The Utility and Perception of Health Insurance Among Healthcare Providers in Delhi: A Cross-Sectional Study

INTRODUCTION

For an impactful health insurance implementation, one of the topics requiring better research is how insurance affects the quality of care and doctor-patient relations.¹ The health insurance industry reported a 25% growth specifically due to expansion of the private health insurance sector.² Healthcare providers play a critical role in the delivery of quality care and establishing eligibility criteria for insurance coverage.³ Insurance status has been known to affect the quality of care delivered.⁴ Hence, the objective of this study was to evaluate the utility and perception of health insurance among healthcare providers in India.

METHODS

The survey-based cross-sectional observational study was conducted in a tertiary care hospital in Delhi, India during March - April 2013. The study participants were healthcare providers in the hospital who provided direct care to the patients. Healthcare providers, having a work experience of more than one year, and freely consenting to participate, were included in the study. After identification and screening of participants according to the eligibility criteria; participants were provided information about the study, including possible benefits and risks; and verbal consent was obtained prior to filling out the study questionnaire.

The study was conducted a self-prepared validated standardized questionnaire including a section for demographic data. Data quality assurance strategies were used in designing the data collection instrument, which underwent validation prior to actual use by participants. Block 1 of the questionnaire consisted of eight items and was designed to collect the healthcare providers’ knowledge of healthcare insurance. Block 2 of the questionnaire consisted of 20 items and focused on the perception of healthcare providers towards healthcare insurance. Printed study questionnaires were distributed to collect the data.

Ethical Considerations: The study was conducted according to the principles stated in the Declaration of Helsinki, as revised in 2000; ICH-GCP Guidelines; and the ICMR’s Ethical Guidelines for Biomedical Research on Healthy Participants, 2011. The study protocol and questionnaire were reviewed and approved by the institute for ethical considerations before collection of data. The study was categorized as associated with less than minimal risk and was permitted for participant recruitment with verbal informed consent (written consent was not required). Participant responses were anonymous and no identifying information was collected.

Statistical Analysis: A data quality review of the responses was performed before analysis. Demographic characteristics were summarized using descriptive statistics. Mean and standard deviation (SD) were used for describing continuous variables like age in years. Categorical variables like sex, qualifications (graduate or post-graduate), professional experience (0-10, 11-20, 21-30, 31-40 years) and present position (senior consultant, consultant, senior resident, junior resident, administrative officer) were reported using frequencies and percentages. Descriptive statistics were used to report the findings of knowledge and perceptions regarding healthcare insurance. Statistical analyses were performed using Microsoft Excel version 16.33 (Microsoft Corporation, Redmond, WA).

RESULTS

Among 132 healthcare providers that were approached and eligible, 98 verbally consented and filled out the study questionnaires. Characteristics of the study participants are presented in Table 1. Participants ranged in age from 25-64 years with a mean age of 39.34 ± 10.41 years. The most common responders were in the categories of 31-40 years (33.67%), female (57.14%), completed post-graduate training (59.18%), 0-10 years of professional experience (50%) and healthcare administrative officers (42.85%); for age, sex, qualification, professional experience and present position respectively.

As shown in Table 2, majority of the responders had an appropriate level of understanding of what health insurance entails. Fifty-five (56%) of the responders correctly identified that ‘healthcare for all is a human right in India’. The fact that ‘insurance is a legally binding’ document was correctly reported by 84 (85.71%) of the responders. In an open-ended question to inquire about the country with best insurance policies, none of the responders reported India. Most of the responders i.e., 68 (69.38%) did not have an answer for that question.

Table 3 summarizes the perception of healthcare providers towards healthcare insurance. Eighty-six (87.75%) responders agreed that the present premium rates were too high, 60 (61.22%) agreed to preferential treatments of insured vs. uninsured patients, and 55 (56.12%) respondents agreed that unnecessary tests and procedures were performed for the insured patients. Sixty-five (66.32%) responders reported that insured patients had a longer hospitalization time. A majority of 87 (88.77%) responders believed that it was not fair to exclude certain diseases from policies and 62 (63.26%) agreed that it was right if not all services and medication were covered by insurance. However, 96 (97.95%) healthcare providers agreed that long term medications should be covered by the insurance policies. Seventy-four (75.51%) respondents disagreed that health evaluations were modified to allow for patients to get a healthcare insurance policy. Eighty-three respondents (84.69%) believed that the hospitals were turning into hospitality centers in the wake of higher insurance costs and everyone agreed that the country needed a better National health insurance scheme. Eighty-three (85.71%) healthcare providers reported that a national insurance policy will alleviate the condition of the poor. However only 27 (27.55%) respondents agreed that 100% coverage is possible in our country.

Ninety-two (93.97%) participants believed that doctors should be competent to suggest right insurance policy for an individual and 85 (86.73%) agreed that community-based insurance policies should be encouraged. All (98) healthcare providers agreed that the cost of procedures should be fixed to avoid steep inflation of insurance charges and employers given policy should extended to entire family. The responders were divided almost equally (48 (48.98%) agreed and 50 (51.02%) disagreed) on the question whether patients became unwilling to undergo a procedure if it cost more than their insurance coverage and 97(98.97%) agreed that the process of claims retrieval was tedious.

DISCUSSION

Our study was conducted at a tertiary care hospital in an urban city, with a large patient population, hence helping us to gather insights from a well-exposed pool of healthcare providers. Fifty-nine percent responders had completed post-graduate medical training, which is a key factor in analysis since a significant association between awareness, level of education and knowledge of health insurance schemes has been seen.⁵

Majority (42.85%) stated private health insurance companies as providing the best policy to patients, indicating that there is an urgent need to improve public health insurance to attain universal health coverage, since the majority of the Indian population cannot afford private insurance. The Ministry of Health and Family Welfare (MoHFW) needs to be more assertive in the demands for health budget and must use proven case scenarios to justify higher budgetary allocations.⁶ Surprisingly, a study conducted in a Middle-Income Household (MIH) population found a 41% health insurance coverage, despite absence of any publicly funded schemes. Poor financial status and a high premium rate were cited as the top causes for not having a health insurance in that study. Focusing on these determinants is of utmost importance.⁷ In our study, majority of the healthcare providers did not know about the country with the best health policy in the world, which highlights the scarcity of knowledge among healthcare providers. The general knowledge on global health insurance is imperative since it guides the development and implementation of insurance policies to improve coverage and access to quality care.

Our study shows that most providers agree that the health insurance premium amount being too high for an Indian population. An analysis of the annual expenditure under the Rajiv Aarogyasri Community Health Insurance (RACHI) in Andhra Pradesh (AP) concluded that the budget spent in private hospitals compared to tertiary public hospitals is unsustainable in the long run.⁸ Hence, even with a public-private partnership, better, affordable schemes need to be introduced to be able to provide sustainable health coverage to all. Ways to decrease the divide in healthcare between the rich and the poor as well as the regional disparities in India need to be developed and implemented.^9,10 We need to understand the contradictions in both private and public health-care and strategize schemes accordingly to solve them.¹¹

Fifty-six percent participants agreed that unnecessary tests and procedures were performed if the patient had a health insurance. Pisarek et al found that insured patients were admitted at a higher rate compared to uninsured patients (18.6% versus 15.4%) for care.¹² Similar to our findings, Englum et al reported increased hospitalization duration for insured (public or private insurance) patients by an risk-adjusted average of 0.9 days [95% confidence interval (CI) 0.8–1.0] compared to uninsured patients.¹³ Optimizing factors like length of stay in hospital, unnecessary investigations, and out of -pocket expenditure, for each patient, will help minimize neglected costs. Waiting times can be reduced by implementing the recommendation of abandoning the concept of prioritization as well as using Telehealth.^14,15 Hence it is important to understand the perception and delivery of care patterns by healthcare providers based on the insurance coverage status of the patient.

Majority of healthcare providers on the survey reported that preferential treatment was provided to the insured patients. This is a critical finding. Hanson et al reported that insurer consolidation may lead to improved patient experience.¹⁶ All participants agreed that the country needs a better National Health Insurance scheme. Karan et al similarly reported the inefficiency of the Rashtriya Swasthya Bima Yojana (RSBY) in reducing the out-of-pocket spending on poor households.¹⁷ The government must look into recommendations provided by studies such as ours and others in the past across the world, to formulate newer policies for the future, which will ultimately lead to attainment of the goal of universal health coverage.¹⁸ Eighty-six percent of the participants reported that a national insurance policy will improve the condition of the poor. One of the reasons for the high out of pocket expenditures was limited access to healthcare in public sectors, compelling the patients to seek private sector healthcare.⁶ It was also seen that health insurance creates overall welfare gains for the country. ¹⁹

Although only 27.55% agreed that 100% coverage is possible in the country, there has been an increase in the health insurance coverage numbers (households with any usual member covered under a health insurance/financing scheme) from 28.7% in NFHS-4 (National Family Health Survey) to 41% IN NFHS-5.²⁰ This, along with learning from other countries Universal Health Coverage (UHC) progress strategies will hopefully help us improve UHC in the long run.²¹ All participants agreed (100%) on the need for procedure costs to be fixed since standardization takes away the power from the administration to inflate charges according to their wishes. There was also a 100% agreement on the inclusion of the entire family of an employee under the health insurance scheme provided by the employer, whether government or private. This is important since the overall health of an individual is seen to be dependent on the health of his/her entire family.²²

There was an equal division in opinion regarding unwillingness to undergo a procedure if it cost more than the patient’s insurance coverage. However, multiple studies have reported that patients with any form of insurance had a higher likelihood to undergo an operative intervention.^{23, 24}

In our study, the claim retrieval process was highlighted to be very tedious for the patients, hence, quality management needs to be upgraded to provide a smoother experience to all economic strata.²⁵ This must include comprehensive and timely access to both electronic health records and health insurance claims data. It has also been seen that the handling of claims by insurance companies plays an important role in the recovery of patients.²⁶

Every study has its limitations, so does ours. The sample size is small and hence further studies with larger sample size need to be developed along similar study guidelines to compare and analyze data. This study is ten years old, hence the data today might be different. It is important to see the factors assessed in our study and analyze similar research conducted in the present to compare the differences.

CONCLUSION

Healthcare providers provided valuable insight into the practical problems of healthcare insurance implementation and these factors can be used to further improve health insurance schemes.