Preface
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What are the GSHISs doing in terms of data collection, monitoring, and analysis and what information is provided to beneficiaries? A few schemes have recently made strides in strengthening monitoring systems, but the general weakness of these systems and dearth of data and analysis underlie all issues. Most schemes have yet to develop robust systems to monitor insurer, TPA, and provider performance regularly. This situation impedes their effectiveness in buying services, selectively contracting providers, supervising and assessing performance (e.g., insurers, TPAs, and providers), gauging beneficiary trust and satisfaction, and systematically correcting emerging problems. Two schemes have only recently planned for impact evaluations. Beneficiaries appear to have insufficient information on enrolment, benefits, and providers. Inadequate information on covered and uncovered procedures can result in denials of preauthorization as well as outof-pocket expenses for beneficiaries. Most consumers lack the information on provider performance (e.g., quality, patient satisfaction, volume) that would allow them to make well-informed choices. To what extent do GSHISs implement sound purchasing and contracting practices? At their current state of development, schemes tend to focus on ascertaining admissibility of a claim under coverage rules and the preagreed package rates, and on simple reimbursement of validated claims to the treating hospitals. Scant attention has been given to purchasing and contracting functions to maximize insurers’ and network providers’ performance. Invariably a scheme contracts a single insurer for a demarcated geographical area (state or district), and in the absence of performance-based contracting instruments, insurers are driven by their own incentives, which may not dovetail with scheme objectives. Similarly, schemes have yet to take advantage of their financial leverage to motivate providers to improve their quality, efficiency, patient safety, and satisfaction. Are GSHISs doing enough to control costs? Insurers under contract with the schemes have incentives to check provider and beneficiary behaviors that negatively impact their bottom line. However, they face weak incentives to control costs over the long term. Because schemes’ contracts with insurers are short term, insurers can reprice the premium or exit the market when costs rise rather than invest in long-term cost containment. Similarly, although package rates are a significant advancement over itemized fee-for-service payments in their ability to contain costs, package rates have not been systematically based on underlying costs or market prices and need improvement. Significant strengthening is needed in such