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Government-Sponsored Health Insurance in India
whether a government agency that directly pays providers would be able to make objective decisions to contain costs and eliminate fraud or possess the technical and administrative efficiency and wherewithal to ensure effective empanelment of hospitals, eliminate leakages, and ensure timely claim payments.93 Recent experience with CGHS and state employee schemes that purchase services directly from private hospitals suggests that, despite several efforts and ongoing reforms, much remains to be done to improve purchasing effectiveness and efficiency. A case can be made that using insurers as intermediaries may be useful in the short to medium term because they have the incentives to check provider and beneficiary behaviors that negatively impact their bottom line. Under RSBY, at least one insurer is implementing an audit system to improve fraud detection. This system involves two features. The first consists of culling claims data to uncover potential cases known as “triggers.� These can include a sudden increase in the volume of claims or high-value claims, multiple admissions for the same patient or procedure, high repetition of certain diagnostic tests, unreasonable lengths of stay, and lopsided gender-based treatment (e.g., large number of hysterectomies). Once a trigger is detected, the second feature entails follow-up hospital visits conducted by surveillance teams staffed by medical personnel to verify records and claims. In some cases, the audit may require home visits to authenticate patient residence and ascertain the services used. RSBY reported that doing audits in 219 hospitals in 2009 resulted in disempanelment of 68 of these facilities (ICICI Lombard 2010). It is unknown to what extent audits have been incorporated by other insurers under contract with RSBY (or other GSHISs) or rolled out to the majority of RSBY empaneled hospitals.
Innovation, Research, and Learning With the possible exception of AP and RSBY, there appears to be a lack of innovation in the schemes examined for this study. Some of the original schemes, such as ESIS and Yeshasvini, have reached a low level of equilibrium and appear to have little interest in or capacity to systematically address faults in the design or implementation or innovate in terms of managerial processes. Some recent state schemes are close carbon copies of early innovators such as Aarogyasri in AP. Scheme planners have rarely examined the contextual conditions in which the earlier schemes were planned and launched, or their potential weaknesses that could be improved with home-grown innovation. Most managers are too involved in day-to-day operations of rollout and their myriad additional assignments. They also do not have adequate technical support. Consequently,