Introduction
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Table 1.1 Analytical Framework Applied to Case Studies Area of inquiry Institutional features
Beneficiaries Benefits package Provider network
Financing and financial status Information environment Utilization and claims
Provider payment mechanisms Cost containment
Quality orientation Consumer information and protection
Other Overall performance Source: Authors.
Specific topics covered Objectives, mission, legal and regulatory framework, contextual enablers (that led to creation of scheme), ownership, organizational structure, interinstitutional linkages, governance arrangements including stakeholder participation, supervisory oversight and decision-making authorities, management capacity, use of intermediaries (insurers and TPAs) Target population, eligibility criteria, enrolment processes, characteristics of enrollees, equity of coverage Services and/or conditions covered, preexisting conditions, exclusions, pre- and postcare coverage Number, location, ownership, and characteristics of empaneled facilities, empanelment criteria, competition among providers, linkages to public delivery system, provider education Sources of income, registration and user fees, premium setting Reporting requirements Number and amount of claims received, paid, and repudiated, including details on geographical distribution, disease distribution (including analysis of top 10 diseases/procedures paid under the scheme and their costs), utilization by different income quintiles as available, concentration of utilization, provider induced demand, timeliness of claims and payments, administrative costs Types and effectiveness of measures, variation in rates across schemes, rate-setting methods, payment procedures Demand- and supply-side measures: copayments, deductibles, use of gatekeepers, second opinion, utilization review and control, prior authorizations, screening, concurrent review, discharge planning, in-depth analysis of claims experience, use of underwriting and actuarial analysis Quality assurance activities, guidelines, or standards; use of quality measures for empanelment, inspections Provision of information to beneficiaries on benefits and responsibilities; complaint and redress systems including statistics of grievances received and settled, comparative information on provider infrastructure, statistics or quality (given to consumers) if any Evidence of moral hazard (overutilization), adverse selection (provider and beneficiary), provider penalty mechanisms Patient satisfaction, political viability, equity of access and utilization, expansion challenges, fraud and corruption