Results and Cross-Cutting Issues
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of the term. For example, ambulatory care constitutes a much higher share of overall health expenditure than inpatient care, and much of this continues to be out of pocket. A chronic ailment requiring regular treatment as an outpatient can involve higher expenditures than an inpatient procedure. As schemes evolve, they will face pressure to deepen the benefits package. This is already the case for some. In Rajiv Aarogyasri (AP), for example, the scheme started in a small geographical area, with coverage for expensive, tertiary conditions that were among the most common causes for which patients approached the chief minister’s discretionary “relief” fund for a grant to cover the cost of care. As the scheme expanded geographically, it also deepened the benefits package, adding several hundred new procedures, including some secondary procedures. Similarly, after a year of implementation experience, RSBY added maternity coverage and removed the exclusion for HIV/AIDS. Based on analyses of claims data, RSBY is also expanding its list of packages to standardize costs for an additional set of conditions. Also with the aim of deepening the coverage, other schemes are considering followup care packages. Evolution of benefits packages is an ongoing process in response to sociopolitical demands, claim experience, and availability of financial resources.
Utilization Insurance coverage contributes to increased utilization by removing or lowering financial barriers. This can help improve welfare. However, controls need to be introduced to reduce unnecessary utilization and overutilization (moral hazard). This section reviews findings on utilization patterns and their determinants for a subset of schemes as well as emerging issues related to induced and unnecessary utilization.
Hospital Utilization Patterns Table 3.5 compares the frequency of hospitalization from selected schemes with the community average, based on NSS/60th (2004–05) round survey data for rural and urban areas. One needs to be cautious about comparing scheme-specific hospitalization frequency with community-level data for any form of hospitalization for two reasons. First, the benefits package of the scheme may not be sufficiently comprehensive and may cover only a subset of community needs for inpatient treatment. Second, insurance may induce changes in health-seeking behaviors.