Uplift Health Mutuals SAURABH SHARMA Uplift Health Mutuals

Uplift Health Mutuals SAURABH SHARMA

Uplift Health Mutuals �Community based health fund (CBHIs, MHOs) �Uplift Mutuals: Group of Social Sector Organisations �Based in Maharashtra & Rajasthan

Uplift Health Mutuals: A Case Study Purpose of Study � Document the Uplift Model & Processes � Review Key Performance Indicators, Sustainability, and Client value Method of Study � Qualitative and Quantitative Literature review Interviews with process managers, clients and senior management Secondary Data Analysis Observation of key procedures

Flow of Presentation �Community Based Health Insurance �Uplift: Timeline, Model & Product �Growth & Impact KPIs Client Value �Program Sustainability Cost model Program Costs �Way Forward

Outreach of Community Based Insurance in India Outreach More Than 1 Million 2 100, 001 -500, 000 5 15 10, 001 -100, 000 5001 -10000 5 1000 -5000 10 Less than 1000 4 0 2 4 6 8 10 12 14 16

Challenges for community based risk solutions Source: ILO, MIF �Low community participation �Lack of professional management �Small size of risk pool �Incomprehensive product �Isolation from formal insurance mechnisms

Uplift: Timeline, Model & Product

A Decade for Uplift 2003 Uplift Mutuals established 2004 Registration of Uplift India Association PSW Pune Joined 2007 -08 Product Modification Arogyanidhi 2 Launched 2010 -11 Enrollments crossed 100, 000 3 More partners Joined 2012 -13 125, 000 Members Expansion to Rajasthan

Partner Members S NO Name Location Year of Joining Primary Activities 1 Swabhimaan Pune, 2003 Microfinance & Health France 2003 Supporting Development Activities Mumbai, 2011 Microfinance & Health 2004 Microfinance , Enterprise Development & Family Maharashtra 2 Inter Aide (Technical partner and Grant Provider) 3 Navnirman Samaj Vikas Kendra Maharashtra 4 Parvarti Swayamrojgar Pune, Program Maharashtra 5 Annapurna Parivar Vikas Samvardhan Pune & 2003 Microfinance , Enterprise Development & Health 2004 Microfinance 2003 Credit Cooperatives 2010 Microfinance, SHG & federation promotion 2012 SHG & federation promotion Mumbai, Maharashtra 6 Disha Kendra Pune, Maharashtra 7 8 Annapurna Mahila Mandal Mumbai, Credit Cooperative Society Maharashtra Chaitanya Pune, Maharashtra 9 PEDO supported Federations Rajasthan

Arogyanidhi: the product Feature Uplift Mutuals Compulsory/Voluntary Compulsory for MFI credit customers Payment Type Reimbursement Eligibility Criteria: No age limit Premium Contribution For a family of four: Rs. 400 (approx. USD 8) per year For individuals: Rs. 150 (approx. USD 3) per year Period of Cover 12 months from the date of issue of policy Sum Insured Rs. 15, 000 person per year subject to policy exclusions In patient hospitalization expenses for treatment in general ward 10 days of pre and post hospitalization cover including expenses for one time diagnosis of the ailment and the cost of medicines prescribed during this period Pre-existing diseases covered from 3 rd year onwards 100% : Public Hospital 80% : Networked Private Hospitals No reimbursement : Non Networked Private Hospitals, except emergencies Benefits Offered Stipulation Pertaining to Health Care Providers

Value Added Services: Reducing Health Risk Service Details Outpatient care Beat doctor Discounts on drugs and Diagnostics Networked pharmacy and diagnostic centres Free generic medicines Health awareness sessions Health camps & Talks Client education 24/7 helpline Access to Uplift’s network of HCPs Referrals/guidance Sessions about insurance and the HMF program Helpline for guidance or referrals Uplift has established a network of more than 300 healthcare providers for better quality of care, and to control cost. Uplift signs Mo. U with these HCPs with negotiated medical costs. Assistance by a service executive

Health Education: Reducing Risk Awareness Material Awareness Sessions

How it Works Uplift Mutuals Inter. Aide Uplift As TPA Uplift as TPA Managers/ Astt Managers Negotiated Rates Monitoring HCPs Networked Health Care Providers Claim Processing Arogyasakhis Arogyasakhi Health seeking Guided by Arogyasakhis Final Claim Settlement & Disbursement at community level

Growth & impcat

Reviewing Growth: Number of Ongoing Members Reviewing Growth: Renewals Ratio 80% 70% 60% 50% 40% 30% 20% 10% 0% 72% 55% 51% 53% 56% 55% 43% 37% 58% PSW APVS Pune, 49% 54% APVS Mumbai, 54% 40% 39% 21% 7% 0% 2003 0% 2004 2005 2006 2007 2008 2009 2010 2011

Uplift: Efficiency & Client Value � 24% Reduction in Out of Pocket expenditure Remarkable impact �Service Ratio at 56% Proportion of clients using IP/OP insurance Services �Claim rejection Ratio at 2% Initial high rate at 10. 5% Key for Community Based Models �Voluntary enrolment at 8 -10%

Client Value: PACE Analysis Source: ILO, MIF

Reducing Out Of Pocket Expenditure 120% 100% 90% 80% 35% 23% 51% 70% 80% Claim amount reimbursed 60% 27% 37% 50% Out of pocket expense 40% 30% 27% 65% 49% 20% 40% 50% 20% 0% 2008 2009 Claim amount reimbursed Out of Pocket expense 36% 10% 0% Cost reduction due to networked HCPs 2008 2009

Improving Client Value �Challenges in improving client value Reimbursement based product High OP Care expenses leading to high OOP �Challenges in providing Cash less system Increase in negotiated prices Role of community diminished Increased chances of Fraud

Program sustainability

Costing Model � 100% Gross Premium Collected 60%: Claim Fund � � 20%: Uplift � � � Claims Disbursed Solidarity Fund TPA Services Value Added Services Opex 20%: Partner Organization � � Value Added Services Opex � Subsidy Provided by Inter Aide Opex Value added services

Total Program Costs 100% 90% 80% 59% 70% 60% 50% 19% 18% 40% 19% 30% 20% Claims Value Added Services Opex TOTAL APVS Pune 56. 5 (41%) 24. 3 (18%) 57. 6 (41%) 138. 4 APVS Mumbai 60. 4 (42%) 26. 6 (19%) 55. 9 (39%) 142. 9 PSW 45 (24%) 31 (17%) 107. 9(5 9%) 183. 9 39% 41% 42% 41% 24% 10% 0% APVS Pune APVS Mumbai Psw Total Program Costs on Per Member basis for Partner Organizations Source: 2009

Dependency on Claim Funds 140. 0% 120. 0% 108. 0% 109. 0% 105. 0% 100. 0% 99. 0% 107. 0% 88. 6% 88. 0% 80. 0% 86. 0% 77. 0% 72. 0% 70. 0% 54. 0% 48. 0% 40. 0% 71. 0% 75. 0% APVS Pune APVS Mumbai 63. 0% 60. 0% 95. 3% 58. 0% 52. 0% PSW 43. 0% 40. 4% Chaitanya 39. 7% 20. 0% 2003 2004 2005 2006 0. 0% 2007 2008 0. 0% 2009 2010 Claim Ratios for Partner Organizations 2011

Operating Expenses 120 107. 9 93. 7 100 80 73. 6 57. 6 60 2008 45. 5 40 2009 31. 2 20 0 Uplift APVS Pune PSW Operating Expenses on Per Member basis for Partner Organizations

Dependency on Subsidy 80% 70% 68% 60% 50% 46% Uplift 40% 32% APVS Mumbai 31% 27% 20% PWS 23% 10% 0% 2008 2009 2010

Way Forward � High Operating expenses for partner organizations Tripling the current outreach Automation of routine functions � Enhancing Client Value Instant Cash Loan Product (Health Expenses) Reinsurance facility to increase cover � Structural challenges Attrition of Service executives Adverse Selection Fund management at branch level

QUESTIONS?