The joint working group of the Insurance Regulatory and Development Authority (IRDAI) and the National Health Authority (NHA) has proposed a unique common hospital registry, empanelment process, grading of hospitals and package cost harmonisation to promote the standardisation and effective utilisation of health care infrastructure under the insurance programme.
At present, health care schemes and private insurance have individual hospital empanelment process, which replicates various activities and contributes to inefficiency and duplication of processes. “It is recommended to have common empanelment portal which can be utilised by all the schemes/insurance companies with standardised empanelment criteria will be hugely beneficial with special focus on standard safety and quality parameters,” said the Report of Network Hospital Management, prepared by the IRDAI-NHA joint working group.
The group also recommended that a standard grading system for hospitals, based on the quality parameters should be prepared, and same grading can be used by PMJAY (Pradhan Mantri Jan Arogya Yojana ) and the private insurance market. “An exercise should be done to agree on these common grading parameters in discussion with National Accreditation Board of Health also,” the sub-committee of the group said.
The committee also recommended a single unique hospital registration process and repository, ideally ROHINI (Registry of hospitals in network of insurance), instead of having several lists. “This list will be beneficial as a central health facility repository/registration number can be used by various schemes and insurance service providers for identification of the health facilities in geographical areas,” it said.
ROHINI is one of the most comprehensive hospital database registries available, with 33,000 unique hospitals from the private industry. During FY17-18, insurance companies collected Rs 37,029 crore as health insurance premium, registering growth of 21.8 per cent over the previous financial year. The share of group health insurance was the highest at 48 per cent, followed by individual business (41 per cent) and the government business (11 per cent). According to the committee, as majority of private hospitals are already registered and part of the ROHINI database, it is important to bring public hospitals under the ROHINI database to meet the goal of a common hospital registry in the country.
Various government-sponsored health insurance schemes (GSHIS) have different nomenclature of procedures across specialties, which create duplication, confusion and restrict interoperability. Also, this is the major hurdle for implementing the standard disease coding across schemes. “IRDAI and GSHIS, led by PMJAY, can set up a committee for development of uniform nomenclature for specialities and packages,” it said. It said some packages/ procedures based on the treatment protocol can be identified and separated for the dynamic nomenclature.
Costing of packages across schemes is a major challenge and private health care providers were always bringing this issue to the attention of the insurance regulators and the industry. The working group has recommended that to arrive at a uniform package cost under all schemes, a comprehensive gradation and incentive mechanism can be established after taking into account cost variations due to geography and quality of care.
The IRDAI-NHA group has recommended that the private insurance industry should also adopt the uniform cost of packages. However, IRDAI can come up with the guidelines on inclusion of additional/ variable cost for implants and category of wards. Private insurance can design the products as per the uniform package cost and the additional cost of implant and ward type.
There are multiple hospital database registries in the country and potentially risk duplication of efforts on collection and managing hospital data.
As per IRDAI Annual Report 2017-18, the insurance sector has covered 48 crore number of lives under health insurance, of which 36 crore people are covered under various government schemes.
Ayushman Bharat Pradhan Mantri Jan Arogya Yojana has developed a rigorous empanelment process and uses Hospital Empanelment Management solution for end-to-end empanelment. AB PMJAY has around 15,680 unique hospitals.