443

79,1

9678

,244

68,3

3177

,685

76,3

10

Ches

t sur

gery

37,6

4735

,857

36,8

3939

,286

39,8

6339

,378

38,2

5434

,813

37,8

3140

,516

37,8

7539

,779

Der

mat

olog

y15

,282

20,3

0615

,444

15,5

7313

,045

15,5

1014

,198

14,7

4014

,224

13,2

5312

,239

13,1

31

Endo

crin

olog

y29

,238

25,9

7427

,778

22,1

9522

,542

22,3

6220

,109

19,2

6419

,954

17,2

1620

,474

18,7

12

ENT

8,46

88,

275

8,32

38,

495

12,7

6911

,528

9,32

015

,129

12,5

6412

,178

16,3

3613

,963

Follo

w-u

p p

roce

dure

5,13

28,

324

6,80

11,

851

1,63

61,

703

2,71

31,

544

1,76

21,

935

1,53

91,

612

Gast

ro-e

nter

olog

y18

,106

22,8

1019

,510

16,9

8519

,573

17,6

1015

,667

16,6

9615

,970

14,9

0921

,743

16,9

58

Gene

ral m

edic

ine

21,0

8920

,559

20,8

1318

,049

22,3

4419

,704

14,5

1921

,457

16,8

2415

,065

23,6

9918

,649

Gene

ral s

urge

ry23

,333

21,2

0922

,309

22,3

4620

,746

21,6

3922

,330

21,0

5321

,791

21,6

4020

,687

21,3

60

Geni

to-u

rinar

y su

rger

y27

,389

21,7

6022

,624

25,3

9621

,557

22,2

2125

,609

21,7

1622

,440

24,3

2921

,279

21,8

70

Hep

atol

ogy

12,1

7918

,992

12,4

877,

408

12,4

597,

803

6,78

58,

967

7,16

05,

486

10,5

156,

380

Inte

rven

tiona

l rad

iolo

gy33

,854

76,1

4646

,352

31,1

5172

,014

45,2

2336

,385

60,8

1944

,770

42,1

6664

,696

50,0

43

Med

ical

onc

olog

y6,

536

5,37

35,

703

6,20

55,

535

5,77

55,

971

5,71

65,

813

5,83

75,

754

5,78

1

Neo

nato

logy

21,8

6129

,066

22,8

2817

,400

28,3

8918

,274

13,4

4928

,978

14,4

6113

,053

26,4

1713

,828

Nep

hrol

ogy

12,4

028,

103

8,58

111

,150

7,96

38,

227

11,2

438,

020

8,34

110

,038

7,97

58,

198

Neu

rolo

gy18

,132

15,9

8917

,045

17,7

5215

,807

17,0

2117

,590

17,0

6917

,457

17,7

4317

,068

17,5

81

Neu

rosu

rger

y42

,552

35,9

0137

,423

42,2

2236

,523

37,9

1939

,898

35,7

5037

,009

38,5

8934

,259

35,7

20

OBG

Y29

,682

18,7

5419

,910

26,0

5719

,240

19,9

8824

,258

19,4

5120

,309

16,0

4919

,861

18,0

51

Oph

thal

mol

ogy

surg

ery

10,1

7211

,717

11,5

429,

824

12,6

2312

,338

9,67

912

,674

12,3

538,

891

13,2

3412

,843

Orth

oped

ic tr

aum

a24

,287

21,8

6522

,316

23,6

7022

,312

22,5

6026

,007

22,1

9523

,127

18,6

1821

,651

19,2

66

Pedi

atric

inte

nsiv

e17

,909

17,4

9017

,809

14,6

2616

,976

14,9

7113

,050

17,1

9813

,515

10,3

5315

,884

10,8

78

Pedi

atric

surg

ery

29,2

7129

,151

29,2

1428

,416

29,2

9428

,791

28,0

5929

,808

28,7

6428

,245

27,8

0528

,064

64

Pack

age

cate

gory

2012

-13

2013

-14

2014

-15

2015

-16

Gov

t.Pr

ivat

eTo

tal

Gov

t.Pr

ivat

eTo

tal

Gov

t.Pr

ivat

eTo

tal

Gov

t.Pr

ivat

eTo

tal

Pedi

atric

s14

,549

11,4

4513

,437

14,2

047,

915

12,4

0512

,389

7,47

610

,752

11,0

077,

182

9,13

5

Plas

tic su

rger

y25

,008

25,1

9225

,081

24,0

0524

,285

24,0

9921

,427

22,9

0321

,831

19,8

4321

,841

20,4

19

Poly

-tra

uma

25,0

3927

,387

26,1

5121

,162

27,7

8222

,708

14,7

8929

,063

16,5

7513

,854

23,4

0514

,567

Pulm

onol

ogy

20,0

5520

,009

20,0

4017

,211

18,3

2817

,536

13,8

8418

,626

14,6

6814

,042

20,8

3516

,171

Radi

atio

n on

colo

gy19

,099

20,9

0020

,506

17,0

8520

,449

19,6

2516

,411

20,4

1019

,419

16,5

6322

,695

21,1

66

Repl

acem

ent

73,8

9267

,711

68,2

3172

,758

66,9

6967

,428

72,7

3566

,988

67,6

0071

,311

66,7

8467

,157

Rheu

mat

olog

y13

,900

10,7

1813

,380

10,1

3310

,130

10,1

3210

,242

8,11

29,

766

9,73

712

,029

10,1

76

Surg

ical

gas

tro37

,632

34,3

3036

,007

38,5

6434

,592

36,5

2737

,584

36,5

1137

,019

37,6

1235

,385

36,3

48

Surg

ical

onc

olog

y20

,867

28,7

7223

,709

18,9

9829

,519

23,5

9821

,118

27,6

7524

,372

24,7

5027

,053

26,0

71

Tran

spla

ntat

ion

111,

667

142,

917

132,

500

146,

364

141,

200

143,

385

141,

739

145,

135

143,

833

134,

615

143,

522

142,

127

Vasc

ular

surg

ery

39,4

1433

,806

35,0

7233

,025

30,5

9131

283

29,7

8326

,273

27,3

8128

,929

25,4

9526

,646

Sour

ce: E

stim

ated

from

sche

me

adm

inist

rativ

e da

ta,

65

Among the packages, cardiothoracic surgery has the highest share of total claim amount (INR 151 crore in 2015-16, 24% of total claim amount), even though it consists of only around 5.7% of total number of claims (20,147 out of 0.35 million, of which 17,614 are in private hospitals).

This is followed by nephrology, which consists of around 20% of total claims, with around INR 56 crore (9%) and knee and hip replacements with INR 48 crore (8%). The broad procedures that had a small share in the number of claims also had a small share in the total amount of claim (see Section 4.2.7).

Table4.5belowgivesthedetailsofspecificproceduresunderthehighlyutilized(andofhighvolumealso)broad categories of cardiothoracic surgery, medical oncology, nephrology, knee and hip replacement, NICU and PICU. Among the broad category of cardiothoracic surgery, PTCA (Percutaneous transluminal coronary angioplasty) with bare metal stent had the lion’s share in the number of claims. The very high utilization of nephrology is primarily driven by hemodialysis, resulting into a total claim amount of INR 49 crore in 2015-16. Among pediatric ICU, bronchiolitis/severe broncho pneumonia related procedures constituted the major share in number, but the average cost was low.

Table 4.5: Share in Number of Claims and Cost of Selected Highly Utilized Procedures under CMCHIS in 2015-16

Procedures

% of Claims among Broad

Category*

Average Reimbursement

(INR)

Total Reimbursement

(INR Crore)Cardiothoracic Surgery

PTCA with bare metal stent 36 65,060 46.2Coronary Bypass 19 90,375 34.4Mitral Valve Replacement (With Valve) 7 123,721 16.1Primary Angioplasty for Acute MI + Drug Eluting

Stent 7 64,908 8.6Medical Oncology

Paclitaxel 11 10,126 4.9Cervical Cancer Weekly Cisplatin 10 1,991 0.9Palliative Chemotherapy 14 4,601 2.9CML Curable T. Imatinib 11 4,899 2.4

NephrologyMaintenance Haemodialysis 92 7,752 49.0ReplacementKnee Replacement 75 65,130 35.5Hip Replacement 25 73,376 13.0

NeonatologyTerm Baby /Culture Positive Sepsis/ Non-Ventilated/ Hyperbilirubinemia 36 10,750 7.8

66

Procedures

% of Claims among Broad

Category*

Average Reimbursement

(INR)

Total Reimbursement

(INR Crore)Preterm Baby/ Clinical Sepsis/ Hyperbilirubinemia (Non-Ventilated) 26 16,907 9.0Term Baby With Severe Perinatal Asphyxia - Non-Ventilated clinical Sepsis with or without Hyperbilirubinemia 29 10,896 6.5

Paediatric ICUSevere Bronchiolitis/Severe Broncho Pneumonia/Severe aspiration Pneumonia (Non-Ventilated) 62 7,732 3.0

Note:* Percentage of the sub-category of the broad package category, for example PTCA with barmetal stent contributes to 36% of claims under Cardiothoracic Surgery; Source: Estimated from scheme administrative data

4.2.9. Utilization by procedures reserved for public facilities Since the beginning of the scheme, 56 procedures have been reserved for public sector facilities. These include the following:

� certain surgical procedures under ENT, � general surgery, � gynae & obstetric surgeries, � orthopedic trauma and � poly-trauma care.

This was done with the aim to strengthen the public hospitals by using the resources (including the money received through claims) through CMCHIS. This also helped in checking possible over-prescription from private providers and possible ‘moral-hazard’ of the treatment of such procedures. Over the years, the utilization under these reserved procedures has increased by almost 44%, from 17,630 claims in 2012-13 to 25,376 claims in 2015-16 (Table 4.6). On the other hand, utilization under the non-reserve category has increased by around 40% over four years. In terms of share in total claims, utilization under these 56 reserve procedures has increased from 6.7% in 2012-13 to 7.7% in 2014-15 and 7.2% in 2015-16.

The average final approved amount was around 97% of the amount claimed by the facilities in 2015-16 for these reserved categories. The average cost of treatment remained more or less the same during the first three years but decreased by around INR 250 to INR 16,942 in 2015-16. Almost all claims made under these procedures were approved by the insurance agency.

67

Table 4.6: Key Indicators of the Procedures Reserved for Government Facilities

Indicators 2012-13 2013-14 2014-15 2015-16

Number of claims 17,630 25,777 28,022 25,376

Percentage of total number of claims 6.9 7.7 7.7 7.2

Average Approved Amount (INR) 17,469 17,104 17,194 16,942

Average of Approved to Claim Amount (%) 98 99 98 97

Source: Estimated from scheme administrative data

At a segregated level, orthopedic trauma and poly-trauma care procedures are the highest and least uti-lized among the reserved procedures for public facilities respectively (Annexure 4.9).

4.3. Claim experience

4.3.1. Claim process

Pre-authorization

The claim settlement process under the scheme starts with pre-authorization (pre-auth) of the provisional diagnosis and proposed line of treatment/procedures administered to the beneficiaries in both private and public facilities, which normally takes 24 hours to get approved. The process follows an online system for submitting the required documents by hospital authorities, which in turn are scrutinized and approved by TPAs.

Claim settlement

At the time of discharge, the claim documents are uploaded online by the Liaison Officer (LO) on the portal along with a discharge summary. Hospitals are required to upload complete treatment details, discharge summary and mandatory reports as per the protocol. These details are processed by the claim validator and approver available with the TPA. After the approval of claims, money gets transferred electronically (e-payment) from the UIIC to the bank account of the concerned hospital (see figure 4.12).

During Key Informant Interviews (KIIs), many representatives from government facilities shared their views that over time, the final approved amount by TPAs has gone down. The TPAs shared their opinion that over the years, they had to tighten the procedures and insist on relevant documents (particularly from govern-ment facilities) in order to improve the overall effectiveness of the claim approval process. Over the years, as a result of stricter assessment of claim bills, proportion of the amount approved (approved amount) by the TPAs to the amount that was originally claimed (claimed amount) by the hospitals, has increased

68

in government facilities from 12% (2012-13) to 21% (2015-16). In private facilities, it has remained high at around 65%.

Table 4.7 throws more light on the difference between the claim amount (billed amount by the providers), pre-authorization amount and the final amount approved. A few key observations can be made from this table: (a) The average claim amount and approved amount have been lower for government facilities than for private facilities; (b) The average claim amount in government facilities has fallen, while that of private facilities has increased; (c) but the difference between average claim amount and the average approved amount for private providers has drastically increased over the years, from INR 4935 in 2012-13 to INR 8473 in 2015-16; thereby reducing slowly the differences in approved amount between government and private facilities.

Table 4.7: Average Pre-authorization, Claim Bill Amount and Final Approved Amount during 2012-13 to 2015-16 - Government, Private & Total

Indicators Government Private Total

Average Pre-authorization Amount (INR)

2012-13 20957 22523 22042

2013-14 18609 22186 20916

2014-15 17786 22291 20558

2015-16 17766 22152 20504

Average Claim Amount by Facilities (INR)

2012-13 21522 27068 25215

2013-14 18827 28501 25052

2014-15 17997 29014 24774

2015-16 17861 29805 24803

Average Approved Amount by Facilities (INR)

2012-13 19745 22133 21276

2013-14 17054 21626 19992

2014-15 16408 21710 19670

2015-16 16313 21332 19239

Source: Estimated from scheme administrative data

Wecanalsomakeobservationsforspecificpackages(seeAnnexure4.10):Withrespecttotransplantation,pediatric intensive care, ploy trauma, neonatology, endocrinology and radiation oncology, private facilities get lower percent of approval to claims than public facilities (Annexure 4.10). As for public facilities, most

69

claims for hepatology and endocrinology, get approved. The average claim amount and average approved amount of the six most accessed packages are provided in Annexure 4.11.

Figure 4.12: Claim Settlement Process under the CMCHIS Scheme

After approval (E-payment) is done from

UIIC to the concerned hospital’s bank account

Submitted claims will be processed by the claim validator and approver available with the TPA

ProjectofficerwithTPAapproves the request

after authenticating ID of patient and medical

documents

Verificationofdetailsandauthentication of identity

of patient by LO

CMCHISbeneficiarymeetthe LO (Help desk)

During dis-charge, claim documents will be uploaded by LO on the

portal

Empaneled hospital provides cashless

treatment (Approved procedure)

Validator at TPA checks the non-medical

documents and BSA (Balance Sum Assured)

DMO of hospital submits required documents for approval of a procedure and Pre-Auth (Via portal)

4.3.2. Turn-around time to settle claims

Figure4.13providesTurn-Around-Time(TAT)forclaimssettlement,withrespecttobothfirstsubmissiondateandfinalsubmissiondate.Asisevident,theTATcalculatedfromthefinalsubmissiondateshowsthatalmost (99%) of all claims are settled within 7 days. But TAT for claims settled within 7 days falls drastically below70%,whenTATiscalculatedfromthefirstsubmissiondate.TAT(fromfirstsubmissiondate)showsa higher proportion (close to 23-26%) of all claims taking more than 10 days, in the past two years. It is importanttoidentifythereasonsforthedifferenceinTATcalculatedfromfirstandfinalsubmissiondate,inordertoimprovetheoveralleffectivenessoftheclaimprocessingmechanismoftheScheme.

70

Figure 4.13: Percentage Distribution of Claims by Turn-Around Time (TAT) by Type of Facility – 2012-13 to 2015-16

98.97 98.66 98.78 99.4 99.5 99.4 93.4 95.5 94.6 99.2 98.8 99.0

3.4 2.4 2.83.2 2.1 2.6

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

GOVT. PVT. TOTAL GOVT. PVT. TOTAL GOVT. PVT. TOTAL GOVT. PVT. TOTAL

2012-13 2013-14 2014-15 2015-16

Perc

enta

ge o

f Cla

ims b

y TA

T

Turn-around Time - from Final Submission Date 0-7 days 8-10 days More than 10 days

85.575.9 79.3 82.4

74.2 77.569.9 72.9 71.6 67.0

73.8 71.2

2.6

4.6 3.9 2.84.7 3.9

4.8 5.1 5.02.7

3.0 2.9

11.919.6 16.8 14.9 21.1 18.6 25.3 22.0 23.4 30.0

22.8 25.9

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

GOVT. PVT. TOTAL GOVT. PVT. TOTAL GOVT. PVT. TOTAL GOVT. PVT. TOTAL

2012-13 2013-14 2014-15 2015-16

Perc

enta

ge o

f Cla

ims b

y TA

T

Source: Estimated from scheme administrative data

Turn-around Time - from First Submission Date 0-7 days 8-10 days More than 10 days

Source: Estimated from scheme administrative data

71

Box 4.5: Findings from Key Informant Interviews on Claim Experience

Aspercontractualarrangements,theTATfromclaimsubmissiontofinalapprovalshouldnotexceed7days. IfTATexceedsthe7-daylimit,theconcernedTPAwillfacecertainpenalty. .Duringfieldsurvey, many facility representatives shared that “in recent times, the TPAs are demanding several documents, thereby the time for monitoring has increased considerably”. Some others said, “The documentation procedure for claim submission has become more cumbersome, particularly for the implants and queries placed by TPAs have also increased. These might have resulted in the delay inthefinalapproval”.ManyTPAssaidthat“whiletheapprovedtoclaimamountratioishighingovernmentfacilities,theyneedsubstantialimprovementindocumentationprocess.We[TPAs]bydecorum, cannot monitor or access documents in the government facilities, which would otherwise fasten the process.”

4.4. discussion and conclusionSincethebeginningofthescheme,numberofutilizationhasincreasedsignificantlyovertheyears(from255,673 in 2012-13 to 353,535 in 2015-16). The rate of increase in utilization has been far greater compared to the rate of increase in enrolment in the scheme over the years. This implies that over the years enrollees havesignificantlyimprovedtheiraccesstohealthcareservices.However,giventhefactthatCMCHIScoversapproximately1/7thofthetotalhospitalizationcasesinthestate,theschemehassignificantpotentialtoexpand its coverage both in terms of ‘breadth’ (coverage of population, and ‘height’ (number of conditions covered).

Total amount of approved claims has also increased from INR 537 crores in 2012-13 to INR 671 crore in 2015-16. This indicates that the scheme has picked up over the years considerably.

The share of private facilities in the provider network remains dominant over public facilities in the scheme. Thisisalsoreflectedinthehighershareofprivatesectorsintotalnumberofclaims(around58%in2015-16). However the share of public sector in the total number of clams made has increased from 35.7% in 2012-13 to 41.9% in 2015-16, which is a welcome step and shows healthy growth of the scheme.

But public sector’s share in the total amount reimbursed remained almost stagnant over the years (33-35%). In absolute terms, it was around INR 237 crore for public facilities and INR 434 crores for private providers in2015-16.Moreover,averageclaimandapprovedamountinprivatesectorhasbeensignificantlyhighertothoseinthepublicsector.ThistosomeextentreflectthathowschemeslikeCMCHIScaneffectivelyusethe existing public sector capacity.

72

Thediseasespecificutilizationshowsthat,thereareafewprocedures(nephrology,kneeandhipreplacement,ophthalmology surgery, cardiothoracic surgery etc.) which have been utilized more frequently than others in private facilities. Such instances need to be monitored more closely in order to avoid and restrict any possible fraudulent behavior.

It is important to examine the reasons for the increasing share of public facilities in total number of claims. Reservation of certain packages can explain it partially. Among other reasons, it is possible that the private facilitiesareturning-down lowcost/lowprofit-margincases.However,an important factorcouldbetheincreasingpositivepublicimageofpublicfacilitiesovertheyears.Toputitdifferently,otherthingsbeingthe same, the average claim amount made by private providers is quite higher than that of public providers. So, for comparable services, enrollees seeking care from public providers have the potential to save a larger amount for the scheme. Or from a provider perspective, private sector may be refusing to treat the cases withlow/noprofitmarginwhoendupbeingtreatedinpublicsector.Thisneedstobeexaminedfurther,as to whether and to what extent this phenomenon is taking place. One possible way to address this issue could be empaneling more public facilities under the scheme, even at secondary level enhancing their quality of service provision with required standards. Additionally more procedures can be reserved for thepublichospitals.Amoreactivecampaignonthepotentialbenefitsofutilizingpublic facilitiescouldenhance the role of the public system in the scheme. Such campaigns eventually could bring about healthy competitive forces and could reduce cost of care by (claims made by) private providers.

An important policy issue that comes up in the discussion with various stakeholders relates to the premiums andratesfixedforvariousservices(therapiesandsurgicalprocedures).Wediscussthisandrelatedissuesinthe following chapter, and assess whether and to what extent elements of strategic purchasing take place and the scope for enhancing such mechanisms under the scheme.

73

5. PuRCHASing oF HeAltHCARe And PRovideR PAyment meCHAniSmS

Strategic Purchasing of health services implies conscious and deliberated decisions on the following questions: (a) which services should be purchased, (b) how they should be purchased and (c) from whom they should be purchased. Such a decision making process would help in ensuring provision of quality healthcareataffordablepricesandinimprovingpopulationhealth.Strategicpurchasingisanimportantinstrumentforpromotingqualityofservicesprovidedandefficiencyintheuseofpublicresourcestowardshealth (Kutzin, 2012; Preker, Liu, Velenyi, & Baris, 2007; WHO, 2000; WHO 2010).

Similarly, the methods and mechanisms for provider payments in a health system, established between providersandpurchasers,haveprofoundeffectsonthewayinwhichhealthcareresourcesareallocatedand services are delivered.More specifically, paymentmechanisms encourage health care providers todeliverqualityserviceswithimprovedequity,whilepromotingtheeffectiveandefficientuseofresourcesand if required, cost containment (Inke Mathauer, 2013; Park, Braun, Carrin, & Evans, 2007).

In India, the growth of social health insurance schemes marked a move from the traditional integrated system of payers and providers through budget-based funding (as found in the government sector) to one with increasing separation of purchasers and providers and strategic purchasing (Box 5.1). Like other health insurance schemes in India, the CMCHIS follows a system of a systematic split between health care providers and the purchaser of services. Contracts are used by purchasers to meet the objectives of purchasing care from providers. Contracts will have incentives and monitoring mechanisms spelt out to have the expected services delivered.

Accordingly, mechanisms for payments to providers become very critical for the success of a scheme like CMCHIS. Although the CMCHIS does not explicitly mention use of strategic purchasing in policy documents or in circulars and guidelines, the Scheme already has several features of strategic purchasing - the contracted insurerviathird-partyadministratorsfulfillstheroleofpayersandpurchaseshealthservicesfromserviceproviders empaneled under the scheme. This chapter focuses on elements of strategic purchasing and payment mechanisms and the embedded incentives for key actors under CMCHIS.

12 http://cmchistn.com/circular.php

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Box 5.1: Purchasing Models

Historically,differentmodelshavebeenusedtopurchasehealthcarefromitsproviders,whichfulfillthehealthfinancingfunctionsofcollectingandpoolingrevenues,andpurchasinghealthservicesfrom providers (presented in Figure 5.1). The models aim to ensure availability of services, access to care,andensuingsocialprotection,whileincreasinghealthcaresystemefficiency.Healthsystemsofdifferentcountriesusethesefunctionstoavaryingdegree.Modelscanbebroadlyclassifiedintothree main categories:

� integration of the purchasing and provision functions through budgets/salaries provided by governments to their own providers;

� a separate purchasing agency which purchases services for the population; and � direct payments by users of care

Source: Robinson et al. 2005; WHO, 2010.

Figure 5.1: Health Financing Functions

Providers of care (doctors, hospitals)Users of care (patients)

Collecting

Pooling

Purchasing

Payments and Contracts

Payments and Contracts

Payers

(Source: Based on De Allegri & Leppert, 2015)

75

5.1. organization of Chief minister’s Comprehensive Health insur-ance Scheme

The purchaser-provider split in CMCHIS is expected to:

� improveproviderperformancethroughfinancialincentivesandmonitoringtoolsandcontracts; � reduce administrative rigidity by separation of functions and introduction of competition between providers,therebyincreasingefficiency.

Under this model, the government of Tamil Nadu contracted an insurer (United India Insurance Company – UIIC) to purchase a package of services from facilities empaneled under the scheme. Contracts between the UIIC and TNHSP have incentives and monitoring mechanisms spelt out for expected services delivered. The main agencies involved in purchasing and providing the health care services are depicted in Figure 5.2.

Funding entity: The TNHSP is the funding entity. It receives funds from the Tamil Nadu budget on an annual basis.

Purchaser: The purchaser, United India Insurance Corporation (UIIC), was selected as the implementing agency (purchaser) through competitive bidding restricted to the public sector. All four major public sector Insurance companies bid for the scheme, but UIIC was selected on the basis of L1 (as lowest bidder), implements the scheme through three TPAs (Vidal, MD India and Medi Assist) in the state who oversee provider payments and contracts.

Providers: A total of 771 (616 private and 155 government) hospitals are empaneled under the scheme. The hospitals are categorized into eight categories (A1-A6 for multispecialty hospitals, and S1-S2 for single specialty hospitals), further details of which are available in Chapter 4, section 4.1. The grading system acts as an overarching guidance for the purchaser in decision-making, and introduces motivation for providers to improve their services.

Figure 5.2: Organogram of the CMCHIS on the Purchaser-Provider Backdrop

Consumers TPA 1 TPA 2 TPA 3

UIIC

Public Provider

s

Private Provider

s

Purchaser

Provider

76

However, in addition to the UIIC, TPAs and providers, there are a number of other actors and institutions which play active role in strategic purchasing and provision of health care services. A detailed description of the key actors, institutions and their roles and responsibilities in the CMCHIS is presented in Figure 5.3.

Figure 5.3: Actors, Institutions and Their Responsibilities in the CMCHIS

Actors

Government

Purchasers

Providers

Citizens

Institution

Legislative Assembly, Council of Ministers, Department of Finance

(Treasury), Tamil Nadu Health Systems Project (TNHSP)

United India Insurance Company (UIIC) limited, [TPAs: Vidal, MD India, Medi

Assist]

Networked hospitals (770+)

Beneficiaries

Responsibilities

Stewardship, Legislation, Budget Allocation and

Management

Ensure better Access, improved Quality,

Efficiency, ensure Equity and Risk Protection,

enforce STG

Provision of quality health services,

People's participation in Decision Making, Feedback

on Service Delivery

77

5.2 Purchasing of Healthcare Services

5.2.1 Purchasing in CMCHIS

Health benefits package

Thehealthbenefits package inCMCHIS is administered through a systemwhich closely resembles theDiagnosis-Related Groups (DRGs) method, although it is not explicitly mentioned in the policy documents. Some follow-up packages are administered on a Fee-For- Service (FFS) basis (refer Box 5.2).

Box 5.2: Purchasing Models in Practice

Diagnosis-Related Groups (DRGs): DRG is a system to classify hospital cases into groups of diseases.ThissystemofclassificationwasdevelopedintheUSAduringearly1908swithanintentto convincing the Congress to use it for reimbursement to hospitals by replacing the then existing “cost based” reimbursement system. DRGs are assigned by a “grouper” program based on ICD (International Classification of Diseases) diagnoses, procedures, age, sex, discharge status, andthe presence of complications or comorbidities. DRGs have been used in the US since 1982 to determine how much Medicare pays the hospital for each “product”, since patients within each category are clinically similar and are expected to use the same level of hospital resources. DRGs are usually considered advantageous due to the ease of administration, possibility to contain costs if rates are set near operating costs, and ability to transfer the risk of treatment to providers who are liable for any failures (Forgia & Nagpal, 2012).

Fee-For-Service (FFS): Providers are reimbursed for each service activity rendered which is included in a list of reimbursable services, for example follow-up treatment for total thyroidectomy in CMCHIS.

There are nearly 1,016 service packages (DRGs -like) in CMCHIS, listed very broadly under three categories: diagnostic procedures, disease treatments, and follow up procedures.

SpecificservicescoveredunderservicepackagesarepresentedinBox5.3.Certainpackages(56innumber)arereservedforgettingtreatedonlyingovernmenthospitals.Theservicesandpackagesarenon-flexiblein nature i.e. the purchaser does not have the freedom to modify them. There are also some common procedures, which may be done by more than one specialty, which have fee-for service payments. Follow-up packages (113 in number, as of August 2016) are in addition to 1016 DRGs. These follow up packages start from the sixth day after discharge and continue for one year after discharge. Follow-up packages

78

arepaidquarterly,withahigherproportionoffundsallocatedinthefirstquarterforhigheranticipatedcosts. For example, a patient with sickle cell anaemia may require regular follow-up; under CMCHIS s/he is permittedamaximumofINR2,000forthefirstquarterandINR1,000forthenextthreequarters.

Box 5.3: Composition of services under CMCHIS packages

(1) Bed charges in general ward, (2) Nursing and boarding charges, (3) Surgeons, (4) Anaesthetists, (5) Medical practitioner, (6) Consultants fees, (7) Anaesthesia, (8) Blood, (9) Oxygen, (10) Operation theatre, (11) Cost of surgical appliances, (12) Medicines and drugs, (13) Cost of prosthetic devices, (14) Implants, (15) X-ray and diagnostic tests, (16) Food for patient, (17) One-time transport, (18) Pre-hospitalization costs 1 day before admission, (19) Diagnostic tests and medicines 5 days after discharge, (20) Carriage of body in case of death, (21) Follow-upmedicines for 120 identifiedprocedures

(Source: http://www.cmchistn.com/tender.html)

Package rates

UnderCMCHIS,thepackagerateforeachprocedurehasbeenstandardizedandfixedex-antethroughaconsultative process involving TNHSP and other stakeholders. In case of diagnostic procedures, the package includes expenses incurred up to 1 day before admission and up to 5 days after discharge. In case of death, the carriage of the body from the network hospital to the village/ township is covered by the scheme. The packagerateisfixedinsuchawayasitcoversfollow-upproceduresforanextendedperiodoftime.

The package rates present the maximum amount that the provider can claim for the service, though the finalamountreimbursedisfinallydecidedbytheTPAs.TNHSPofficialsreportedthatpackageratesweredesigned on the basis of a series of consultations held with technical experts, medical professionals and representatives of private and public hospitals and other relevant government stakeholders. During this process, vast databases on the other morbidity conditions and incidence rate of various life threatening diseases based on the experience until 2012, were also used.

Thepackagerateswerefixedinthebeginningoftheschemein2012.Discussionwithdifferentholdersrevealsthattherateswerefixed,bytakingintoaccountprospectiveinflationforthenext4-5years.However,ourinteractionswithdifferentstakeholdersalsorevealedthattheuserandthenetworkproviderrepresentationin the process of package design was not as intensive as it should have been, and many providers claimed thatinflationarypressureshavenotbeenaccountedforadequatelyinthepackagerates.

The rates are linked to the six-tier gradation of service providers, with higher grade facilities having higher package rates.

13 http://www.cmchistn.com/tender.html

79

“There is an inflationary pressure on the system. Hence for few procedures, the hospital is making loss. The providers were of the opinion that there should be an increase in the package rate by certain percentage, say 10 percentage every year.”

Official of a Private Hospital Network

Price setting and premium setting

“Price setting” (Package Rate setting) and premium setting depends upon the risk pool size, morbidity patternsandpredictabilityofhealthcarecosts,andcompositionofthebenefitpackage.UnderCMCHIS,theinsurancepremiumispaidtotheUIICbytheofficeofProjectDirector,TNHSP,onbehalfoftheeligiblepersons. Thepremium for everypolicy year (definedasbeing from11 Janof a year to10th Jan of the following year) is paid in four quarterly instalments and is released based on the number of health insurance cards issued. In case a member is enrolled in the middle of the year, only proportionate premium is paid.14

Box 5.4: Actuarial Methods for Premium Calculation

1) Income-related premiums/contributions: A certain percentage of the income of the insured ispaidas(premium)contributionfora(standard)benefitspackage.Thisistypicallythecaseforsocial security schemes in most countries, such as Employees’ State Insurance scheme of India.

2) Community rated premiums/contributions: Premiums/contributions are adjusted for the averageriskofagroup,sothatthesameflatratecontribution/premiumforastandardbenefitspackageisfixedforeachinsuredperson.Thisisthecaseforsomesocialhealthinsuranceandemployer-based insurance plans, such as Yeshashvini Scheme.

3) Risk–related premiums/contributions: Premiums to health insurance vary by expected morbidity risk of the insured person and are calculated according to actuarial principles.

(Source: http://www.actuariesindia.org/micb/Premium_Calculation.pdf)

The premium under CMCHIS has been calculated using a combination of community rated and risk rated premium (see Box 5.4). The estimates used in the calculation were reported to be based on the population covered and claims data available from the previous state insurance scheme, until 2012. The total population covered under the previous scheme was estimated to be 1.29 crore; so the claims incidence were calculated forthisoverallpopulation.DiscussionswithUIICofficialsrevealedthattheincidencerates(ratioofnumberof claims incurred by total population covered) were calculated by category of illness/ treatment by disease

14 http://cmchistn.com/tender.php

80

category, that is, separately for cardiac patient, for dialysis and so on. Using the data from the previous scheme the ratio of incurred claims (claims paid out and claims outstanding) to premium was also derived. The quantum of liability for four years was determined in discussions with the medical doctors, and this was added or ‘loaded’ to the premium. Costs for additional procedures added over the procedure list of pre-CMCHIS was also loaded to the premium.

ThepremiumamountwasdecidedfortheentiredurationofthecontractandfixedforfouryearsatINR497per annum, per family plus service taxes by UIIC, approximately 6% higher than in the pre-CMCHIS level. The payment is made to UIIC on quarterly basis. The method of pro-rata premium calculation is presented in Box 5.5.

Box 5.5: Pro-rata Premium Calculation in CMCHIS

Whenanewbeneficiary isadded,sayforexample, if thebeneficiary isaddedonthe180thdayof the year, the TPA calculates the daily premium cost (497/365) and applies it from the 181th day to the next 185th day, i.e., TPA calculates the premium cost for the remaining 185 days as per daily premium rate, as a “pro-rata” premium. Every quarter UIIC collects the premium based on the number of families enrolled, and takes the district-wise family as a unit for calculation. If a beneficiaryisbeingaddedinthe3rdyearofthescheme,thefamilywillgetacoverageof2lakhs.This is the principle of the insurance that the pro–rated premium might increase or decrease but year-wise summation never decreases.

Package rates under CMCHIS and market rates

We compared the prevailing package rates in CMCHIS with the unit cost of surgical episodes by ailment categories from the National Sample Survey Organization (NSSO) 71st Round15 in Tamil Nadu. In order to ensure better comparability between the actual claim and the NSSO data, we considered any hospitalization with surgery in the NSSO data (Table 5.1). Unit costs incurred per episode on medical expenditure and total expenditure including medical, transport and food are estimated for private facilities. The costs estimated from NSSO are compared with the maximum package rates under the CMCHIS for comparable ailments or ailment categories.

Table5.1shows,thatasperNSSOfigures,thepackageratesinCMCHISarecomparabletothetotalprivatecost of services (covering total medical, transport and food costs taken together) obtained from private hospitals, for similar ailment categories.

For example, for jaundice-related surgeries, the average per episode cost in private facilities from the NSSO survey was INR 50,200 in the year 2014; the maximum package rate for a surgical jaundice-related category in the CMCHIS was INR 45,000 for the DRG TN0787: Choledochal Cyst – Jaundice.

15 NSSO 71st round provides information related to cost of treatment including bed charges, medicine purchase, diagnostics, and other medical and non-medical costs. This is available in the data set by public and private facilities separately.

81

For bronchial asthma, patients accessing private facilities spent INR 45,555 per surgical episode in the NSSO survey; the CMCHIS rate for TN0643: Acute Bronchitis and Pneumonia with Respiratory Failure is INR 50,000.

Similarly, CMCHIS DRG rates for the per episode costs for endocrine/metabolic disorders, glaucoma, acute respiratoryinfections,bronchialasthma,lumporfluidinabdomen,skininfection,jointorbonediseaseandaccidental injury compare favorably expected expenditures in private facilities as per NSSO estimates.

There are certain ailment categories in which the episodic surgical costs from the NSSO survey are quite lower than CMCHIS DRG rates. For example, the following packages have much higher CMCHIS package rates than the rates reported in the NSSO survey:

� surgical oncology, � bleeding, � hemophilia and coagulation disorders, � cardiothoracic surgery, � surgery for bleeding ulcers and � obscure gastro intestinal bleed.

Conversely, metabolic coma requiring ventilator support and acute stroke thrombolysis with RTPA have package rates considerably lower than the expenses reported in the NSSO. Such comparisons should take into account severity of illness and heterogeneity of treatment options. It is important to note that overall, among the packages examined, most rates compare favorably with market rates estimated from the NSSO survey in 2014, in spite of the fact that package rates were set four years earlier.

82

Tabl

e 5.

1:

Sele

cted

Mea

n Su

rgic

al E

piso

de E

xpen

ditu

res

by A

ilmen

t Cat

egor

ies

from

NSS

O a

nd C

MCH

IS P

acka

ge R

ates

, Tam

il N

adu

(INR)

NSS

O A

ilmen

t Cat

egor

yCM

CHIS

Pac

kage

(with

cod

e)

Ailm

ent C

ateg

ory

Priv

ate

Faci

litie

s M

edic

al

Expe

nditu

re

Priv

ate

Faci

litie

s To

tal

Expe

nditu

re

Proc

edur

e N

ame

Rate

(m

axim

um

amou

nt)

Jaun

dice

49,8

0050

,200

TN07

87:

Chol

edoc

hal C

yst –

Jaun

dice

4500

0

Canc

ers

72,0

0277

,275

TN00

80-2

08 :

Surg

ical

Onc

olog

y10

0000

Blee

ding

diso

rder

s23

,428

24,8

19TN

0650

-52:

Ble

edin

g, H

emop

hilia

and

Co

agul

atio

n di

sord

ers

5000

0

Dia

bete

s62

,705

65,7

31Va

rious

dia

bete

s pac

kage

s35

000

Oth

er e

ndoc

rine/

met

abol

ic35

,709

39,8

24TN

0649

: Met

abol

ic C

oma

Requ

iring

Ven

tilat

ory

Supp

ort

3000

0

Stro

ke/h

emip

legi

a12

7,11

114

1,64

0TN

0910

: Acu

te S

troke

Thr

ombo

lysis

with

RTP

A10

0000

Glau

com

a11

,071

11,3

55TN

0615

: Adu

lt Gl

auco

ma

Surg

ery,

Tr

abec

ulec

tom

y, Im

plan

t Sur

gery

1200

0

Hea

rt di

seas

e10

9,71

111

6,03

8Ca

rdio

thor

acic

surg

ery

1500

00

Acut

e re

spira

tory

infe

ctio

ns43

,181

54,1

78TN

0665

: Acu

te R

espi

rato

ry F

ailu

re (W

ith

Vent

ilato

r-fo

r Min

imum

5 D

ays)

5000

0

Bron

chia

l Ast

hma

42,7

2345

,555

TN06

43: A

cute

Bro

nchi

tis a

nd P

neum

onia

with

Re

spira

tory

Fai

lure

5000

0

Gast

ric/p

eptic

ulc

ers

24,3

8725

,916

TN07

48: S

urge

ry fo

r Ble

edin

g Ul

cers

4000

0Lumporfluidinabdom

en/

scro

tum

30,1

6031

,834

TN06

74: C

irrho

sis w

ith H

epat

o-Re

nal S

yndr

ome

4000

0

Gast

ro-in

test

inal

ble

edin

g11

,645

12,3

28TN

0672

: Obs

cure

GI B

leed

5000

0

Skin

infe

ctio

n28

,821

33,8

33D

erm

atol

ogy

3000

0

Join

t or b

one

dise

ase

36,7

8539

,750

Rheu

mat

olog

y 50

000

Acci

dent

al in

jury

48,2

9051

,764

Orth

opae

dic

traum

a 50

000

Burn

s and

cor

rosio

n34

,354

36,1

19Pl

astic

Sur

gery

12

0000

Source:NSSOestimationsarefrom

NSSO71stround;CMCHISratesarefrom

officialrecordsofTNHSPandUIIC.

83

5.2.2 Strategic purchasing

Box 5.6: Principal-Agent Framework in CMCHIS

1. Is the purchasing centralized or decentralized? Is there competition among purchasers? If so, what is the degree of competition?

2. Purchaser-usersrelationship:Howarethebeneficiaries’needsandpreferencesreflectedinthepurchasingdecision?Whatroledothebeneficiaries’playinthepurchasingprocess?

3. Purchaser-provider relationship: What type of provider organizations are used (public or private)? What type of contractual arrangements and provider payment methods govern their relationship? What monitoring and regulatory mechanisms are used?

4. Purchaser-government relationship: To what extent does the purchaser, as an agent of the government,fulfillthegovernment’sobjectiveintermsofitspurchasingactivities?

Recognizing the potential of purchasing in a health system, the WHO recommends ‘strategic purchasing’ as a major tool for improving performance of a health systems (WHO, 2000, 2010). We use the triple Principal-Agent framework (Box 5.6 and Figure 5.4; Figueras, 2005) to analyze the CMCHIS with respect to the components of strategic purchasing.

Figure 5.4: Principal-Agent Relationship in CMCHIS

Government

Purchaser

UIIC

TPAs

Providers Users

P

P

A

A P

A

84

Purchaser-government relationship

In a health system, the primary function of the government is to play a stewardship role over purchasers and support them. Through the selection of the purchasing agency, the government is able to introduce competition among potential purchasing agencies, to obtain quality services at low cost.

HoweverinCMCHIS,UIICistheonlypurchasingagency.Someofthebenefitsofappointingapublicsectorpurchaserincludeitsabilitytooperateatlowerprofitmarginsascomparedtoprivateinsurers;thisinturnisbeneficialtousersofhealthcarewhoareabletomaximallyutilizethecoverageamountforhealthservices.It has also been suggested that in the case of UIIC, the health portfolio pertaining to CMCHIS constitutes a very small proportion of its overall insurance portfolio, therefore it has minimal impact on its turnover and profitmargins.16

Contractual arrangements between the government and UIIC spell out the operating and quality guidelines neededtobefulfilledbythepurchaser.Theregulatorytargetsetbythegovernmentforthepurchaseristhat the purchaser (UIIC) should ensure the availability of minimum 50 networked hospitals in the areas under each district cluster (i.e. under Northern, Central, Western and Southern clusters of the state).17 Such a clause restricts the purchaser from violating the contracts (e.g. canvassing and poaching patients from neighboringdistricts)andincreasingaccesstobeneficiaries.

The stewardship role of the government is strongly present, as reflected in government documents.12Government’s role in the Scheme, represented by TNHSP, is more direct in:

� Designing the package, � Setting the standards for network hospitals (and mandatory inclusion of government hospitals), � Representation in the committees of the TPA/UIIC, � Monitoring and evaluating the TPAs (monthly meetings, health camps, audit reports etc.) � Collecting feedback from consumers (See Chapter 6 for more on this).

Financially, the scheme is well decentralized. Due to IRDA regulations, the government pays the UIIC 95% of thepremiuminfourquarterlyinstallments.ThisallowsfinancialfreedomfortheUIIC.Oneintervieweeinafocus group discussion with providers stated, “The claims in CMCHIS are settled by the payer faster than any other private insurance payers.”Thisisanimportantremarkasthisnotonlyshoesconfidenceofprovidersin the insurance company but also helps in sustaining the providers’ interest in the scheme in the long run.

Purchaser-user relationship

Influence: In CMCHIS, enrollees do not have a choice to switch purchaser, given the fact that there is only one purchaser in the scheme. The purchaser and TPAs are involved in extensive information dissemination tobeneficiaries.Strategicpurchasingensuresthepurchaserisaccountabletowardstheusers.Oneofthemethods by which this can be ensured is by formal representation of the users in purchasing organizations.

16 Information obtained through communication with UIIC representative. 17 Information obtained through communication with UIIC representative.

85

In CMCHIS, however, apart from the feedback mechanisms from the beneficiaries of the scheme, theparticipatorymechanismsforbeneficiariesarelimitedandthereisnoinfluenceoftheusersonthepurchaserin most decision-making processes. For example, there was no formal public involvement or representation in the consultative process of package design. However, there is a strong feedback mechanism for the users and the government’s willingness to address user feedback to add value to the system. To quote one of the representatives from the government:

We don’t necessarily add all the treatments requested by the people, but if many patients are asking for it we will definitely consider adding it to our package in the future. We are open to suggestions from the people.

Health needs: Assessing the health needs of the population is an important feature in strategic purchasing. It ensures that the purchaser is buying only the necessary interventions for the target population. This acts as an important cost-containment measure. Health needs of the population within CMCHIS were studied during the stage of package design, utilizing morbidity and mortality patterns from the previous health insurancescheme.Apartfromthis,therehavenotbeenanyprimaryfield-levelhealthneedsassessmentsthat have fed back into the package design.

Awareness and grievances: An ideal strategic purchasing system is expected to publicly report on use of resources and other performance measures. Through various awareness campaigns the purchaser takes necessarymeasurestoensurethatthebeneficiariesarewellinformedoftheirentitlements.Theseinclude:

� settingupahelplineforbeneficiaries, � publishing handbooks of information, and � intimating the amount settled for the procedure utilized via Short Message Service (SMS).

InCMCHIS, thepurchaserand thegovernmenthave taken-upsignificantefforts togenerateawarenessabout the scheme in general and among the scheme enrollees in particular (refer to Chapter 2). The governmentreportsthefundsspentontheschemeandthenumberofusersbenefittedonthewebsiteofthescheme,andinofficialgovernmentadvertisementsinnewspapers.

Purchaser-provider and government-provider relationship

Contractual arrangements exist between the purchaser and the providers and between the purchaser and the government. These contractual arrangements set the framework of their relationship. More information on the empanelment of hospitals can be found in Chapter 4. The criteria laid down between the UIIC and hospitalsfulfillselementsofmarket-entry(forhospitalsoperatingwithinCMCHIS)andservicecontracts(forservice norms between the UIIC, TPAs and hospitals). Similar contracts exist between the UIIC and diagnostic centers. Other service obligations of UIIC include:

� operation of management information systems to monitor the scheme in conjunction with TPAs; � monitoringofstaffandinfrastructure; � maintenance of website and call centers.

Once empaneled, providers are responsible to provide quality health care, and competition among providers

86

allows the purchaser to emphasize the quality of the services. The gradation system of the network hospitals (see Chapter 4, section 4.1.1 and Annexure 4.1) in the scheme ensures that the hospitals strive for this objective.

Thereisnodirectgovernment-providerrelationshipinthescheme,andthegovernmentexertsinfluenceover providers indirectly through the insurer/purchaser. Once empaneled in the scheme, providers agree to function according to scheme criteria, such as defined package rates, input standards and skillmixcriteriasuchasMedicalCouncilofIndiacertificationandNationalAccreditationBoardforHospitalsandHealthcare Provider/ Diplomate of National Board (NABH/DNB) accreditation, etc. Performance and service cost control is implicitly regulated through pre-authorization process.

5.2.3. Purchasing in other Indian social health insurance schemes

A comparison of strategic purchasing features across Indian social health insurance schemes is given in Table 5.2. CMCHIS has the largest network of empaneled hospitals and also has a substantive number of DRGs. However, the scheme does not cover secondary care services like the RSBY Plus scheme in Himachal Pradesh (throughRSBYmaincomponents).The totalfinancial coverage isalso lower than thatofotherschemes except the Rajeev Gandhi Jeevandayee Arogya Yojana (RGJAY) in Maharashtra.

87

Tabl

e 5.

2:

Stra

tegi

c Pu

rcha

sing

Fea

ture

s ac

ross

Indi

an S

ocia

l Hea

lth In

sura

nce

Sche

mes

Feat

ure

Sche

me

Chie

f Min

iste

r’s

Com

preh

ensi

ve

Hea

lth In

sura

nce

Sche

me

(Tam

il N

adu)

Rajiv

Aar

ogya

sri

Com

mun

ity H

ealth

In

sura

nce

Sche

me

(And

hra

Prad

esh)

Rash

triy

a Sw

asth

ya

Bim

a Yo

jana

Plu

s (H

imac

hal P

rade

sh)

Vajp

ayee

A

rogy

asri

Sche

me

(Kar

nata

ka)

Raje

ev G

andh

i Je

eban

daye

e A

rogy

a Yo

jana

(M

ahar

asht

ra)

Num

ber o

f hea

lth

cond

ition

s cov

ered

(p

acka

ges)

1,01

6 p

roce

dure

s +

follo

w-u

p pr

oced

ures

163

treat

men

ts

cove

red

thro

ugh

942

proc

edur

es +

125

follo

w-u

p pr

oced

ures

1500

pac

kage

s 40

2 te

rtiar

y ca

re

proc

edur

es +

50

follo

w-u

p pr

oced

ures

971

proc

edur

es

Fina

ncia

l cov

erag

e (p

er a

nnum

)

INR

1 la

kh a

nd 1

.5

lakhspecificto

identifiedserviceson

afamilyfloaterbasis

INR1

.5 la

kh p

er fa

mily

onafloaterbasis;plus

INR

0.5

INR

1.75

lakh

on

a familyfloaterbasis;

INR1

.5 la

kh o

n a

familyfloaterbasis;

plus

INR

0.5

INR

1.5

lakh

on

afamilyfloater

basis

;

Type

of p

rovi

ders

Publ

ic a

nd p

rivat

elakhthroughbuffer

Publ

ic a

nd p

rivat

elakhthroughbuffer

Publ

ic a

nd p

rivat

e

Rese

rve

for p

ublic

se

ctor

Yes

Publ

ic a

nd p

rivat

eN

oPu

blic

and

priv

ate

Yes

Num

ber o

f em

pane

lled

hosp

itals

761

(607

priv

ate

and

154

gove

rnm

ent)

hosp

itals

No

177

(155

pub

lic a

nd

22 p

rivat

e) h

ospi

tals

No

174

(153

pub

lic,

21 p

rivat

e)

hosp

itals

Num

ber o

f TPA

s3

380

(97

publ

ic a

nd

283

priv

ate)

hos

pita

ls2

150

hosp

itals

3

Num

ber o

f in

sure

rs1

(Uni

ted

Indi

a In

sura

nce

Com

pany

Lt

d)1

1 (N

ew In

dia

Insu

ranc

e Co

mpa

ny)

Non

e (M

oUs

with

em

pane

led

hosp

itals)

1 (N

atio

nal

Insu

ranc

e Co

mpa

ny)

1 (S

tar H

ealth

& A

llied

In

sura

nce

Com

. Ltd

)*

*The

sche

me

star

ted

out w

ith th

e St

ar H

ealth

& A

llied

Insu

ranc

e Co

mpa

ny a

s the

insu

rer (

phas

e 1)

; lat

er th

e sc

hem

e w

as c

onve

rted

into

a tr

ust m

odel

undertheArogyasriHealthCareTrust,GovernmentofAndhraPradesh,inwhichtheinsurerfulfilledtheroleoftheTPA(phase2).Source:Author’s

compilationfromschemespecificwebsites.

88

5.3. Provider payment mechanismsPaymentmethodsforprovidersarelinkedtopurchasingarrangements.Internationally,differentpaymentmechanisms used include

� fixed(independentofthequantumofservicesprovided)orvariable(dependentonthenumberofservices rendered);

� the unit of service activity may be fee for service (individual services from a list such as for medicines, diagnostics, bed charges, etc.);

� a per diem or daily charge; � payment by case or diagnosis-related group (DRG); � capitation; and � other units of rate-setting such as salaries and output/performance based payments (Langenbrunner,

Orosz, Kutzin, & Wiley, 2005). Payments are also linked to provider costs: retrospective payments (ex post)orreimbursementarefixedafter the delivery of services to fully cover provider costs without clear constraints on price or quantity of servicesprovidedoraccordingtoaspecificfeeschedule;prospectivepayments(ex ante)arepre-definedand not normally linked to actual provider costs of services (Jegers, Kesteloot, De Graeve, & Gilles, 2002). For larger insurance schemes, the objective is to capitalize on macro-level considerations, while incentivizing individual provider earning and quality. The typology of provider payment mechanisms is varied and most systems operate using mixed methods. As discussed earlier, CMCHIS appointed a sole purchaser (UIIC) to operationalize payments to providers through three third-party administrators (TPAs). Government hospitals under the scheme operate with a mixed payment system, with elements of both ex ante (from the CMCHIS scheme) and budget-based (from government budget) payment methods.

5.3.1. Provider payment mechanisms and incentives in CMCHISThe CMCHIS follows a payment method closely resembling a FFS and DRG-based system in which package ratesarefixedex ante through a consultative process. Health care providers are paid for each case (treatment, diagnostic test, or post-operative procedures) treated. The price for each type of provider and procedures arefixedfor theentiredurationof thescheme, it isalsorelativelyeasier to implement,as thepaymentprocesses now well in place and operating procedures are better understood and followed up.

ProviderscanclaimpaymentunderacombinationofuptofiveDRGs,follow-upservicesanddiagnosticsfor one patient. This is expected to take care of patients with co-morbidities and severe complications, and incentivizeproviderstotakeoncomplicatedcasesbyminimizingtheirrisktobearhighercosts.Thedefinedfollow-up packages help to ensure the success of treatments under the scheme. Follow-up packages may be an added incentive to providers, whereby they are assured of a captive patient for a year (based on initial provision of satisfactory clinical services), as well as safeguarding the success of their treatments (and quality of their care) by regular follow-up which may be forgone in the absence of the scheme.

Package rates depend on the grade of hospital in which service is provided (refer Chapter 4, Box 4.1). Hospitals in the higher grade categories have higher package rates for the same DRG, for certain procedures.

89

Therefore,hospitalgradingcreatesan incentive forhospitals to fulfilqualitycriteria laidout inCMCHISguidelines, and move to higher grades in subsequent appraisals.

GovernmentprovidersarefurtherincentivizedtocatertoCMCHISbeneficiariesthroughfinancialincentivesprovided to the team of operating doctors.18 The total designated DRG package rate is divided among the cost of consumables, institutional development and incentive to the operating team in the ratio of 60:25:15. This creates incentives at two levels in government facilities:

� ThemanagerialstaffareincentivizedtomaximizeservicesundertheCMCHIS;therevenuegeneratedcan be deployed in to respective facilities for upgrading the quality of care; and

� The operating team has motivation as they receive a proportion of package funds.

Further, CMCHIS guidelines stipulate that the TNHSP will facilitate institutional strengthening of government hospitals through the creation of separate CMCHIS wards. Private providers are not mandated to have separate wards for patients of this scheme, although many of them do have such wards in practice.

Ex ante rate setting, with adequate checks and controls, is expected to incentivize providers to innovate and introducecost-containmentmethods,inordertomaximizefinancialgains(Forgia&Nagpal,2012).

However,theincentivestructureinCMCHISalsohaspossibilitiestoinfluenceproviderbehaviorinundesiredways.Sinceprovidersalreadyknowthemaximumamount(fixedcost)theycanclaimunderaprocedure,they may choose low-risk patients at the expense of those who are high risk and actually need care, and reduce quality of care to minimize costs (Langenbrunner et al., 2005). The ability to claim payment under a combinationofuptofiveDRGs,follow-upservicesanddiagnosticsforonepatientopensuppossibilitiesfor providing unnecessary combinations of services. How far the current monitoring system, given the weak informationflow,iseffectiveincontrollingsuchpossibilities needs to be examined.

5.3.2. Refund – an incentive to make claims

As per the TNHSP, the State Empowered Committee in 2011 recommended an amendment to previous orders and postulated that the tender for the insurance company for running CMCHIS would be valid for four years and extendable by an additional year based on performance indicators.19 These indicators include a claim ratio of more than 80% and annual IRDA renewal. The UIIC is asked to refund to the TNHSP a proportion of the premium earned under the scheme, should the claim amount be less than 80% of premium in that policy year.20 Though this refund is not a payment mechanism per se, it creates an incentive for the insurer to meet the 80% claims target and maximize the number and/or amount of claims in a given policy year; failing which non-extension of the tender of the insurance company may ensue.

18 Refer http://www.cmchistn.com/tender.html for more details. 19 G.O. (Ms.) No. 189, dated 29/07/2011, Health and Family Welfare Department, CMCHIS, Amendment 20 The guidelines further state: “After providing 20% of the premium paid towards the companies administrative cost, if there is any surplus after the claims experience on the premium (excluding service tax) at the end of the policy period, of the balance 80% after providing for outstanding claims if any, 90% of the leftover surplus will be refunded to the society within 30 days after the expiry of the policy year. If the claims experience on the premium is more than 100%, the excess above 100% may be compensated from out of the refunded amount remitted by the Public Sector insurance company in the block of 4 years.”

90

5.3.3. Penalties for providers for non-adherence to guidelines

Failure to meet CMCHIS guidelines by providers elicits penalties which serve as a disincentive structure. For healthserviceproviders,theseincludeapenaltyasdecidedbytheTNHSPforanydeficiencyinservicesandfailure to meet timelines, ranging from suspension of services of the hospital to complete delisting from the network. If there is any evidence of fraudulent claims by providers, they can be removed from the scheme and subjected to appropriate penalties.

TheUIIC implements thenecessarymonitoringmechanisms in thefield to ensure fraudprevention. Bymandating such penalties in the system, the government is able to ensure the accountability of the providers towards the purchaser and the users. The UIIC via TPAs is expected to settle all claims from hospitals within one week from the time of submission; failure to adhere to the timeline incurs a penalty comprising the expenditure incurred by the hospital towards treatment and an 18% cumulative interest rate.21

5.3.4. Provider payment features across Indian social health insurance schemesAlmost all government-sponsored health insurance schemes in India follow a type of case-based payment such as a fee-for-service or DRG, and all follow cost control measures such as pre-authorization, in-depth analysis of claims, and surveillance/monitoring of claims. CMCHIS has the highest premium of all schemes, at INR 497 per family enrolled. However, the average per person premium in CMCHIS compares favorably with other schemes in the country. Nearly 15.7 million households are enrolled in CMCHIS. Considering an average family size of 2.7 person per family among the enrolled households (refer to Chapter 3, Section 3.4), we get an annual premium of INR 184 (INR 497/2.7) per person.

21 Please see http://www.cmchistn.com/tender.html for more details.

91

5.4. Claim ratio under the CmCHiS schemePayment mechanisms should be sustainable for both purchaser (UIIC) and providers. Purchasers use the following two indicators to ascertain the viability of payment mechanisms by the purchaser:

� Claim ratio, and � Burnout ratio.

Theyaredefinedasfollows:

1. Claims Ratio (CR) = Total incurred amount divided by Premium amount (excluding service tax)22

2. Burn out Ratio (BR) = Total Expenditure divided by Premium amount (excluding service tax)

Total expenditure includes 10% of premium plus total incurred amount.

Table5.3andFigure5.5reflectsthetrendsinCRandBRfortheperiod2012-13to2015-16.

Table 5.3: Claims Ratio and Burnout Ratio, 2012-13 to 2015-16*

PeriodTotal

Premium (INR Crore)

Total Claim (INR Crore)#

Total Expenditure (INR Crore)$

Claim Ratio (Total Claim

/ Total Premium), %

Burn Out Ratio (Total Expenditure

/ Total Premium), %

2012-13 644 479 543 74 84

2013-14 642 689 753 107 117

2014-15 658 701 767 107 117

2015-16 755 811 887 107 117

Overall 2699 2679 2949 98 109

*Policy year follows January-December cycle#Total claim for 2015-16 include outstanding amount$includes 10% on premium. Source: Estimated from scheme administrative data

22 UIICofficialinformedusthatCRiscalculatedforapolicyyear,whichcommenceson11Janofagivenyearandclosesonthe10thJanofthefollowingyear.Butitcanbecalculatedwithrespecttofinancialyearalso,whichisfrom1Aprilofayeartill31Marchofthefollowingyear.Hereweshowtheresultsasperpolicyyear.Theresultsareabitdifferentifweusedfinancialyear,whichisshowninthe Appendix 5. 1. Here the total incurred amount refers to the total claims settled plus claims outstanding.

92

Figure 5.5: Claims and Premiums under CMCHIS: 2012-13 to 2015-16*

0

100

200

300

400

500

600

700

800

900

2012-13 2013-14 2014-15 2015-16

Tota

l Am

ount

(IN

R Cr

ore)

*As per policy year; Source: Estimated from scheme administrative data

Total Premium Total Claim

It is evident that during the past three years both CR and BR are above the premium received by the UIIC, clearlyindicatingthatthepurchaser(UIIC)hasbeenmakingaloss;thefirstyearwitnessedalargesavings(more than 15% of premium). Prima facie, several reasons could be attributed to this trend, but one thing canbesaiddefinitively:thetotalclaimsandaverageclaimssettledaremuchmorethanforecasted.Thereis, prima facie, a clear case for revisiting the premium per household and per person, and also for revisiting the package rates for various procedures, across grades of providers.

Therefore the rate setting mechanism needs to be redesigned. As suggested earlier, a mid-term appraisal (every two to three year) of the package rates will help in addressing some of the genuine challenges being faced by providers as well the purchasers. We recommend this as one of the crucial aspect of strengthening theoveralleffectivenessandrobustnessoftheschemeinthefuture.

5.5. discussion and conclusionTheCMCHIS is in linewith recenthealth sector reforms,which followsdemand-sidefinancing throughhealth insurance. In comparison to other schemes, CMCHIS is fairly liberal in terms of the breadth (of population covered) and height (proportion of total health care costs) dimensions of universal health coverage. However, it can be expanded in terms of the depth of services covered, as only high-end tertiary services are provided by the scheme. Overall, we can state that that CMCHIS has institutionalized elements of strategic purchasing.

The CMCHIS service-basket is fairly comprehensive for tertiary care. Tamil Nadu has an overall higher hospitalization rate in India - (5.7% of population reported to have hospitalized over the past one year). Considering this trend, CMCHIS should perhaps consider secondary inpatient services as well to take care

*As per policy year; Source: Estimated from scheme administrative data

93

ofthisvastsectionsofpatientswhowouldbesufferingfromhugeoutofpocketexpenditureasaresultofhospitalization. Disease burden data from National Sample Survey 71st round indicates that Tamil Nadu has an increasing burden of many non-communicable and life-style diseases such as diabetes, hypertension and cardiovascular. The scheme may be expanded to include secondary level and non-surgical care for these ailments.

CMCHIS has established elements of competition, especially at the level of market entry for the insurer. There are diverging points of view regarding bringing in competition at the insurer-level: on one hand, competition gives choice to consumers to select among several insurers; conversely if there is a single insureritmayenjoymonopsonypowerandexertinfluenceoverproviders(Mikkers&Ryan,2014).CMCHIShas followed the second line of reasoning.

DespitebeingthesoleinsurertheUIICenjoyslimitedpowerintermsofpackageselectionandratefixation.Moreover, the purchaser acts only as an implementer of the scheme and evidence suggest that the purchaser does not have much scope to bring in innovations to the scheme.

On the other hand, providers face a true competition at the level of market entry. They agree to both pre-decided package rates, and comply with quality norms and government grading criteria. Once empaneled, theyenjoythebenefitsofacaptivemarketprovidedbythegovernmentandtheinsurer,whichmayprovidethemthecapacitytooperateevenatlowerprofitmargins.

Thepremiumperenrolledfamilywassetatthebeginningofthepolicyperiod,andwasfixedfortheentiredurationofthescheme;suchauthorityofthegovernmentoverthebenefitspackageandpremiumrateshelpscontrolling thecost.On theotherhand this inflexibilityalsomakes thesystem less responsive toemerging and changing needs and expectations of people. Since premium rates have been pre-decided, the monopsony power of UIIC, the sole purchaser under the scheme, is further limited, and they are only implementers of the scheme. A revision of the rates would help to increase the buying and negotiating power of the insurer. However, while revising the premium rates, average family size of the households covered in the scheme should be an important indicator. The experiences of other social health insurance schemesinthecountry,suchasthoserelatedtoannualpackageandratefixation,linkingbothtoinflation,and comparison with market rates, may help in this endeavor.

The future of the scheme should try to engage citizens or welfare groups in revising the overall design and seeking ideas on improving its implementation. The past four years of the scheme has provided enough insightsintothewaysinwhichexperienceofthebeneficiariesinparticularcouldcontributetomakingtheschememoreeffective.

Ingeneral,CMCHISisacomprehensiveandliberalschemeandhasbeenverybeneficialforthepopulationat the tertiary level. The scheme has endeavored to incorporate strategic purchasing and payment-related incentive structures within the existing pluralistic government and private health providers. Reserving certain procedures for public sector hospitals can be replicated in other Indian social health insurance schemes to prevent the over-utilization of these procedures. CMCIHS has created incentives for both public and private providerstoaffiliatewiththescheme,whileatthesametimebuildingaccountabilitystructurestomonitorprovider performance.

94

6. monitoRing meCHAniSm

Thischapterdiscussesvariousaspectsofthemonitoringmechanism,implementedatdifferentstagesofthe scheme. Monitoring is an ongoing process in which stakeholders collect feedback at regular intervals andassesswhetherandtowhatextentprogressisbeingmadetowardsthefinalgoalsandobjectivesoftheprogram (UNDP, 2009).

We adopted a qualitative approach to understand the monitoring mechanism of the scheme. In-depth interviews wereconductedwithkeyinformantsatdifferentlevelsincludingrepresentativesfromUIICandTPAs,concernedpersons from private and public empaneled hospitals, LOs and DPOs. In addition, information was also collected from various government documents such as Minutes of Meetings, Government Orders and tender documents that are available on the website of the scheme. The monitoring process is shown in Annexure 6.1.

6.1. overall monitoring of the scheme by tnHSPThe overall monitoring of the scheme is done primarily at two levels:

(1) periodic weekly review meetings with stakeholders conducted by TNHSP, and

(2) the grievance cell, operated through the toll-free number (Figure 6.1).

Review meetings are attended by representatives from the UIIC, TPAs and the empaneled facilities. Feedback and issues, raised by stakeholders are addressed in these meetings. TNHSP also provides feedback, particularly to the facilities, about their performance, based on the utilization of the scheme (obtained fromtheclaimdataoftheschememanagementinformationsystem).Asanofficialsaid,[inthesereviewmeetings, we discuss a range of issues]:

“They may be related to pending or delay in approval of claim amount (both pre-authorization and the final approved amount), or regarding purchasing of the drugs, implants and other consumables, expenditure of money received under the CMCHIS scheme, etc. “

Apart from this, there is a toll-free number, where the beneficiaries of the scheme can register theirgrievances against stakeholders. The grievances may be related to refusal of treatment under the scheme by a facility, demand of money by the hospitals. Based on requirement, an enquiry is undertaken by UIIC/TNHSP, and if found at fault, appropriate steps are taken by the TNHSP to address the grievance raised, and also to prevent recurrence of such issues. Facilities may even get de-empaneled based on complaints bybeneficiaries.

95

Figure 6.1: Overall Monitoring of the Scheme by TNHSP

UIIC

TPA

Facilities

Grievance Cell (toll-

free number)

TPA

Facilities

Stakeholder Meeting

TNHSP

Beneficiaries

6.2. monitoring mechanism involved in overall functioning of the scheme

UIIC, with the help of TPAs, monitors the major domains of the scheme:

� fresh enrolment, � distribution of cards, � health camps and � data base management.

TNHSPlooksafterthehospitalempanelment,de-empanelmentandfinancialaudit.

6.2.1. Fresh enrolment

As mentioned in Chapter 3, people can get enrolled through various enrolment kiosks by producing the rationcardandtheincomecertificateissuedbytheVAOortheRevenueInspector(RI).Asboththeofficials,VAOs and RIs expected to be knowledgeable of the enrollees’ economic status, they, make decisions about households’ eligibility to the scheme.

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6.2.2. Distribution of CMCHIS Card

As mentioned in Chapter 3, one of the major tasks under this scheme is to distribute the new smart cards to about 1.29 crore families continuing from the pre-2012 Scheme. MSP-Eagle (a private company) was given the responsibility to do this task (Figure 6.2). As the distribution of CMCHIS cards could not be done at one point of time, the scheme management (here the TPAs), made an arrangement that a person can availbenefitsofCMCHISiftheyhavetheoldpre-CMCHIScard/requiredrationcardandincomecertificateby VAO/RI.

TPAs (through DPOs) monitor the distribution of the new cards by MSP-Eagle and validate the earlier scheme/ration card. After distribution, both TPAs and MOs of TNHSP randomly cross-check details of 20% ofhouseholdsandcomparetheirfindings;cardswithseriousmismatcharerejected.

Manybeneficiariesreporteddelay inreceiptof theircards,duringour interviews.TPAsrespondtosuchcomplains by stating that several patients forget to bring their cards and they therefore undergo another verificationprocess,whichisthecauseforthisdelayinre-issueofcards.

Figure 6.2: The Monitoring System during Scheme Enrolment

Enrolment Process

Old Card Holders – Distribution of cards by

Eagle is monitored by DPOs, recruited by TPAs

Fresh Enrolment

KIOSKs in District Collectorate / Medical Colleges

• GoTN monitors the eligibility in terms of issuing the Income Certificate by VAO/RI & Ration Card

• TPA monitors the enrolment process & card distribution

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6.2.3. Health camps

DPOs monitor the health camps organized by empaneled hospitals. They oversee:

� number of camps being organized, � number of individuals screened, and � referrals to hospitals.

Other than DPOs, JD and MOs (recruited by TNHSP) also monitor health camps.

6.2.4. Database management

When the CMCHIS was launched in 2012, the entire database of enrolled individuals in the pre-CMCHI scheme was imported to a database software designed and maintained by Oracle (a private company recruited by TPAs). Oracle was asked to manage the database of CMCHIS enrollees and scheme utilization. TPAs also monitor the database maintained by Oracle. The license fee for the database is borne by the TPAs, and later reimbursed by the UIIC, which is later on adjusted in the premium amount.

6.2.5. Hospital empanelment and de-empanelment

Overall, the Empanelment and Disciplinary Committee (EDC) looks after the process of empanelment of hospitals (Figure 6.3). The process of empanelment has already been discussed in Chapter 4 (also refer to annexure 4.1 for details on grading system). For empanelment or up-gradation to higher grades, a team representingTPAandTNHSPphysicallyverifiestheconcernedhospitalsandsubmitsareport(withtheirrecommendations);EDCmakesthefinaldecisionbasedonthisreport.

This team monitors/visits empaneled hospitals bi-monthly.23 On the basis of their observations they submit a report to the EDC. MOs recruited by TNHSP also make surprise visits to hospitals.

EDC’s recommendation for de-empanelment also follows the same procedure: every complaint against anempaneledprovider,eitherbybeneficiaries,orbyevidenceontheirperformance, is followedbytheMonitoring Team in order to ascertain facts, and to be able to make the right decision.

6.2.6. Financial audit of empaneled hospitals

All empaneled government facilities are required to submit their department-wise detailed expenditure statementtoTNHSPbeforethe5thofeverymonth.AteamofAdministrativeOfficers(AOs)(representativesfromDME,networkhospitalsandTNHSP)physicallyverifiesthebankstatementsorpassbooks,recordsofexpenditure,andcashflowtotallyaccountswiththeindividualfacilitiesatregularintervals.Also,hospitals

23 The frequency of these visits used to be much more in the initial stage of the scheme; there were monthly visits, which seem to have been reduced to once in two months.

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need to upload their details on the corpus fund and incentives to the CMCHIS portal every month. The vigilanceofficer (VO) in respectivedistricts visits facilities onceor twice everymonth and checks all therecords. TPAs do the auditing of the scheme payments through private auditors. The audit report (Annual Accounts) is then submitted to the Auditor General of the state government.

Figure 6.3: Hospital Monitoring System under the CMCHIS Scheme

Monitoring of Hospitals

Empanelment of Hospitals

Post-empanelment

Financial Monitoring – Weekly Report

update on scheme website

(TNHSP)

Quality &

Safety – NABH,

JCI, IPHS

Physical infrastructure monitoring by

UIIC,TPA, TNHSP

Financial Monitoring – Annual Audit by External Auditors &

report submission to TNHSP

Quality & Safety – NABH, JCI, IPHS

6.3. monitoring during hospitalization

6.3.1. During admission

Once a cardholder reaches a hospital for admission, the LO verifies the card number, card balance andother demographic details. LO then submits details to the JD (Joint Director) of the respective facility (Figure6.4).The JDverifies theclinicaldetails (suchasprovisionaldiagnosis,proposed lineof treatmentand corresponding expected cost) and approves and submits for pre-authorization. Next, the validators recruited by TPAs validate the demographic and clinical details and also the amount for the procedure. The pre-authorizationshouldbedonewithin24hoursofsubmissionbyJD.Thustheoverallverificationofthebeneficiaries,andmonitoringofthepackageselectionbyfacilitiesarealldoneatthepre-authorizationstageby TPA and UIIC. According to one of the representatives:

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“ Overall 90% of the pre-auths are approved within 4 hours (out of that 60% of the pre-auths are approved in less than 2 hours), rest 10 percentage is settled within in first 24 hours.”

6.3.2. During hospitalization

Once the patient is admitted, the LO visits the patient at least once a day. They also report details of admitted patients and vacant beds in the CMCHIS ward to the TPAs. The DVO also makes unannounced visits to the facilities to monitor admissions. DVOs usually interacts with patients after discharge in their homes to assess their level of satisfaction. The DVOs also monitor the work of LOs (Figure 6.4).

TNHSP isalso involved invalidationofprescribedtreatments;TNHSPhasrecruited10MedicalOfficers,who have access to MIS of CMCHIS data. Every day they validate at least 50% of the new data, such as the number of claims submitted and rejected. They also conduct trend analysis, go through prescribed procedures and make surprise visits to hospitals.

Figure 6.4: Monitoring Process during Hospitalization under the CMCHIS Scheme

Hospitalization Process

At the time of Admission

During Hospital Stay

Verification of eligibility

by LO (TPA)

Verification of procedure

by JD (TPA)

Daily -Visit by LO

(TPA) -MIS data

check by MO (TNHSP)

Random visit by

Vigilance Officer (TPA)

& MO (TNHSP)

TNHSP monitors the Facilities through Grievance Redressal Cell and Team of MOs

Timeframe Monitor by

UIIC

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6.4. Post-hospitalization – claim settlementAftercompletionoftreatment,facilitiessubmitthefinalclaimalongwithallsupportingdocuments(includingitem-wise expenditure and stickers of implants) and the patient satisfaction form. At this stage, a detailed verificationofalldocumentsiscarriedoutbyphysiciansrecruitedbytheTPA.FacilitiesshouldclarifydoubtsraisedbytheTPAsduringtheverificationprocess(Figure6.5).

Regarding claims settlement, as mentioned earlier, TPAs need to settle claims within 7 days. If any further clarificationisneededinanycase,theTPAsforwardittotheirpanelofspecialists.Afterredressaloftheissues, TPAs settle the claim as soon as possible. In case of unsuccessful procedures/referred cases, 24 only up to 25% of the claim amount is reimbursed.

Figure 6.5: Monitoring Process during Post-Hospitalization (Claim Settlement) under the CMCHIS Scheme

Post-Hospitalization, Claim Settlement Process

During Discharge After Discharge

Satisfaction Form Beneficiary

Claim Documents by Validators

(TPA)

Random visit to patient’s residence

by Vigilance Officer (TPA)

Timeframe Monitor by

UIIC

Monitors the Facilities through Grievance Redressal Cell and Weekly Meetings by TNHSP

24 The procedures for which the hospital have started the treatment and the patient developed further complications, but the hospital does not have the capacity to handle it, are referred as unsuccessful procedures. In these cases, the case is then referred to other hospitals for further treatment.

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6.5. Purchasing of consumables and implantsAs per the GO (Ms.) No. 127, dated 10 April 2012, by Health and Family Welfare Department, GoTN, implants need to be purchasedby the vendor identifiedbyUIIC or by TamilNaduMedical ServiceCorporation(TNMSC).ThefacilitiescanpurchasetheselocallyattheratefixedbytheCentralPurchaseCommittee(CPC),constituted by the GoTN.

To ensure the quality of implants, for example, the current policy of the scheme is that they should have been approved by United States Food and Drug Administration (USFDA). To validate the actual use of implants at the facility level, hospitals need to send the sticker of the implants after the surgery along with the bills.

6.6. discussion and conclusionMonitoringalargescalepubliclyfinancedprogramsuchastheCMCHISwillfaceconsiderablechallenges.Considerableeffortshavegoneintoplanning,designingandimplementationoforganizationalstructure,assigningindividualresponsibilitiesandspecificmechanismstomonitortheentireschemeacrossthestate.Thefollowingissuesneedcloserattentiontomakethemonitoringmechanismsmoreeffectiveinthefuture:

1. The scheme faces a huge challenge in reducing (if not eliminating) the number of “ineligible beneficiaries”asonerepresentativeoftheschemeputit.Thisisreferredtoasan“inclusionerror”,thatis, those ineligible households having an annual income above the criterion as per the scheme, have got enrolled. As on representative from a private facility in Salem district observed:

“There are few cases where the patient holding a CMCHIS card did not seem like they belonged to the economically poor families (going by the jewelry they wore or the cars they drive in to the facility).”

Manyrepresentativeshaveremarkedthatwhile“about80%”ofthebeneficiariesarefromtheeligiblepopulation(enrollees),thesizeoftheineligiblebeneficiariesisquitehigh.Incontrast,therecouldalsobe “exclusion error”, that is, those who were eligible for the scheme have not yet been enrolled and thereforecouldnotbenefitfromCMCHIS.Again,thereisnoestimateavailableonthis.

IdentificationofeligiblebeneficiariesalwaysposeschallengesinIndianconditions.SomeDPOsweremore hopeful of ways to trace family income over time.

2. Monitoring of health camps requires improvements, with regard to conduct of the health camps: DPOs observed that the health camps organized by private facilities are periodic (as per guidelines); however, in case of public facilities, these camps are not so periodic: at times, “personal preferences of the doctors of the concerned facility could decide the choice of the venue of the camps”, as one representative put it.

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3. Gradations of providers (from A1 to A6, and S1/S2) have caused considerable “disquiet” among many private providers. Private providers are skeptical of the fact that all public facilities have been graded as A1. This requires a revisit and careful calibration of various facilities and more transparency, in order toenhancethepublicimageofthescheme,andtostrengthentheeffectivenessofthescheme.Theoverall role of the management of the scheme in ensuring the quality and safety of the patients’ needs to be spelt out more clearly.

4. Public facilities seem to enjoy considerable autonomy in purchasing consultant services from the private sector, as one representative from a public facility remarked:

We can buy whatever we needed and hire from outside consultants paying higher remuneration using the money from the scheme, though those in private facilities may have greater autonomy and flexibility in this respect.

5. The monitoring processes during hospitalization and post-hospitalization process are well documented andtoagreatdegreewell inplace.However, themechanismtovalidatebeneficiarydetailsbeforeapproving treatment under the scheme during emergency (where the treatment cannot wait for the time for pre-auth) needs more attention.

6. Paysandsalaries tothose in themonitoringsystemdoplayan important role inensuringefficientexecution of their functions and effective functioning of the scheme. Several representatives havepointed out that “salaries paid to the key functionaries, such as LOs, are not high enough to keep them motivated to promote the overall interest and goals of the scheme”. LOs, for example, spend almost the whole day working in a facility. While facilities take care to some extent of the every-day needs of LOs, we cannot expect the overall loyalty of LOs to be in tune with the TPAs’ expectations, given their low salary level. Besides, there are sociological and peer pressures impinging on their commitment. A representative from a TPA said:

“TPAs need dedicated MBBS doctors who can visit hospitals and check details of patients. However, their salary is much less compared to what they could get from their private practice. Also the doctor under TPA is from the same district as of the doctors from the empaneled facility. Quite often the treating doctors are his/her seniors or juniors.

7. InChapter4,wehavealreadypointedtothegapbetweenthefirstsubmissiondateofclaimsdataandthefinalsubmissionofdateoftheclaims.Wewouldliketohighlightthisissuehereagain,asitrelatestotheoveralleffectiveimplementationofthescheme.Inadditiontothis,wewouldliketoemphasizethat reasons for not approving full claimed amount should be provided. This will help strengthen the overalleffectivenessofthegovernanceofthescheme.

8. TPAs advocate uniformity in documentation of records, in both private and public facilities. “The scheme seems more stringent with respect to private providers,” as one representative, remarked. A sense of fairness among private providers in the implementation of guidelines of the scheme is vital in ensuring theirroleinenhancingtheoveralleffectiveness.AsoneTPAremarked:

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“Presently TPAs face challenges in accessing documents in the MRDs (Medical Record Departments) of government facilities and various high-end private hospitals. The government hospitals also do not share full case history. If TPAs cannot access these detailed documents, they cannot validate the genuineness of opted procedure.”

9. TPAs over the years have strengthened the monitoring system to curb malpractices both in government and private hospitals. Many have said that in government facilities sometimes normal pathological conditions associated with a new born (for example, neonatal jaundice) are being charged under NICU and PICU “high cost procedures”. Recently they have curbed such activities by asking for additional investigation details, or original case sheets. Of late, there appears to be a tendency to manipulate even in reserved packages. As one representative put it: “Chance of forgery is greater in certain categories of services in public facilities” – he was referring to the potential in NICUs. Misrepresentation of categories of patients is not uncommon in private facilities as well. A DPO informed us:

A simple fracture is reserved for the Government hospitals but the private hospitals accept the patients and they show the case of an old fracture or soft tissue injury, multiple facture or open wound. And when TPAs go for inspection, there is complete plaster and they cannot ask patient to open it.

Needlesstosay,suchpracticesdeservemoreattentioninthefuturetoenhancetheoveralleffectivenessof the scheme

Attention to the above issueswill go a longway in strengthening the overall effectiveness of theschemeinthefuture. 

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7. ConCluding obSeRvAtionS

The Chief Minister’s Comprehensive Health Insurance Scheme, launched in 2012, has since then has progressed in three dimensions:

(a) The scheme has grown in coverage (in terms of households enrolled, across districts, total claims and total approved amount),

(b) The scheme has enhanced access to tertiary care (in terms of network of empaneled providers, range oftreatmentsandproceduresprovided,andinreducingthetotalfinancialburdenpatientmayhaveincurred had he/she had no support from the scheme),, and

(c)Theschemehasadoptedeffectivemanagerialpracticestowardsproviderpaymentandpurchasingofcareandinimplementationofeffectivemonitoringsystem.

Overall, the scheme is well established. Our assessment is that the scope of the scheme should now be revisited.Thereisalsoconsiderablescopeforimprovingtheoveralleffectivenessofthescheme.

The scheme has been a pioneer in introducing round-the-year enrolment of eligible families through differentmeanssuchashealthcamps,kiosks,andfinallyenrolmentevenatthetimeofseekingcare.Thisisaneffectivewaytoexpandcoverageofthescheme,minimize‘exclusionerror’andreachouttothepoorestof the poor.

Thescheme,forthefirsttimeinIndia,hasreservedtreatmentofhigh-endandfrequentlyutilizedhealthcare for public sector facilities. This has helped to a great extent in checking unnecessary treatments, which hasresultedinsignificantcostcontainment.Thisisreflectedinconsiderablymoderatepremiumrate,belowINR 500 and manageable claim premium ratio, on an average 98%. The strength of the public providers, intermsofcoverageandshareofoverallclaimamount,hasevidentlyincreasedovertheyears,reflectingthe enhanced competitiveness of public facilities. The scheme has positively contributed to building and strengthening public healthcare institutions over the past four years.

A fewspecificpolicydirections to further strengthen theoveralleffectivenessof theschemearebrieflyoutlined below:

1. AmuchstrongerIECstrategy,specificallyincreatinganawarenessofthetreatmentscovered,andinpromoting healthy practices that would reduce chances of life-threatening conditions, will make the schememoreworthy.TheIECstrategyshouldgobeyonddetailsoffinancialcoverageofthescheme.Healthcampsareaneffectivewaytocreateawareness,butamoreintenseandenhanceduseofmediawouldmakeIECmoreeffective,therebystrengtheningtheoverallfunctioningofthescheme.

105

2. The scheme should introduce a mid-term appraisal of premiums and revision of rates. A provision in the contract between UIIC and TNHSP for revision of rates (both premium and package rates) is necessary in sustaining the interest of insurer and providers in the long run and in enhancing the level of competition among them.

3. There is scope to increase the utilization rate in the scheme. Many people are not accessing healthcare under theschemeevenaftergettingenrolled.Asustainedeffort to increase theaccessbyenrolledpopulation is the need of time.

4. Astheschemehasgainedstabilityandconfidenceofthepeopleovertheyears,itisworthwideningthebase of enrollees, and attracting potential enrollees - those with an annual income above Rs.72,000 - at apremiumcompetitiveenough,consideringthefinancialburdenonthepeopleseekingcareforsimilarservices from the private sector.

5. There is abundant evidence from National Sample Surveys (71st Round, 2014) on the increasing burden of chronic diseases (such as diabetes), and aging population; the scheme may explore ways to integrate with other national programs targeted at non-communicable diseases, very much like the way it has done with NICU initiatives under the National Health Mission (NHM).

6. Improved provider payment system is crucial for sustaining the providers’ interest in the scheme. The current payment system in the scheme can be improved by reducing the processing time of the claims. Attention to this issue will go a long way in enhancing the commitment and overall functioning of the providersandthereforetheoveralleffectivenessofthescheme.

7. Theschemeshouldundertakespecificresearchstudieswithaviewtoimproveitseffectivenessinfuture.For example, empirical studies on cost of services and procedures provided through public facilities would strengthen the negotiating power of UIIC with providers. Active engagement with public policy research communities will go a long way in expanding, improving and strengthening the CMCHIS in the future.

8. Theschemehasalsoreachedastagethatascientificimpactevaluationstudyoftheschemeshouldbeconducted in order to have strong evidence on welfare dimension of the scheme.

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Figueras. (2005). Purchasing to Improve Health Systems Performance. McGraw-Hill Education (UK).

Forgia, G. L., & Nagpal, S. (2012). Government-Sponsored Health Insurance in India: Are You Covered? Washington, D.C.: The World Bank.

Inke Mathauer, F. W. (2013). Hospital payment systems based on diagnosis-related groups: Experiences in low- and middle-income countries. Bulletin of the World Health Organization, 91(10), 746–756A.

Jegers, M., Kesteloot, K., De Graeve, D., & Gilles, W. (2002). A typology for provider payment systems in health care. Health Policy (Amsterdam, Netherlands), 60(3), 255–273.

Kutzin, J. (2012). Anything goes on the path to universal health coverage? No. Bulletin of the World Health Organization, 90, 867–868.

Langenbrunner, J., Orosz, E., Kutzin, J., & Wiley, M. (2005). Purchasing and Paying Providers. In Purchaing to Improve Health Systems Performance. Maidenhead, UK: Open University Press.

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Park, M., Braun, T., Carrin, G., & Evans, D. (2007). Provider payments and Cost-containment: Lessons from OECD Countries. WHO Technical Brief for Policy-Makers, WHO/HSS/HSF/PB/07.02, 1–10.

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AnnexuReS

Annexure 3.1: District-wise Distribution of Hospital Network across Tamil Nadu under the CMCHIS Scheme, 2015-16

DistrictNumber of Empaneled

Hospitals

Percentage Distribution of

Empaneled Hospitals

Percentage of Population Enrolled

in CMCHIS

Number of Claims per

HospitalAriyalur 6 1 65.0 114Chennai 78 10 39.7 980Coimbatore 74 10 54.9 540Cuddalore 6 1 63.6 122Dharmapuri 16 2 70.7 243Dindigul 27 4 62.7 185Erode 40 5 74.7 359Kanchipuram 40 5 54.3 558Kanyakumari 33 4 64.3 308Karur 13 2 75.7 244Krishnagiri 15 2 64.2 76Madurai 46 6 59.2 850Nagapattinam 9 1 58.1 110Namakkal 28 4 63.8 239Nilgiris 11 1 60.7 125Perambalur 7 1 69.4 357Pudukkottai 7 1 70.6 266Ramnadhapuram 20 3 60.7 291Salem 47 6 64.5 487Sivagangai 11 1 62.9 419Thanjavur 25 3 62.3 490Theni 13 2 65.2 474Thiruvallur 16 2 54.6 359Thiruvannmalai 11 1 57.7 287Thiruvarur 8 1 68.5 1251Tirunelveli 17 2 53.2 300Tiruppur 20 3 61.5 390Trichy 41 5 56.4 440Tuticorin 9 1 48.6 627Vellore 24 3 56.3 527

109

DistrictNumber of Empaneled

Hospitals

Percentage Distribution of

Empaneled Hospitals

Percentage of Population Enrolled

in CMCHIS

Number of Claims per

HospitalVillupuram 15 2 64.6 286Virudhunagar 20 3 55.7 344TAMIL NADU 744 100 59.3 466

Source:Estimatedfromschemeadministrativedata;PopulationfiguresarecompiledfromCensus2011

Annexure 4.1: Grading Criteria under CMCHIS for Multi-specialty Hospitals

Sl. No Criteria Scores 1 No. of beds 30 1 30-100 2 >100 3 2 MRD with ICD Coding 1 3 Well-Equipped ICU A) Up to 15 beds 1 B) With beds above 15 2 4 Patho lab 1 Bio-Chem lab 1 Micro lab 1 5 A)OT-Laminar Air Flow 1 B)HEPA Filter 1 6 SCAN A) CT 1 B) MRI 1 C) PET 1 7 A) IT Solution 1 B) Computer Billing 1 8 DNB Recognition 2 9 In-House Pharmacy -24 Hours 1 10 Blood Bank A)Registered 2 B)Storage centre 1 11 Medical Audit 1 12 A)Fire Safety Equipment 1 B)FireSafetyDrill&Certificate 1 C)CSSD 1

Extra Credentials 1 Full Time Consultants Not Less Than 10 Specialty 2 2 A)Cath Lab 1

110

Sl. No Criteria Scores B)Cardio Thoracic OT 1 3 A) JCI 1 B) NABH Accreditation 2 C)IPHS 1 4 Laennec RT 2 5 Location-Metro City A)Chennai 2 B)Other Metros 1 6 Ambulance 1 7 No. of Duty Doctors 5-15= 1 >15= 2 8 No.ofQualifiedNurses 5-15= 1 >15= 2 9 NICU/PICU Beds: 3-6= 1 >6= 2 10 No. of Warmers/Incubators 3-6= 1 >6= 2 11 Neonatal Ventilators 2-5= 1 >5= 2 12 Transport Incubators 1 13 Registered for Human Organ Transplant Act 1 14 Bio-Medical Engineering Department 1 TOTAL 51

Source: http://www.cmchistn.com/hospitallist1.php

Annexure 4.2: District-wise Number of Active Hospitals Empaneled under the CMCHIS Scheme – 2012-13 to 2015-16

District Jan-12 – Mar-12 Apr-12 – Mar-13 Apr-13 – Mar-14 Apr-14 – Mar-15 Apr-15–Aug-16

Ariyalur 5 5 5 5 6Chennai 56 62 64 66 78Coimbatore 65 69 79 76 74Cuddalore 18 20 20 13 6Dharmapuri 14 15 15 16 16Dindigul 22 25 27 27 27Erode 44 45 46 46 40Kanchipuram 34 39 39 41 40

111

Kanyakumari 34 35 35 35 33Karur 11 12 14 13 13Krishnagiri 14 16 16 15 15Madurai 34 34 40 40 46Nagapatinam 7 8 8 8 9Namakkal 19 25 30 29 28Nilgiris. 5 6 6 8 11Perambalur 6 6 6 6 7Pudukkottai 9 9 9 9 7Ramanathapu-ram 11 17 20 20 20

Salem 39 43 42 44 47Sivagangai 13 14 14 14 11Thanjaur 21 22 22 22 25Theni 14 14 14 14 13Thiruvallur 11 16 17 17 16Thiruvannamalai 10 10 11 11 11Thiruvarur 8 18 19 8 8Tirunelveli 17 8 8 19 17Tirupur 18 21 23 24 20Trichy 30 34 37 36 41Tuticorin 7 7 9 9 9Vellore 18 20 22 23 24Villupuram 11 14 15 15 15Virudhunagar 12 13 15 15 20Total 637 702 747 744 753

Source: Estimated from scheme administrative data

112

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114

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115

Ann

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Annexure 4.5: Percentage Share of Utilization by Female across Package Categories

Package Category 2012-13 2013-14 2014-15 2015-16OBGY 88.8 84.3 83.9 88.5Radiation oncology 58.8 56.5 52.7 54.9Medical oncology 54.1 50.1 48.3 53.4Surgical oncology 61.8 57.5 51.0 52.0Replacement 46.8 44.3 44.8 46.1General surgery 48.4 43.9 40.4 40.1Dermatology 43.5 40.7 39.6 38.5Neonatology 31.6 31.6 32.5 37.8Endocrinology 44.7 39.2 42.9 37.5Ophthalmology surgeries 34.7 34.9 34.9 36.5Surgical gastro enter 42.1 35.8 33.4 34.5ENT 38.3 35.8 33.2 34.2Paediatric intensive 34.6 30.5 26.6 33.9General medicine 28.5 28.5 30.8 33.8Paediatrics 34.3 26.2 27.8 33.2Neurosurgery 38.1 36.0 34.7 33.2Rheumatology 60.0 57.5 34.3 33.1General Surgery 38.8 32.6 32.0 31.3Follow-up procedure 37.1 36.1 22.1 28.3Transplantation 11.1 34.6 25.0 27.7Chest surgery 29.0 10.0 21.5 27.3Plastic surgery 29.7 25.9 23.5 26.2Neurology 30.4 28.1 26.9 25.5Cardiothoracic surgery 33.3 28.7 24.7 25.2Pulmonology 29.2 28.8 23.0 24.5Orthopaedic trauma 22.9 22.0 20.9 21.1Nephrology 21.9 19.7 20.4 21.1Gastroenterology 17.6 17.3 17.4 21.1Genitourinary surgery 19.7 18.7 19.0 20.0Cardiology 20.4 20.4 19.6 19.3Poly-trauma 38.2 26.6 28.7 18.8Paediatric surgeries 20.8 19.5 18.8 18.4Hepatology 33.3 27.4 21.8 18.1Vascular surgeries 23.4 21.6 15.8 17.8Interventional radiology 22.8 22.2 20.1 15.5Total 39.5 36.0 33.6 34.7

Source: Estimated from scheme administrative data

116

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121

Ann

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Annexure 4.9: Key Indicators by Package Categories Reserved for Government Facilities

Indicators 2012-13 2013-14 2014-15 2015-16Orthopedic Trauma

No. of Claims 5,369 7,772 9,851 8,824% of Total Claims under Reserve Procedures 30.5 30.2 35.2 34.7Average of Approved to Claim Amount (%) 98 98 97 97Average Turn-Around-Time (days) 7 8 16 20Average Cost of Treatment (INR) 18,682 18,033 18,241 18,214

Poly TraumaNo. of Claims 186 211 224 223% of Total Claims under Reserve Procedures 1.1 0.8 0.8 0.9Average of Approved to Claim Amount (%) 94 96 95 93Average Turn-Around-Time (days) 9 9 22 32Average Cost of Treatment (INR) 17,759 16,182 16,670 17,035

ENTNo of Claims 4,717 5,432 5,114 4,718% of Total Claims under Reserve Procedures 26.8 21.1 18.2 18.6Average of Approved to Claim Amount (%) 96 99 99 97Average Turn-Around-Time (days) 6 6 10 11Average Cost of Treatment (INR) 14,209 14,112 13,882 13,834

OBGYNo. of Claims 3,263 6,317 6,568 5,848% of Total Claims under Reserve Procedures 18.5 24.5 23.4 23.1Average of Approved to Claim Amount (%) 99 99 99 98Average Turn-Around-Time (days) 6 8 15 24Average Cost of Treatment (INR) 14,712 14,184 14,089 13,618

General SurgeryNo. of Claims 4,095 6,045 6,265 5,763 of Total Claims under Reserve Procedures 23.2 23.5 22.4 22.7Average of Approved to Claim Amount (%) 99 99 99 97Average Turn-Around-Time (days) 7 8 19 25Average Cost of Treatment (INR) 21,819 21,679 21,524 20,938

Source: Estimated from scheme administrative data

122

Annexure 4.10: Percentage of Final Approved to Claim Amount by Packages across Government and Private Facilities

Package category2012-13 2013-14 2014-15 2015-16

Govt. Pvt. Govt. Pvt. Govt. Pvt. Govt. Pvt.Cardiology 94 84 90 81 88 83 89 82

Cardiothoracic surgery 98 85 99 84 99 83 98 80

Chest surgery 93 86 96 80 97 80 100 72

Dermatology 95 92 95 76 94 90 97 77

Endocrinology 97 80 84 91 88 77 92 59

ENT 99 91 100 92 100 91 100 89

Gastro-enterology 92 86 91 79 92 68 91 68

General medicine 92 83 87 85 88 86 84 81

General surgery 98 85 99 81 99 80 96 75

Genito-urinary surgery 98 88 99 86 99 84 97 83

Hepatology 88 85 86 84 81 83 70 82Interventional radiol-ogy 98 91 95 90 94 89 94 86

Medical oncology 98 86 99 86 99 85 99 81

Neonatology 91 81 86 75 90 74 90 65

Nephrology 95 82 95 85 96 85 95 83

Neurology 95 82 89 77 88 77 88 74

Neurosurgery 95 87 97 85 95 82 95 79

OBGY 94 89 89 87 88 87 86 84

Ophthalmology surgery 98 98 100 98 99 97 98 96

Orthopedic trauma 96 84 97 85 97 84 96 80

Pediatric intensive care 93 78 91 74 93 64 96 61

Pediatric surge 98 91 98 90 98 89 97 84

Pediatrics 94 85 89 92 93 87 93 75

Plastic surgery 95 87 92 84 90 82 92 77

Poly trauma 98 76 93 77 94 67 97 56

Pulmonology 95 81 91 75 92 72 94 71

Radiation oncology 97 85 97 82 95 77 93 78

Replacement 98 94 99 93 98 92 97 91

Rheumatology 96 86 97 78 93 80 96 70Surgical gastro 95 82 95 78 94 77 93 76

123

Package category2012-13 2013-14 2014-15 2015-16

Govt. Pvt. Govt. Pvt. Govt. Pvt. Govt. Pvt.Surgical oncology 92 86 95 81 94 77 93 72

Transplantation 100 57 100 64 97 36 100 33Vascular surgeries 98 91 98 89 96 86 98 84

Source: Estimated from scheme administrative data

124

Ann

exur

e 4.

11: A

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and

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mou

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00

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00

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00

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515

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60,

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80,

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100

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120

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85

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20,

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30,

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40,

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50,

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Average Amount (in Rs.)

10,4

12

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94

9,86

8

12,9

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9,77

1

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9,23

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9

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8,89

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34

125

Annexure 5.1: Claim and Burnout Ratios under CMCHIS as per Financial Year, 2012-13 to 2015-16

Period Total Premium (INR Crore)

Total Claim (INR Crore)

Total Expenditure (INR Crore)*

Claim Ratio (Total Claim

/ Total Premium), %

Burn Out Ratio (Total Expenditure

/ Total Premium), %

2012-13 644 537 601 83 932013-14 642 664 728 103 1132014-15 658 708 774 108 1182015-16** 755 684 760 91 101Overall 2699 2593 2863 96 106

#CalculationsaredonewithrespecttoApril-Marchcycleasperthefinancialyear* Assuming an additional 10% of premium for administrative expenditureSource: Estimated from scheme administrative data

126

Ann

exur

e 6.

1: I

Inst

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for M

onito

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Fres

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Mon

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About the Projectthe Strengthening ecosystem for Sustainable and Inclusive health Financing India (SeSSIhFI) project is being supported by uSAID India to generate robust evidence on financial flows and evaluation of innovative health financing models, which combined with strategic outreach is geared to lead to improved accountability and transparency in public health systems in India. the overall goal is to germinate and foster health care financing ecosystem that ensures equity and improves poor households’ access to quality and comprehensive health care and protect them from financial loss and impoverishing impact of illness. the project is implemented by Public health Foundation of India (PhFI) in partnership with Post Graduate Institute of Medical education and research (PGIMer), chandigarh; tata Institute of Social Sciences (tISS) Mumbai, Indian Institute of technology (IIt), chennai and Sree chitra tirunal Institute for Medical Sciences and technology (SctIMSt), thiruvananthapuram.

For further information about this project please contact:Dr. Sakthivel Selvaraj, Director and Additional Professor, health economics, Financing and Policy, Public health Foundation of India, New Delhi; email: shakti@phfi.orgDr. Anup Karan, Associate Professor, Public health Foundation of India, New Delhi; email: anup.karan@iiphd.orgDr. Vr Muraleedharan, Professor, Indian Institute of technology - Madras, chennai; email: vrm@iitm.ac.in

Public Health Foundation of India Plot No 47, Sector-44,Institutional Area, Gurgaon-122002, India

Website: www.phfi.org

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