3-Axes Triangle of – “Mobility, Simplicity & Automation”, is required to achieve ‘Accessible & Affordable Healthcare’

Believes, Ninad Raje, CIO & Director, HealthAssure. HealthAssure, a primary care services aggregator is led by the former CEO of United Healthcare India, Varun Gera, the company has grown steadfastly over the last 5 years by building a network of 2000 primary care centers in India across 800 cities. This huge technology backed operation gives the company a unique leverage into the Indian healthcare ecosystem, making them a partner of choice with major insurance companies as well as corporates who are looking at healthcare solutions that are based on robust technology and are yet cost effective. Ninad Raje, in an interaction with Ekta Srivastava, Health Technology…

What is the concept underlying HealthAssure? Any model that you emulate?

HealthAssure is a ‘Network Based Product Company’ focused on providing flexible solutions to the ‘Primary Care’ segment within the healthcare eco-system. We provide aggregation services within this space including widespread access coupled with huge discounts.

Our motto is to bring ‘Healthcare Closer to Everyone’ at affordable costs.

We provide packaged as well as highly customized healthcare solutions to multiple communities including corporates, the insurance sector and pharma sector among others. Additionally, we provide Health & Wellness solutions to corporates. We have, in fact, recently started designing special cashless preventive care products for our corporate clients.

One of our primary objectives is to focus on providing preventive care services, which are ‘Accessible, Available & Affordable’.

We are able to build and deliver innovative products because of our unique proposition of providing a widespread quality ‘medical network’ across 800+ cities in India. We have a wide array of general as well as specialized medical networks including diagnostic, opthal, dental, diabetic, cardiac, specialist etc. Additionally, we offer health & wellness services such as HRA (health risk assessment), EAP (employee assistance program), customized health programs for corporates, health talks & seminars, health analytics among our wide range of health related products.

The above is delivered through our centralized technology platform ‘mPower’, which is an advanced & feature rich app enabling anytime, anywhere medical appointment scheduling & tracking.

 What’s your vision for HealthAssure and how affordable it is for Indians?

“Our vision is to improve quality of life by providing integrated, affordable, accessible and best in class healthcare services to global citizens through innovation”.

Making quality healthcare accessible and affordable

Good health is a valued asset, however staying healthy costs a lot these days. Exclusion of some prominent ailments like diabetes from health insurance cover, restrictions for senior citizens willing to take health insurance policies and lack of knowledge regarding various healthcare facilities provided by hospitals and consumers’ rights for availing various facilities in hospitals, calls for a healthcare education provider. A need has always been felt for a person who can educate patients about various diseases and can spread knowledge on leading centres that are affordable. However, the wait for such a health facilitator is now over with the emergence of ‘affordable healthcare facilitators’.

Though in its nascent and highly unorganised stage, concept of healthcare providing consultancies is evolving as a promising business opportunity. Health Assure aims to offer one of the most extensive consumer driven primary healthcare saving programs in the country to citizens by facilitating discounts and value additions and empowering them to come under one umbrella similar to a large corporate and facilitating bulk group bargained rates and services.

What are the most pressing challenges for health insurance companies in India?

Health of its citizens is one of the top priorities of a Nation. Total healthcare boosts economic growth, reduces poverty and lowers mortality rates. The saga of success of many countries lies in their special effort to cover the entire population with a scheme of health insurance that keep them protected against unforeseen health hazards through insurance coupled with wellness program. The moral imperative to have in place health insurance coverage is well established straightaway. In India as also in many other countries with low per capita income, the burden of having to pay for unplanned and hefty expenditure for medical treatment is very acutely affecting large population. World Bank data suggests that even one hospitalization would be estimated to account for 58% of per capita annual spending driving 2.2% of population below poverty line. Insurance schemes are designed to be commercially viable and therefore, do not reach all sections of people.

Financing healthcare thus becomes a major concern for any society. In many countries the Government provides major healthcare funding. Unfortunately, the spending by the Government in India is well below par because of which the burden falls on private households and employers and a portion of it is passed on to Insurance Companies.

The total health expenditure in India is around 5% of the Gross Domestic Product (GDP) within which bulk funding comes from private households as mentioned above. Broadly the composition is as follows:

Central, State and Municipal Governments – 20%

External Donors – 1%

Private Insurance and employer payment – 4%

Private Households – 75%

(Source : Health Insurance Reports)

In a scenario like this and with resource constraints faced by the Government, it is unlikely there will be any significant increase in Government spending for which private spending should remain strikingly dominant. It would be interesting to increase the base with suitable insurance coverage by converting the major private households’ “out of pocket” expenditure to appropriate insurance schemes.

Based on the above, health insurance companies in India face the following key challenges:

  1. Health insurance financing
  2. Containing provider behavior
  3. Cost of treatment
  4. Shrinking public health budget
  5. Escalating health care cost
  6. Necessity of quality health care
  7. Low distribution & penetration
  8. High customer expectations
  9. Limited Influence over healthcare delivery mechanism: Limited healthcare delivery network with top few cities
  10. Limited bargaining power.
  11. Varying treatment costs across providers due to limited bargaining power.
  12. Lack of standardization & accreditation in most healthcare facilities leading to difficulty in judging the authenticity of procedures & costs.
  13. High claim ratio: Insufficient data on consumers & disease patterns, absence of standardization of healthcare costs & significant levels of frauds leading to under-pricing of insurance products and higher value of claims
  14. Low level of consumer awareness: Low level of awareness among consumers about health insurance products and their benefits
  15. Limited product development: Insufficient data on Indian consumers & disease patterns and limited control of healthcare delivery network resulting in limited product and pricing innovation.
  16. Funding Support: Limited funding support from the Insurance company impacting the claims disbursement time. Delays and issues in claims processing leading to negative perceptions by insurance companies & consumers about TPAs.

How can IT help address other issues such as frauds in claims, data management, etc?

Fraud encompasses a wide range of illicit practices and illegal acts involving intentional deception or misrepresentation. Fraud impacts organizations in several areas including financial, operational, and psychological. While the monetary loss owing to fraud is significant, the full impact of fraud on an organization can be staggering. The losses to reputation, goodwill, and customer relations can be devastating. As fraud can be perpetrated by any employee within an organization or by those from the outside, it is important to have an effective fraud management program in place to safeguard your organization’s assets and reputation.

Insurance fraud has probably existed ever since the inception of the insurance industry itself. Insurance fraud affects not only the financial health of the insurers, but also of innocent people seeking effective insurance coverage. Fraudulent claims are a serious financial burden on insurers and result in higher overall insurance costs. The types of insurance fraud are widespread and diverse with many schemes targeting specific sectors in the industry. Vigilance is critical.

Technology is at the forefront in not only helping but ensuring frauds are detected prior to these actually taking place. Big data analytics play a pivotal role in this respect.

Solutions for analyzing big data can play a critical role in addressing the increasing prevalence of claims fraud. Traditionally, fraud is estimated to account for approximately 10 percent of insurance company losses, and that percentage is rising. Insurance companies need ways to quickly identify potential fraudulent claims, enhance the efficiency of investigations and prosecutions, and facilitate rapid reporting and visualization to improve ongoing antifraud efforts.

At the underwriting stage, insurance companies can employ solutions for big data that scrutinize applicant identities by searching and analyzing large volumes of information rapidly. Companies can determine whether applicants—and people associated with those applicants—have been linked to fraud in the past. Through a review process, companies can avoid fraud by denying applications for disability, health, homeowner or automobile policies with high fraud risks.

During claims intake, companies can use solutions designed to collect and analyze streaming data, such as social media posts or geospatial data, to inform investigations and policy decisions. This streaming data can help insurers discover, for example, whether policyholders are being honest about accident details or if services rendered are legitimate.

Predictive analytics solutions can help categorize risk and deliver fraud propensity scores to claim intake specialists in real time so they can adjust their line of questioning and route suspicious claims to investigators. For ongoing analysis of fraudulent claims and their impact on the business, companies can use solutions to analyze, report and create visualizations of data patterns.

By using big data analytics to look for patterns of fraudulent behavior in enormous amounts of unstructured and structured claims-related data, companies are detecting fraud in real time. The return on investment for these companies can be huge. They are able to analyze complex information and accident scenarios in minutes as compared to days or months before implementing a big data platform.

With enhanced information insight, companies can rapidly prevent, predict, detect and investigate potentially fraudulent claims and enhance the efficiency of ongoing antifraud efforts

How has technology adoption impacted your operations?

For years now, Technology has been considered as an enabler. However, Technology is no longer just an enabler, it is a ‘driver’ & ‘disruptor’. There are several disruptive technology innovations being introduced daily, that are changing the way we live today. From the basic day-to-day rituals to the most challenging & complicated tasks, technology has a solution & answers to all.

I consider Technology as the single-most revolution that has propelled HealthAssure to newer heights. At HealthAssure, we always believed in harnessing the power of technology to seamlessly scale our operations. Additionally, we believe in technology-led innovation to drive customer focused quality & operations focused productivity & efficiency.

We recently embarked upon our journey of embracing digital technology & self-service driven mobility. This has helped us immensely in all aspects of our business including productivity & efficiency improvement, achieving customer delight, delivering quality services, reducing cost, increasing revenues etc.

We have recently launched our technology driven and highly acclaimed ‘mPower’ product, which is an advanced & feature rich app enabling anytime, anywhere medical appointment scheduling & tracking. This innovative product has proved to be a highly successful technology implementation and has been adopted by our customers with aplomb and high degree of utilization. This has not only led to customer satisfaction, but has helped our organization to reduce costs by 25-30%.

Additionally, we implemented an entirely integrated workflow enabled technology platform with high degree of automation, which has resulted in tremendous productivity & efficiency gains combined with considerable cost reduction.

In what ways can Information Technology help fill the gap between insurance companies, TPAs and hospitals?

Technology has already been an enabler in bringing health services and solutions closer to the end user during much of last year. The transition for the healthcare industry to this extent has already kicked off. However, that’s just the beginning for the Indian healthcare industry.

The complexity of the medical field combined with the challenge of the changing human behavior has left us exposed to a host of new and chronic lifestyle diseases. And like in other industries in the past, here in healthcare too, technology can be the only answer to India’s rapidly growing health conundrum.

Driven by the rise of new technologies, healthcare is moving from hospitals and clinics to homes and communities. From smartphones to social media to sensors, new tools have started empowering consumers with more information and control over their healthcare decisions and this power is only likely to grow in the years to come.

Insurance aggregators, primary care service aggregation are prime examples of this changing wave in the Indian healthcare industry. By providing an end to end primary care solution to people at a better cost, is only likely to open up the market in the years to come.

Where do you see health insurance industry is likely to move in over the next few years?

I spent quality time in the recent weeks with a small working group developing an understanding of affordable healthcare.  As a part of this exercise, I visited several insurance companies, healthcare providers and met with technology providers across the country.  Also, I researched a good amount of literature on the future of healthcare across the globe.  I was surprised to learn that affordable healthcare is a significant problem not only in the emerging economies, but in the western world as well.  In the US, as an example, 27% of the population has serious problems paying their medical bills.  In India, lower unit costs for healthcare are accomplished through higher throughput; however, cost in general and accessibility in rural areas still remain areas of concern.

Based on the above, I clearly see that both health insurance & healthcare provider industries will move towards the rural sector. In fact, this shift in focus has already begun and is likely to continue for the next 5-10 years.

Moreover, I also see the health insurance industry working alongside the healthcare provider industry to make healthcare accessible & affordable for the citizens, especially in the rural sector. In my opinion, the above would be achieved by what I call as the “3-Axes Triangle of – Mobility, Simplicity & Automation”.

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