The Constitution of India, under article - 47, incorporates provisions guaranteeing everyone's right to the highest attainable standard of physical and mental health.
The government hospitals run by the State and the medical officers employed therein are duty-bound to extend medical assistance for preserving human life. Failure on the part of a government hospital to provide timely medical treatment to a person in need of such treatment results in violation of his right to life guaranteed under Article 21.
The Supreme Court held in its judgment that the lack of financial resources cannot be a reason for the State to shy away from its constitutional obligation.
Hence it is all the more important fix responsibility, people and the courts to act. In every State the Principle Health Secretary, his office and the health care Managers under him, directly responsible and accountable for the public sector health care provider network to provide quality care to every citizen.
Comprise of Care Provider, Financier, TPA and the Policyholder. In this industry we deal with human lives, pain and misery. Here the hospitals practice cross subsidy, i.e. rich pay for the poor. This is an essential service and we need this industry to create a marginal surplus to self-sustain and scale up. This industry heavily depends on integrity and ethical practice of each chain link and the major role is played by the doctors and the hospitals. The truth is that it is the Doctors and the Hospitals alone bring the care costs down.
In Health Care industry, the Financiers (Insurer) cannot interfere with the treatment process and hence they require doctors in the form of TPA, to prevent Moral Hazards and contain costs to stay healthy. The patient on the other hand requires a doctor based TPA, to make them understand the need for admission, advantages of hospitalized care as against domiciliary care. He needs to know the number of hospitalized days, the line of treatment, investigations, procedure, medication and costs to plan his and family future. He also wants to know his part and the insurer part of payment towards the treatment costs.
Healthcare Financing is possible by Health Insurance, Self-funded Scheme, Community - funded scheme and by Self-funding. The first three use the Risk pooling and sharing method. In Self-funding, one can deposit a fixed amount annually in a health care account and use it in case of health care needs.
At present the Insurance Premium is high due to high administration costs and Moral Hazard. The solution is simple. Allow the Policyholder to choose his insurer and the TPA of his choice allow portability, then the claim ratio will fall and so will be the Premium on the cover offered.
Since the Insurance Company and the TPA in Health care are both licensed and regulated by IRDA, a transparent claim process, documentation, billing, accounting and claim settlement, will emerge preventing Moral Hazard in the Industry. Here the Claim settlement should be by the Insurer. The way it works now, the insurer transferring funds to the TPA and the TPA making payments to the claimant, is nothing but duplicating work adding costs.
In any industry, one should not deviate from his core competency. In reality, the Insurer is the financier and auditor whereas the TPA is the Doctor based company with Health care being its core competence. When each one of them handles their specialty, then only quality health care becomes affordable and available to every Indian. The people should also participate in the process, monitor the system and give their inputs to improve.
To make healthcare affordable and available, people should participate to set up and manage an IRDA regulated “Not for Profit” Insurance Company. This company should provide cashless quality care through MCI regulated hospitals networked by a “Not for Profit” TPA. The health law should insist on the insurer spending on at least 80 percent of the premiums paid on medical care and quality improvements. If insurers spend too much on overhead, such as salaries, bonuses, or administrative costs, as opposed to health care, they must issue premium rebates to consumers at the end of the year.
is a Doctor based, IRDA licensed TPA in Health care, to provide Cashless quality healthcare, through its network hospitals and to prevent Moral Hazard in Health care Industry. There are only two promoters in this company and the company has in depth knowledge of Health care, health insurance, networking hospitals, fraud detection, claim process and settlement. The company is professional and believes in ethical and best management practices. We want the Insurer and the Care provider to generate marginal surplus to sustain and scale up while providing the best of care to the Policyholders.
Many aspects of the current health care system are rather unaffordable, uncertain to an extent and also wasteful. Certainly, the injured and the sick need adequate health care, but people have been declined proper care due to the ever growing cost of insurance, while the health care industry has continued to profit at staggering rates. Hence, we decided to find a balance between the "profit health care system" and the one that looks at "patient care before profit".
To put “Patient care before profit” we should work together and create a powerful market force. It is this market force that will allow us to choose the Doctor, Hospital, Insurance product, Insurer and the TPA of choice. It will also make the hospitals to provide quality care at an affordable cost and force the Insurer to reduce Premium and settle the claims in time without prejudice. It will also force the State governments to provide quality health care to every citizen, at a small premium. It is this market force that will integrate the Public and Private Health Care delivery system that allows the Doctor of our choice to admit and treat us in the hospital of our choice.