Indian Institute of Public Health Shillong, Shillong, Meghalaya, India.
Department of Health & Family Welfare, Government of Meghalaya, Shillong, India.
PLoS One. 2022 Jun 3;17(6):e0268858. doi: 10.1371/journal.pone.0268858. eCollection 2022.
The Megha Health Insurance Scheme (MHIS) was launched in 2013 in the North-East Indian state of Meghalaya to reduce household out-of-pocket expenditure on health and provide access to high-quality essential healthcare. Despite substantial expansion of the MHIS since the scheme's inception, there is a lack of comprehensive documentation and evaluation of the scheme's performance against its Universal Health Care (UHC) objectives.
We analysed six years of enrolment and claims data (2013-2018) covering three phases of the scheme to understand the pattern of enrolment, utilisation and care provision under the MHIS during this period. De-identified data files included information on age, sex, district of residence, the district of provider hospital, type of hospital, date of admission, status at discharge, claimed category of care, package codes, and amount claimed. Descriptive statistics were generated to investigate key trends in enrolment, service utilisation, and Government health spending under the MHIS.
Approximately 55% of the eligible population are currently enrolled in MHIS. Enrolment increased consistently from phase I through III and remained broadly stable across districts, gender, age group and occupation categories, with a small decline in males 19-60 years. Claims were disproportionately skewed towards private provision; 57% of all claims accrued to the 18 empanelled private hospitals and 39% to the 159 public sector facilities. The package 'General Ward Unspecified' was responsible for the highest volume of claims and highest financial dispensation across all three phases of the scheme. This likely indicates substantial administrative error and is potentially masking both true burden of disease and accurate financial provision for care under the MHIS. Anti-rabies injections for dog/cat bite contributed to 11% of total claims under MHIS III, and 1.6% of all claims under MHIS II. This warrants investigation to better understand the burden of animal bites on the Meghalayan population and inform the implementation of cost-effective strategies to reduce this burden.
This paper describes the first analysis of health insurance enrolment and claims data in the state of Meghalaya. The analysis has generated an important evidence base to inform future MHIS enrolment and care provision policies as the scheme expands to provide Universal Health Coverage to the state's entire population.
2013 年，印度东北部梅加拉亚邦推出了 Megha 健康保险计划（MHIS），旨在降低家庭医疗支出，提供高质量的基本医疗保健。尽管自该计划启动以来，MHIS 已经大幅扩张，但缺乏对该计划在实现全民健康覆盖（UHC）目标方面的表现进行全面记录和评估。
我们分析了 2013 年至 2018 年的六年参保和理赔数据（共涵盖该计划的三个阶段），以了解在此期间 MHIS 参保、使用和提供医疗服务的模式。去标识数据文件包含了年龄、性别、居住地区、医疗机构所在地区、医院类型、入院日期、出院状态、所申请的护理类别、套餐代码和理赔金额等信息。我们生成了描述性统计数据，以调查 MHIS 参保、服务使用和政府健康支出方面的关键趋势。
目前，约有 55%的符合条件的人口参加了 MHIS。从第一阶段到第三阶段，参保人数持续增加，且在各地区、性别、年龄组和职业类别之间基本保持稳定，只有 19-60 岁男性略有下降。理赔数据严重偏向私人医疗机构；所有理赔中有 57%来自 18 家入围的私立医院，39%来自 159 家公立医疗机构。套餐“普通病房未指定”在所有三个阶段的计划中都产生了最高数量的理赔和最高的财务支出。这可能表明存在大量的行政错误，并且可能掩盖了 MHIS 下的真实疾病负担和准确的医疗服务财务支出。狂犬病疫苗接种（针对狗/猫咬伤）占 MHIS III 总理赔的 11%，占 MHIS II 总理赔的 1.6%。这需要进一步调查，以更好地了解动物咬伤对梅加拉亚邦人口的负担，并为实施降低这种负担的成本效益策略提供信息。
本文描述了对梅加拉亚邦医疗保险参保和理赔数据的首次分析。该分析为未来的 MHIS 参保和医疗服务提供政策提供了重要的证据基础，因为该计划正在扩大，为该州的全部人口提供全民健康覆盖。
