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SAURABH SHARMA Uplift Health Mutuals

Uplift Health Mutuals

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Uplift Health Mutuals. Saurabh Sharma. Uplift Health Mutuals. Community based health fund (CBHIs, MHOs) Uplift Mutuals: Group of Social Sector Organisations Based in Maharashtra & Rajasthan . Uplift Health Mutuals: A Case Study. Purpose of Study - PowerPoint PPT Presentation

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Page 1: Uplift Health Mutuals

SAURABH SHARMA

Uplift Health Mutuals

Page 2: Uplift Health Mutuals

Uplift Health Mutuals

Community based health fund (CBHIs, MHOs)

Uplift Mutuals: Group of Social Sector Organisations

Based in Maharashtra & Rajasthan

Page 3: Uplift Health Mutuals

Uplift Health Mutuals: A Case Study

Purpose of Study Document the Uplift Model & Processes Review Key Performance Indicators, Sustainability, and Client

value

Method of Study Qualitative and Quantitative

Literature review Interviews with process managers, clients and senior management Secondary Data Analysis Observation of key procedures

Page 4: Uplift Health Mutuals

Flow of Presentation

Community Based Health Insurance Uplift: Timeline, Model & ProductGrowth & Impact

KPIs Client Value

Program Sustainability Cost model Program Costs

Way Forward

Page 5: Uplift Health Mutuals

Outreach of Community Based Insurance in India

Less than 1000

1000-5000

5001-10000

10,001-100,000

100,001-500,000

More Than 1 Million

0 2 4 6 8 10 12 14 16

4

10

5

15

5

2

Outreach

Page 6: Uplift Health Mutuals

Challenges for community based risk solutionsSource: ILO, MIF

Low community participation

Lack of professional management

Small size of risk pool

Incomprehensive product

Isolation from formal insurance mechnisms

Page 7: Uplift Health Mutuals

Uplift: Timeline, Model & Product

Page 8: Uplift Health Mutuals

A Decade for Uplift

2003Uplift Mutuals established

2004Registration of Uplift India AssociationPSW Pune Joined

2007-08Product Modification Arogyanidhi 2 Launched

2010-11Enrollments crossed 100,0003 More partners Joined

2012-13125,000 MembersExpansion to Rajasthan

Page 9: Uplift Health Mutuals

Partner MembersS NO Name Location Year of

JoiningPrimary Activities

1 Swabhimaan Pune, Maharashtra

2003 Microfinance & Health

2 Inter Aide (Technical partner and Grant Provider)

France 2003 Supporting Development Activities

3 Navnirman Samaj Vikas Kendra

Mumbai, Maharashtra

2011 Microfinance & Health

4 Parvarti Swayamrojgar Pune, Maharashtra

2004 Microfinance ,Enterprise Development & Family Program

5 Annapurna Parivar Vikas Samvardhan

Pune & Mumbai, Maharashtra

2003 Microfinance , Enterprise Development & Health

6 Disha Kendra Pune, Maharashtra

2004 Microfinance

7 Annapurna Mahila Mandal Credit Cooperative Society

Mumbai, Maharashtra

2003 Credit Cooperatives

8 Chaitanya Pune, Maharashtra

2010 Microfinance, SHG & federation promotion

9 PEDO supported Federations

Rajasthan 2012 SHG & federation promotion

Page 10: Uplift Health Mutuals

Arogyanidhi: the product

Feature Uplift MutualsCompulsory/Voluntary Compulsory for MFI credit customers

Payment Type Reimbursement

Eligibility Criteria: No age limit

Premium Contribution For a family of four: Rs. 400 (approx. USD 8) per year

For individuals: Rs. 150 (approx. USD 3) per yearPeriod of Cover 12 months from the date of issue of policy

Sum Insured Rs. 15,000 per person per year subject to policy exclusions

Benefits Offered In patient hospitalization expenses for treatment in general ward

10 days of pre and post hospitalization cover including expenses for one time diagnosis of the ailment and the cost of medicines prescribed during this period

Pre-existing diseases covered from 3rd year onwards

Stipulation Pertaining to Health Care Providers 100% : Public Hospital 80% : Networked Private Hospitals No reimbursement : Non Networked Private

Hospitals, except emergencies

Page 11: Uplift Health Mutuals

Value Added Services: Reducing Health Risk

Service Details

Outpatient care Beat doctor

Discounts on drugs and Diagnostics Networked pharmacy and diagnostic centresFree generic medicines

Health camps & Talks Health awareness sessions

Client education Sessions about insurance and the HMF program

24/7 helpline Helpline for guidance or referrals

Access to Uplift’s network of HCPs Uplift has established a network of more than 300 healthcare providers for better quality of care, and to control cost. Uplift signs MoU with these HCPs with negotiated medical costs.

Referrals/guidance Assistance by a service executive

Page 12: Uplift Health Mutuals

Awareness Material Awareness Sessions

Health Education: Reducing Risk

Page 13: Uplift Health Mutuals

How it Works

Uplift Mutuals

Uplift As TPA

Managers/ Astt Managers

Arogyasakhis

Arogyasakhi

Arogyasakhis

InterAide

Uplift as TPANegotiated RatesMonitoring HCPs

Health seekingGuided by Arogyasakhis

NetworkedHealth Care Providers

Claim Processing

Final Claim Settlement & Disbursement at community level

Page 14: Uplift Health Mutuals

Growth & impcat

Page 15: Uplift Health Mutuals

2003 2004 2005 2006 2007 2008 2009 2010 20110%

20%

40%

60%

80%

21%

0%

43%37%

53% 55%49%

54%

APVS Pune,

0.4 0.39

APVS Mumbai; 0.54

0%7%

29%

51%55% 56%

58%

72%PSW

Reviewing Growth: Renewals Ratio

Reviewing Growth: Number of Ongoing Members

Page 16: Uplift Health Mutuals

Uplift: Efficiency & Client Value

24% Reduction in Out of Pocket expenditure Remarkable impact

Service Ratio at 56% Proportion of clients using IP/OP insurance Services

Claim rejection Ratio at 2% Initial high rate at 10.5% Key for Community Based Models

Voluntary enrolment at 8-10%

Page 17: Uplift Health Mutuals

Client Value: PACE Analysis

Source: ILO, MIF

Page 18: Uplift Health Mutuals

Reducing Out Of Pocket Expenditure

2008 20090%

20%

40%

60%

80%

100%

120%

50%

36%

27%

37%

23% 27%Cost reduction due to networked HCPs

Claim amount re-imbursed

Out of Pocket expense

2008 20090%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

65%

49%

35%

51%

Claim amount re-imbursed

Out of pocket expense

Page 19: Uplift Health Mutuals

Improving Client Value

Challenges in improving client value Reimbursement based product High OP Care expenses leading to high OOP

Challenges in providing Cash less system Increase in negotiated prices Role of community diminished Increased chances of Fraud

Page 20: Uplift Health Mutuals

Program sustainability

Page 21: Uplift Health Mutuals

Costing Model

100% Gross Premium Collected 60%: Claim Fund

Claims Disbursed Solidarity Fund

20%: Uplift TPA Services Value Added Services Opex

20%: Partner Organization Value Added Services Opex

Subsidy Provided by Inter Aide Opex Value added services

Page 22: Uplift Health Mutuals

Total Program Costs

APVS Pune

APVS Mumbai

Psw0%

10%20%30%40%50%60%70%80%90%

100%

41% 42%

24%

18% 19%

19%

41% 39%

59%

Claims Value Added Services

Opex TOTAL

APVS Pune

56.5 (41%)

24.3 (18%)

57.6 (41%)

138.4

APVS Mumbai

60.4 (42%)

26.6 (19%)

55.9 (39%)

142.9

PSW 45 (24%)

31 (17%)

107.9(59%)

183.9

Total Program Costs on Per Member basis for Partner Organizations Source: 2009

Page 23: Uplift Health Mutuals

Dependency on Claim Funds

2003 2004 2005 2006 2007 2008 2009 2010 20110.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

140.0%

43.0%

70.0%

54.0% 52.0%

72.0%

63.0%

99.0% 107.0%

88.6%

0

0.710000000000002

1.09 1.08

0.952900000000002

0.0%

48.0%

77.0%

58.0%

105.0%

88.0%

75.0%

120.0%

86.0%

0

0.4038 0.397200000000002

APVS Pune

APVS Mumbai

PSW

Chaitanya

Claim Ratios for Partner Organizations

Page 24: Uplift Health Mutuals

Operating Expenses

Uplift APVS Pune PSW0

20

40

60

80

100

120

45.5

73.6

93.7

31.2

57.6

107.9

20082009

Operating Expenses on Per Member basis for Partner Organizations

Page 25: Uplift Health Mutuals

Dependency on Subsidy

2008 2009 20100%

10%

20%

30%

40%

50%

60%

70%

80%

46%

31%23%

32%27%

68% 68%

UpliftAPVS MumbaiPWS

Page 26: Uplift Health Mutuals

Way Forward

High Operating expenses for partner organizations Tripling the current outreach

Automation of routine functions

Enhancing Client Value Instant Cash Loan Product (Health Expenses)

Reinsurance facility to increase cover

Structural challenges Attrition of Service executives

Adverse Selection

Fund management at branch level

Page 27: Uplift Health Mutuals

QUESTIONS?