1. Government of Karnataka Department of Health and Family Welfare Improving health protection coverage by convergence International Conference on Health Insurance Aug 25 th & 26 th 2016 Chennai Dr P Boregowda Executive Director

2. Introduction Suvarna Arogya Suraksha Trust was established in 2009 as a special purpose vehicle to administer and implement health schemes in Karnataka under the Department Of Health & Family Welfare, GoK. – SAST vision - Quality Healthcare for All – SAST was created to achieve the objectives of Universal Health Coverage in Karnataka

3. REGULATORY MECHANISM FOR SAST IMPLEMENTATION Special Purpose Vehicle established under Trust Act The Chief Minister - Chief Patron The Minister for Health & Family Welfare & The Minister for Medical Education – are member patrons SAST Governing Bodies Board of Trustees. Executive Committee Empanelment & Disciplinary Committee

4. Schemes under implementation by SAST to achieve universal health coverage esp in tertiary sector SAST JSSVASRABMSSRBSKRSBY For BPL For APL For State Govt Employees For RTA Victims For Govt aided schools/AW children For RSBY card holders All the above health schemes except RSBY is implemented under Assurance Mode.

5. Health assurance is defined as “an assurance that people receive an essential package of required and quality health services without suffering financially by having to pay for such services. Reasons to ensure scale up of health assurance Unregulated private health sector and asymmetry of information leading to failure private health insurance (PHI). Demographic (ageing of population), epidemiological (rising spectrum of cost-intensive non-communicable diseases), and social (increased awareness and expectations of consumers of healthcare for technologically advanced care) has spiraled the healthcare treatment costs multifold. Need for Health assurance

6. Necessity for health assurance scheme for BPL Large portion of income of BPL families is spent on health issues (requiring Out patient and In patient care) Super Specialty Care - not available in Government Hospitals except for a handful of institutions Catastrophic illness Leading to In 2009-10, Vajpayee Arogyashree (VAS) was introduced by GoK wherein all BPL card holders are automatically enrolled to be eligible for free tertiary treatment in network of super specialty hospitals through PPP mode Deaths and serious illness Burden on the pocket

7. Comparison – Assurance Vs Insurance Mode ParticularsAssuranceInsurance Enrolment Criteria Automatic – All families having BPL / APL cards / KGID Separate Smart Cards – Many families may get left out Enrolment RateAutomatic - 100 %Only those having Smart Cards Scheme Administrator SAST Insurance company through single or multiple TPAs Premium No premium – GoK releases funds to Trust Advance premium to be paid to insurance company Avg. Unit CostRs. 212/- per familyMin Rs. 450/- per family Administrative Cost 6 – 7 % included in unit cost20 % included in unit cost Provider Payment Case based OOP & Co payment VAS, JSS, RBSK & MSHS - Nil RAB – Co payment Yes

8. Comparison – Assurance Vs Insurance Mode ParticularsAssuranceInsurance Gate Keeping SAST - By Experienced Doctors By Insurance Cos. Through multiple TPAs. Flexibility of making changes in the scheme (Eg. Adding new procedures or group of people) Can be done & implemented with immediate effect Time consuming plus additional premium is to be paid to Insurance Cos. Financial SecurityCashless TreatmentUnpredictable MotiveService – Welfare of people Profit – Tendency towards less utilization, more profit Grievance redressal-Strong ResponsiveNot dependable

9. Due to competitive bidding involved, some insurance companies may quote very low thereby compromising on the quality of service to the insured people whereas in assurance model this is avoided. The RSBY premium has been reducing over the years. The premium rate has decreased from Rs. 475 to an average of Rs. 194 in the current Phase (59% reduction). If total payout is more than 70 % of the premium collected, insurance companies will slow down utilization to reduce losses compromising the health security of the needy people. Good hospitals are kept out of empanellment Active Hospitals will be targetted and continuation of empanellment will be very subjective All approvals and servicing of claims is at the discretion of Insurance Cos. & TPAs. The government will have no control over TPAs to ensure proper & full utilization. Assurance Vs Insurance Mode - SAST Experience

10. There will be no effort to increase awareness among beneficiaries. Denial of claims would be higher on the slightest pretext Due to the profit motive of the insurance companies, the tendency is to ensure less utilization of the scheme defeating the very purpose of the health schemes. Under tertiary, there is no empirical evidence as to the incidence / prevalence rate. The insurance cos. Will assume incidence to be between 0.8 % to 1.2 % & charge very high premium, which may or may not be utilized. Under Assurance, there is conscious effort to increase participation of Government / Public Hospitals and maximum utilisation of benefits by beneficiaries

11. Need for convergence While the National Health Mission (NHM) is providing adequate and free primary health care to all those living in both the rural and urban areas, and Suvarna Arogya Suraksha Trust (SAST) is protecting the poor from medical expenses for tertiary care, the secondary care in Karnataka is fragmented. It is being provided by different departments through multiple schemes, NHM (Health Dept.), Yeshasvini (Cooperative Dept), ESIS (Labour Dept.) and the RSBY (SAST) Large proportion of informal sector workers not covered under any health insurance.

14. Yeshaswini Scheme – One of the early State Government health insurance scheme implemented by the Co-operation Department. The benefits of the scheme can be availed only by the members of the cooperative societies in Karnataka. The scheme is based on voluntary participation with a contribution of Rs. 210/- per head per year. The scheme covers primary, secondary and tertiary diseases with a maximum financial protection upto Rs. 2.00 lakhs per family per year. Non members are not eligible. All members may not get enrolled as it is voluntary. Yeshaswini enrolment is conducted only once in a year in a particular period – people who could not get enrolled are deprived from the coverage. Convergence – Yeshaswini under SAST

15. Compared to total 1.25 crore members in the rural cooperative sector, only about 12.5 lakh families have been enrolled constituting about 10 % of the target group. Almost all the Yeshaswini members do also possess either BPL or APL card, in which case free tertiary treatment is already available under VAS / RAB without having to pay any premium Yeshaswini covers only surgical procedures. Under RSBY, both surgical and medical management is covered. There is scope for co-payment if the beneficiary decides to avail higher services which invariably leads to high out of pocket expenditure.

16. Yeshaswini covers 892 surgical procedures which includes both secondary & tertiary. RSBY has 1516 primary & secondary procedures and VAS has 567 tertiary procedures totalling to 2082 procedures under SAST. For secondary care, they could be migrated to RSBY and for tertiary care under VAS or RAB. Under Oncology, SAST covers all three modalities of treatment whereas Yeshaswini covers only surgical and radiology. Yeshaswini covers upto Rs. 2.00 lac per year for both secondary and tertiary. Under SAST, tertiary coverage is upto Rs. 1.50 lac with Rs. 50000 buffer per year and Rs. 1.00 lac under RSBY as per new proposal. Integration of schemes may improve care while being cost effective Convergence – Yeshaswini under SAST

17. Due to overlapping of beneficiaries and procedures, it may lead to duplication of claims and mis-use. This results in duplication of payment by the government for the same beneficiary and treatment. For secondary care, they could be migrated to RSBY and for tertiary care under VAS or RAB. Technically, it is feasible and economical to converge under SAST, so that all health schemes will be under ONE umbrella avoiding duplication and wastage of resources. What is essential is better planning and avoiding duplication of activities by different stakeholders to ensure continuum of care for the people. Bu t politically it needs vision and commitment to achieve the same

18. With this 100% of the whole population in Karnataka has been covered under tertiary care making it the first state to reach that milestone in the county. Achieving Universal health coverage in Tertiary care through existing schemes for Karnataka Scheme NameYearTarget population Population coverage in crores Population Coverage in % No. of beneficiarie s treated till March 2016 Vajpayee Arogya Shree (VAS) 2009-10 All BPL families in Karnataka 4.569%46588 Rajiv Arogya Bhagya (RAB) 2014-15 All APL families in Karnataka 1.319%2022 Jyothi Sanjeevini (JSS)2014-15 All State Government Employees and their dependents 0.35%1466 Other schemes2014-15 Coverage under CGHS and other private insurance 0.46% Total SAST 50076

19. Summary SAST has already achieved comprehensive coverage of tertiary care and initiatives are needed to ensure the same in secondary care with better co-ordination and pooling of resources through convergence of not just one scheme but multiple scheme already being implemented in Karnataka