Health insurance reforms must go beyond rates to address the cost of care:

Experts cautioned that the NHCX would have to be properly integrated across stakeholders and implemented consistently

India’s proposed health insurance reforms could reshape how hospitals, insurers and patients interact, with the government looking at standardised treatment rates, common insurance coverage and wider adoption of the National Health Claims Exchange (NHCX). While the reforms are aimed at containing rising healthcare costs and improving transparency, industry experts say the success of the exercise will depend on whether it addresses both the price of treatment and the underlying cost of delivering quality care.

Gurmeet Singh, Vice President and Head-Health Underwriting at IFFCO-TOKIO General Insurance, sees standardised treatment rates and a common claims platform as important steps towards making health insurance more efficient and affordable. 

Siddhartha Bhattacharya, Secretary General of NATHEALTH, however, argues that we must look beyond fixing rates and address the structural cost of delivery faced by healthcare providers to deliver quality outcomes , including land, capital, manpower, myriad regulatory compliance, weak purchasing systems resulting in fraud and delayed payments from insurers and government schemes.

Welcome Step

Singh said standardising treatment costs across private and government hospitals could help keep expenditure on tertiary and super-speciality care within manageable limits. He described the proposed reforms as a “welcome step”, particularly for lower-middle-income households struggling with rising medical expenses.

“If they standardise these costs in private hospitals and government hospitals, then overall, for tertiary care, super speciality hospitals, the expenditure will always be in tolerable limits,” he said.

He also backed the NHCX, describing a health claims exchange as “the correct way for the future”. He said a common platform could allow insurers, hospitals and third-party administrators to work with standardised rates and processes for diseases, surgeries and hospitalisations.

However, Singh cautioned that the platform would have to be properly integrated across stakeholders and implemented consistently.

Drawbacks

Bhattacharya argued the NHCX could help address some of these problems by creating common digital infrastructure for hospitals and insurers.

According to Singh, fraud and abuse could account for around 5-10 per cent of claims, with abuse also covering cases where the actual cost of a service is inflated in a claim. Standardisation, he said, could potentially reduce claim costs by 8-10 per cent.

“If we get savings in our claim cost, we can definitely have a yearly reduced incurred loss ratio and you would pass on this benefit to the client in terms of premiums,” he said.

Bhattacharya, meanwhile, said the debate should begin with the cost of healthcare rather than simply what’s the visible price charged for a procedure.

Quality…