Was your mother under the influence of alcohol?

About eight years ago when I wrote in Express Healthcare Management about the need for electronic claims processing standards for India, (http://www.expresshealthcaremgmt.com/20021015/medtech1.shtml) little did I know that questions like these could mean endless struggles for patients grappling with the beauty of insurance claims processing in India.

In my article in 2002, I made the case for a standards based claims processing system modeled on HIPAA standards, than trying to re-invent the wheel. Not sure how many healthcare managers paid attention that story in 2002. Health Insurance was in its infancy. Today claims processing worries have come to the fore front of the healthcare executives' agenda.Not sure if the patients concerns are being heard…

Today I am writing, not as a healthcare management consultant, but as an ordinary citizen, handling his mother’s hospital admission in a reputed hospital in India, frustrated working with the health insurance unit in the hospital, faxing and re-faxing documents coupled with several calls to the TPA across various cities, listening to a wide variety of “the put on hold” music etc.

I tried my best to go through the painful experience and not pull strings/use short cuts, because I wanted to endure the whole process as a lesson learnt in a patient’s experience with claims processing.


Now going back to whether my 65 year old mom involved in an accident was under the influence of alchohol …. This was a question on one of the forms provided by the TPA and had to be completed by the doctor. The doctor had omitted this question, because she did not think this was a relevant question. Unfortunately the hospital’s insurance cell which has been working for several years with TPAs did not cross check the form prior to faxing it to the TPA. A few days hence, the TPA rejected the claim that came in an incomplete form. From then on it was a back and forth of discussion with doctor who did not want to fill the form again, to more detailed documentation requirements from the TPA. This was just the beginning; wrong address on the hospital admission form, wrong age on the record; we had a cocktail of issues to sort out leading to endless calls and faxes… I was even thinking this could be the plot for a Hindi movie.

My intent is not to blame the TPA or the sympathetic but untrained insurance clerks at the hospital. The entire system around health insurance in India needs a revamp; claims processing challenges are only a symptom of a health insurance system that is ill. However issues with claims processing have major implications that can cripple the progress of insurance adoption in the country.

Even with my back ground,if I found navigating claims processing a nightmare, one can imagine what an ordinary patient, often illiterate has to endure to make cashless insurance processing a reality.

It was also a lesson that could be useful in our start up organization, health FIRST Hospital Network. For me it was a grim reminder that transferring best practices to the Indian healthcare sector is not as easy as it seems on slicks presentations and that India shining is a long way off atleast in healthcare sector.


Shall be writing about some of the issues with claims processing and TPAs in my next blog.

MassGen Hospital to enter India?

This recent story carried by Economic Times caught my attention.

http://economictimes.indiatimes.com/News-by-Industry/Hindujas-scout-for-hospital-JV-partner/articleshow/4835610.cms

To me this is a sign of the times ahead. As the purchasing power of the Indian middle class improves and insurance penetration increases, we will see more US based healthcare players look at India as a destination for expansion.

For these players the revenues from operations in India may not a huge impact on the top line in dollar terms. However this could be seen as a medical tourism play and/or a pilot project to test out the Indian market. Though several US based payers have started to push medical tourism packages in India, the perception of quality has been an obstacle to adoption of India as a healthcare destination by employee unions,thus slowing the momentum. Mass Gen may be able to break those perception barriers and channel patients to its Indian venture. The other possibility is for MassGen to recruit high value patients for its centers in the US.


For the Indian healthcare industry, this could be turn to be an inflection point. Indian healthcare providers deliver some of the best quality care in the region. However there is potential to adopt better management practices and technology in the hospitals.

The arrival of competition would definitely change the healthcare delivery model in India.

Healthcare sector in India to grow from $75 billion in 2012 to $150 bllion by 2017

http://www.ibef.org/industry/healthcare.aspx


Please refer to excerpts from recent study by Technopak advisors.

Healthcare, which is a US$ 35 billion industry in India, is expected to reach over US$ 75 billion by 2012 and US$ 150 billion by 2017, according to Technopak Advisors in their report – ‘India Healthcare Trends 2008’.

The sector offers immense potential to healthcare players as the country witnesses a rise in the incidence of lifestyle-related and other diseases. A growing elderly population and rise in income levels are also pushing for better facilities in the country.

To meet this growing demand, the country needs US$ 50 billion annually for the next 20 years, says a Confederation of Indian Industry (CII) study. India needs to add 3.1 million beds by 2018 to the existing 1.1 million, and requires immediate investments of US$ 82 billion, as per the Technopak Advisors report.

Future of Healthcare IT Outsouring

Please refer to my recent publication on Express Healthcare Management website

http://www.expresshealthcaremgmt.com/200906/it@healthcare02.shtml

Globalization of Healthcare

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My problem with PHR

PHR seems to be the new panacea for all healthcare ills... vendors and consultants are in a frenzy pitching this new solution that would fix the healthcare system... the noise is huge...

To me though, there are various challenges, the definition of PHR being the first. NAHIT had to spend several hours and meeting with several groups representing different interests to get the definitions right(?) http://www.healthnewsdirect.com/?p=329.

I agree that the patient should have the right to information, but the RIGHT information.
This is where the google concept of letting patients update their clinical information becomes tricky to me.

My key concern is that, though the patient should have access to the information, when it comes to entering /editing clinical/medication/procedure info, that should NOT be left to the patient .

It's nice to have the enduser centric view of the world,but once patients tinker with their prescriptions/procedures etc, we lose the integrity of the data. The physicians cannot use this info as a source of truth and face the legal implications.

Here's my thinking on what a patient would like to see on her PHR.

Clinical& Demographic information
»Demographics
»Social/Family History
»Allergies/Alerts/Immunizations
»Clinical Information
•Diagnoses
•Lab/imaging results
•Rx history
•Inputs from home monitoring devices
•Discharge summary/
Financial
»HSA related information
»Benefits -Co-payments/deductibles etc
»User friendly statements (Explanation of Benefits)
»Medical expense management
Other
»Provider information
»Plan information
»Calendar/Schedule management

In a market place crowded with niche product vendors, each owning a piece of the data,collating all the information and displaying in a standard format is a challenge.However if major vendors,payers and providers collaborate ( which is easier said than done) this can happen.

Some of the providers provide online access to medical records to their patients. I think all providers should do the same, might be a good start.

For more, please view my ppt on role of PHR in an integrated clinical engagement model at http://www.linkedin.com/in/sajisalam

PHR In an Integrated Clinical Engagement Model

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