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 Interview
of Mr George Mathew, M D, ICAN Medicare
The health insurance sector is brimming with activity. A
never-before breed of third party administrators (TPAs) are
all set to play a major role in packaged healthcare. And ICAN
Medicare is one of the major ones.
In a tete-a-tete, George Mathew, Managing Director
speaks on the several products on offer, benefits for policyholders
as also the manipulations that can take place in the absence
of proper regulations.
How exactly will TPA's go about in their functioning?
Third Party Administrators (TPAs) enter into an agreement
with an insurance company to offer health services to the
policyholders for a remuneration. Their functioning will be
as follows:
- The insurer forwards the list of Mediclaim policyholders
to the TPA.
- The TPA issues the identification cards to the Mediclaim
policyholders.
- Policyholders can also call on the 24 hours help line.
- The TPA responds immediately, and a doctor will call
on the policy holder who will be sent to an authorized doctor
near by. Later in case of an emergency he will be sent to
a hospital.
- The TPA issues a authorization letter to the hospital,
for the treatment, wherein the TPA will pay the hospital
for the treatment.
- The case is managed by a doctor of the TPA at the hospital
till discharge.
- At the point of discharge , the documents are sent to
the TPA.
- The TPA meanwhile makes the payment to the hospital.
· The TPA audits the claim and sends the processed claim
to the insurer.
- The insurer reimburses the claim money to the TPA.
Recently newspaper reports spoke of home care services
to happen soon. This will entail taking blood tests etc. in
the comforts of ones home. How long will it take for such
conveniences to turn to reality?
These services are already in operation in several cities
but will take atleast a year to become popular. Home care
is one of the services of Managed care. Among others these
will include:
Cashless Hospitalisation, 24 hours telephone hotline, Claims,
Management and Administrative services, Critical Care services,
to coordinate admission in ICU, emergency, Doctor on call,
Managed Care programme, Range of Preventive Care services,
Occupational Health care, Consumer health programs, Alternative
Care, Spiritual Care, Infant Birth services etc.
The entry of TPAs in the insurance sector is said to
benefit the lower rung of society too. How?
TPAs will be a boon to the lower strata. The rich class can
afford medical treatment while the poor cannot afford them.
Their usual tendency is to defer/delay treatment till it becomes
acute or go to a small nursing home which charges low with
neither qualified doctors nor sophisticated equipment to deal
with or seek alternative therapy (ayurveda, homeopathy, naturopathy
etc ). In this process valuable lives are lost. But very soon
all this will change.
Insurers may forge a tie up with several hospitals or
clinics in future to service their policyholders. How far
can manipulations be ruled out?
National insurance has already tied up with many hospitals
in Bangalore, Chennai and Delhi. I believe that all the insurers
will eventually tie up with most of the hospitals, in about
3 to 5 years time to service policyholders.
As regards manipulations, they will be there since the service
provider (hospitals), will inflate the bills and recommend
unnecessary tests with prolonged length of stay. There are
several filters which insurance companies can implement, to
prevent such manipulations.
In future TPAs will provide primary, secondary and tertiary
care, all under one management. How far would such a system
be feasible?
Has any market research been undertaken to assess the success
of such a plan? A TPA is only 1/15th of an activity of a Managed
Care company which provides primary, secondary and tertiary
care to the consumers, under the same management. This is
feasible, if a single Managed Care company manages the entire
healthcare of a patient.
This is the very reason, why Managed care companies, also
functioning as TPA's want to sell to the public, so that the
entire system can be handled by a single entity. However,
insurers do not seem to understand and are trying to restrict
the same.
We conducted a market research in 1999 and 2000, in Bangalore
and Delhi to assess this plan, and we found it very successful
( 73%). We also found that there is a booming market for the
same, which on a very modest scale is about Rs 3000 crores.
What is the role of Information Technology in Medicare?
Information technology (IT) is very crucial and important
for Medicare services. It is often a life saving link, in
critical emergency operations. As regards TPA's, IT provides,
the national data online, in the following areas.
Hospital admissions across the country (Data analyzed per
city, per hospital, per institution etc)
Analysis of treatment of diseases, instant access to Medical
history of policyholders, tracking cross-country claims, tracking
shortfalls in claims and collection thereof, centralized information
resource for all claim processing.
Other benefits, such as analyzing the data, will help in
disease control as also identifying the prevalence of certain
diseases in specific areas.
Which are the products you plan to introduce and when?
Are you planning any innovative covers? Which are the main
sectors you plan to target first?
The sectors that we will be concentrating on are:
- Corporate groups. (Direct sales, coupled with agents
and consultants)
- Institutions (Direct sales, coupled with agents)
- Individuals (marketing only)
As regards products, our R & D team has worked with BAIF
(largest NGO) and developed a few which will be launched in
the following September. Our regular products can be accessed
at www.icanmedicare.com
The current situation as far as primary health care is
concerned is pathetic in the rural areas. More attention needs
to be paid and preventive care needs to be introduced. How
do you plan to take up these issues?
We have done several projects for villages with BAIF (India's
largest NGO) and have realised that rural folk do not take
health care seriously. With such a scenario, I believe, educating
them in primary health care and preventive care is important.
Also by getting rural women, to participate in healthcare
committees, better awareness can be spread.
We will be introducing health programs in co-payment from
the health committees. Such a model has already been tested,
with a satisfactory participation of 82%. Villagers can be
advised to opt for a Mediclaim policy, which will be a focus
workshop for the Preventive care committees. This will ensure
better healthcare to villagers over a period of three years.
A sound healthcare system would mean quality facilities
at economical costs. How far would this be made feasible by
TPAs and within how much time?
TPA's will only revolutionize the administration of the
medical insurance policy as regards cashless hospitalisation
and benefits thereof. The popular perception that TPA's will
reduce the cost of treatment is wrong as:
- Hospitals have not agreed to bulk purchase of services.
In fact these hospitals blacklist any TPA which asks them
for discounts (which thereby reduce the cost).
- There is no governing regulator for hospitals, and hence
they charge as per their likes. For instance last year,
you will see that there has not been even a single case
where a hospital’s license was revoked. Due to such a system
hospitals fleece the patients and insurers.
- Metros have an acute shortage of hospital beds besides
consumer laws are so weak that no one knows the rules and
regulations for filing cases.
TPA's can however act by forming an association like NASSCOM,
which can have memberships of the insurers and TPA's , and
will issue license to hospitals across India. If there are
several complaints against a particular hospital it will be
blacklisted and no insurance claims will be entertained from
the hospital.
We have moved this proposal to the IRDA and leading insurers
and TPA's, and the idea is being hotly debated upon.
Safely we can look at reducing the costs for quality facilities,
within a period of a year.
Recently the IRDA brought about amendments in the TPA
regulations, which earlier restricted sale of healthcare products.
In the changed scenario what kind of benefits can one look
forward to?
In the current scenario there will be about 10 different
types of Medical insurance policies and about 40 managed care
products in the market. Policyholders can look forward to
a wide choice at reasonable price.
Your overall views, suggestions regarding present situation
in the health care industry please.
Presently there exists a vacuum in the healthcare industry
with no regulator for the hospitals, to cross check the procedures
used, hygiene, treatment cost analysis, procedures for treatment
etc. On the other hand, the insurers do not settle claims,
as per the stipulated regulations, with claims taking more
than 90 days to settle. This has led to a public apathy for
the medical insurance policies and people have revulsion,
when you speak about healthcare insurance or products.
This vacuum can be bridged by a Managed Care company, which
will work in close coordination with Hospitals, Insurers,
and the public to bridge the gap.
Our R&D team sees a huge market for healthcare products and
services here - (about 10000 crore by 2005). To achieve this
there needs to be close interaction between the insurers,
service providers and managed care companies to focus on the
end result - A very healthy nation.
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