A digital backbone for healthcare payments is coming!
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very over 60 million Indians are pushed into medical poverty, and countless others are not able to access care. There are many reasons for this, a major factor is a fact that India’s public expenditure on health as a proportion of our GDP is woefully under what countries at a similar stage of development spend and orders of magnitude lower than the expenditure in high-income countries. All of this leads to families paying for care out of pocket for a majority of their healthcare needs. The Sustainable Development Goals that India has signed up to achieve envisages Universal Health Coverage (SDG 3) of which access to financial risk protection is a key aspect. Given our mixed health system, this will likely be achieved by a combination of public and private healthcare providers serving the country’s growing needs as well as public (Ayushman Bharat) and private (Health Insurance, Employers etc.) payors helping avoid catastrophic medical expenditure by creating various pooling mechanisms. However, to achieve this for every Indian, our current payment system needs an overhaul.
The Ayushman Bharat network doesn’t currently have enough providers, especially in rural areas. Cashless facilities are not uniformly available at all providers, while reimbursements require lengthy paperwork and have long wait times. Processing claims themselves are a cumbersome process, leading to delays in the patient getting discharged from hospitals as well as very long receivables cycles for hospitals. This also means that a lot of the costs incurred by the patient, for example, outpatient visits, drugs and diagnostics are not covered.
All of these ultimately lead to a poor experience for patients, healthcare providers as well as payors. These problems have been solved in other industries with digitisation and healthcare is ripe for such a change.
All these ultimately result in poor patient/provider experience and lack of trust in the health benefits offerings, thereby reducing the availing/facilitation of such benefits. This calls for rebooking the way the health financing is processed and looking for better alternatives that allow for smooth patient experience, and seamless and standardised information exchange between stakeholders.
Imagining a Health Benefits Network facilitated by Health Claims Exchanges (HCX)
In 2019, a Joint Working Group of NHA and IRDAI (2019), proposed the concept of Health Claims Exchange (earlier named Platform) to address these critical issues by aiming to pave the way to build a digital health benefits network. In 2020, the Hon’ble Prime Minister of India announced the launch of the Ayushman Bharat Digital Health Mission, which also included a health claims platform/exchange as a key component.
Such a network would provide a seamless way for all stakeholders to interact and create a win-win for all by providing the following key benefits to each of the key stakeholders.
Where we are and what is the path ahead?
At Swasth, we have been lucky to work with volunteers from a large number of organisations across the country to build the standards for such an exchange (the HCX Protocol) through an open and collaborative process. We are also working on a proof of concept/pilot connecting payor software with hospital software through this switch. This will help demonstrate the workings of the exchange and allow us to fine-tune the protocol as well as the software.
The HCX protocol is not static and the working groups coordinated by the Swasth Alliance hold regular cadences to add new features to the exchange and evolve the protocols. Current efforts include expanding provision beyond cashless claims to reimbursement use cases, enabling coverage of outpatient use cases, enabling auto-adjudication etc.
We believe that the HCX is a significant step in building the nation’s capacity to deliver Universal Health Coverage and would love to partner with all ecosystem stakeholders on this journey. For more information please write to us at hcx@swasthalliance.org
