Do patients need additional coverage for chronic ailments? Insights from hospital data

Area of Science:

• Health Economics
• Public Health Policy
• Healthcare Management

Background:

• Private health insurance is promoted as a strategy to overcome financial barriers in healthcare access.
• This aligns with the United Nation's sustainable development goals for universal and affordable medical care.
• The study examines the effectiveness of private health insurance in protecting individuals from financial risks associated with medical expenses.

Purpose of the Study:

• To investigate the coverage trends of private health insurance plans.
• To assess the financial risk-protective nature of these insurance plans.
• To analyze the extent of coverage and reimbursement for major disease categories.

Main Methods:

• Analysis of 12 months of hospital billing and insurance claim data from a tertiary care hospital in southern India (April 2022-March 2023).
• Inclusion of 5002 patients with cancer, cardiac, neurological, and renal diseases.
• Proportionate random sampling of 250 patients for detailed cost incurred and reimbursement analysis.

Main Results:

• Private health insurance was found to be insufficient for comprehensive coverage, resulting in under-insurance.
• Analysis revealed the reimbursement trends across various cost categories.
• This study uniquely utilized institutional data, offering a distinct perspective compared to survey-based research.

Conclusions:

• Healthcare policymakers, providers, and insurers must collaborate to improve healthcare affordability and accessibility.
• Strategies are needed to enhance the financial risk protection offered by private health insurance.
• Promoting health and wellness requires addressing systemic gaps in healthcare financing.