Ranson Michael Kent
Health Policy Unit, London School of Hygiene and Tropical Medicine, London, England.
Bull World Health Organ. 2002;80(8):613-21. Epub 2002 Aug 27.
To assess the Self Employed Women's Association's Medical Insurance Fund in Gujarat in terms of insurance coverage according to income groups, protection of claimants from costs of hospitalization, time between discharge and reimbursement, and frequency of use.
One thousand nine hundred and thirty claims submitted over six years were analysed.
Two hundred and fifteen (11%) of 1927 claims were rejected. The mean household income of claimants was significantly lower than that of the general population. The percentage of households below the poverty line was similar for claimants and the general population. One thousand seven hundred and twelve (1712) claims were reimbursed: 805 (47%) fully and 907 (53%) at a mean reimbursement rate of 55.6%. Reimbursement more than halved the percentage of catastrophic hospitalizations (>10% of annual household income) and hospitalizations resulting in impoverishment. The average time between discharge and reimbursement was four months. The frequency of submission of claims was low (18.0/1000 members per year: 22-37% of the estimated frequency of hospitalization).
The findings have implications for community-based health insurance schemes in India and elsewhere. Such schemes can protect poor households against the uncertain risk of medical expenses. They can be implemented in areas where institutional capacity is too weak to organize nationwide risk-pooling. Such schemes can cover poor people, including people and households below the poverty line. A trade off exists between maintaining the scheme's financial viability and protecting members against catastrophic expenditures. To facilitate reimbursement, administration, particularly processing of claims, should happen near claimants. Fine-tuning the design of a scheme is an ongoing process - a system of monitoring and evaluation is vital.
根据收入群体评估古吉拉特邦自营职业妇女协会医疗保险基金的保险覆盖范围、索赔者免受住院费用影响的情况、出院与报销之间的时间间隔以及使用频率。
分析了六年间提交的1930份索赔申请。
1927份索赔申请中有215份（11%）被拒绝。索赔者的平均家庭收入显著低于普通人群。索赔者和普通人群中处于贫困线以下家庭的百分比相似。1712份索赔申请得到了报销：805份（47%）全额报销，907份（53%）平均报销率为55.6%。报销使灾难性住院（>年度家庭收入的10%）和导致贫困的住院的百分比减半以上。出院与报销之间的平均时间为四个月。索赔申请的提交频率较低（每年18.0/1000名成员：估计住院频率的22 - 37%）。
这些发现对印度及其他地区基于社区的医疗保险计划具有启示意义。此类计划可以保护贫困家庭免受医疗费用的不确定风险。它们可以在机构能力过于薄弱而无法组织全国范围风险共担的地区实施。此类计划可以覆盖贫困人口，包括贫困线以下的个人和家庭。在维持计划的财务可行性与保护成员免受灾难性支出影响之间存在权衡。为便于报销，管理，特别是索赔处理，应在索赔者附近进行。对计划设计进行微调是一个持续的过程——监测和评估系统至关重要。
