• UGI USER
  • May 31, 2024
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INDIA AND THE MANAGED CARE PROMISE

Syllabus:

GS 2:

Welfare Schemes for Vulnerable Sections of the population by the Centre and States.

Issues Relating to Development and Management of Social Sector/Services relating to Health.

Why in the News?

A prominent health-care chain in South India has announced the introduction of a comprehensive health insurance model, integrating insurance and health-care services. This development highlights the potential for managed care organizations (MCOs) in India, offering a pathway to improved health coverage and cost management.

Source: HT

The Rise of Health Insurance in India

  • Policy Integration: Health insurance is becoming a core component of India’s approach to universal health coverage (UHC).
  • Digital Revolution: Technological advancements are driving reforms similar to those seen in the United States, but adapted to avoid excessive health expenditure.
  • Comprehensive Health Insurance: A prominent South Indian health-care chain has recently ventured into offering comprehensive health insurance, merging insurance and health-care provision.
  • Managed Care Organizations (MCOs): This initiative represents India’s version of MCOs, which integrate insurance and health services.
  • Potential for UHC: It’s important to assess whether MCOs can contribute significantly to India’s goal of achieving UHC.

Historical Context of MCOs

  • U.S. Precedents: MCOs have their roots in early 20th-century U.S. prepaid health-care practices.
  • 1970s Evolution: The concept gained traction in the 1970s in response to high health-care costs and economic downturns.
  • Insurance and Provision Fusion:

MCOs combined insurance and care provision to control costs and emphasize prevention.

  • Cost Control: This model aimed to reduce high premiums and make health insurance more attractive by focusing on cost containment.
  • Lack of Robust Evidence: Despite mixed evidence on improving health outcomes, MCOs have effectively reduced hospitalizations and associated costs.

Indian Health Insurance Landscape

  • Indemnity Insurance Focus: Since the 1980s, Indian health insurance has primarily covered hospitalization costs, overlooking the vast market for outpatient care.
  • Innovation Deficit: Health insurance in India has seen limited innovation and high operational costs, often overshadowed by life and general insurance.
  • Market Characteristics: The Indian health insurance market is urban-centric and caters predominantly to the affluent.
  • Informal Practices: Outpatient care in India is characterized by informal practices and a lack of standardized clinical protocols.
  • Systemic Challenges: The absence of incentives for cost control has hindered the evolution of a managed care approach.

Managed Care in Developing Nations

  • Characteristics of MCOs: Studies have shown that MCOs in developing nations are typically urban-focused and attract higher-income groups.
  • Financial and Managerial Clout: Successful MCOs require significant financial resources, managerial skills, and defined beneficiary bases.
  • Indian Contrasts: Unlike the U.S., India’s health insurance has not naturally evolved to encourage consumer-driven cost control.
  • Urban Affluence Focus: Indian insurance has targeted the urban well-off, with limited impact on broader health care accessibility.
  • Potential for Public-Private Partnerships: Large health-care brands with loyal urban patient bases could drive initial MCO initiatives, but broad-based UHC contributions are unlikely without public support.
Universal Health Care Initiatives in India

1.   Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY):

  • Launched in 2018, PM-JAY aims to provide health coverage of up to ₹5 lakh per family per year for secondary and tertiary care hospitalization.
  • It targets over 10 crore vulnerable families, covering nearly 50 crore individuals.
  • Focuses on providing free access to health care services at the point of delivery.

2.   Ayushman Bharat Health and Wellness Centres (HWCs):

  • Part of the Ayushman Bharat initiative, HWCs aim to transform 1.5 lakh sub-centres and primary health centres into HWCs.
  • Focus on comprehensive primary health care, including maternal and child health services, and non-communicable diseases.

3.   Rashtriya Swasthya Bima Yojana (RSBY):

  • Introduced in 2008, RSBY provides health insurance coverage for unorganized sector workers below the poverty line.
  • Offers up to ₹30,000 coverage per family annually for inpatient care.

4.   National Health Mission (NHM):

  • Encompasses the National Rural Health Mission (NRHM) and the National Urban Health Mission (NUHM).
  • Aims to provide accessible, affordable, and quality health care to rural and urban populations.

5.   Janani Suraksha Yojana (JSY):

  • A safe motherhood intervention under the NHM.
  • Promotes institutional delivery among poor pregnant women to reduce maternal and neonatal mortality.

6.   Mission Indradhanush:

  • Launched in 2014, it aims to increase immunization coverage by targeting unvaccinated and partially vaccinated children.

7.   Pradhan Mantri Swasthya Suraksha Yojana (PMSSY):

  • Aims to correct regional imbalances in the availability of affordable and reliable tertiary health care services.
  • Establishes AIIMS-like institutions and upgrades existing government medical colleges.

8.   Pradhan Mantri Matru Vandana Yojana (PMMVY):

  • Provides cash incentives for pregnant and lactating women to improve their health and nutrition.

Opportunities for Managed Care in India

  • Outpatient Care Costs: Comprehensive outpatient care coverage offers significant potential for cost reduction through early intervention.
  • Patient Journey Control: Current insurers have little influence over patient care until hospitalization, highlighting the need for integrated care models.
  • NITI Aayog Endorsement: A 2021 NITI Aayog report supports outpatient care insurance schemes that could yield substantial savings through better care integration.
  • Preventive Care Focus: Managed care could streamline management protocols, consolidate practices, and embed a preventive care approach in the private sector.
  • Public Incentives: Incentives similar to those under the Ayushman Bharat Mission could promote MCOs, initially targeting PMJAY beneficiaries and private clients on a pilot basis.

The Complex Path to UHC

  • Incremental Approach: UHC requires multifaceted solutions, and MCOs could be part of the broader strategy.
  • Pilot Programs: Initial public support and pilot programs could help MCOs gain traction and demonstrate their effectiveness.
  • Awareness and Expansion: Public initiatives could increase awareness and expand the reach of MCOs, gradually growing the self-paying client base.
  • Comprehensive Solutions: UHC is complex, and while MCOs aren’t a panacea, they offer valuable contributions to a more integrated health-care system.
  • Balanced Strategy: Managed care should be part of a balanced approach, addressing both public and private health-care needs to achieve sustainable UHC.

Way Forward for Managed Care in India

  • Public-Private Partnerships: Foster collaboration between government initiatives and private health-care providers to build robust Managed Care Organizations (MCOs).
  • Regulatory Framework: Develop a comprehensive regulatory framework to ensure quality, transparency, and accountability in MCO operations.
  • Pilot Programs: Launch pilot projects in urban and semi-urban areas to test the feasibility and effectiveness of MCOs, focusing on integrating outpatient and preventive care.
  • Incentivize Participation: Provide financial and policy incentives to health-care providers and insurers to adopt the managed care model.
  • Technology Integration: Leverage digital health technologies to streamline patient management, reduce costs, and enhance care coordination within MCOs.
  • Training and Capacity Building: Invest in training programs for health-care professionals and administrators to equip them with the skills needed for managing MCOs effectively.

Conclusion

Managed care organizations (MCOs) offer a promising solution to India’s health-care challenges by integrating insurance with care provision, focusing on prevention, and reducing costs. With careful implementation and public-private collaboration, MCOs can significantly contribute to achieving universal health coverage in India.

Source:The Hindu

Mains Practice Question:

Discuss the potential benefits and challenges of implementing managed care organizations (MCOs) in India’s health-care system. How can MCOs contribute to achieving universal health coverage (UHC)?

Associated Article:

https://universalinstitutions.com/ayushman-bharat-centres-renamed-as-ayushman-arogya-mandir/