Sugunan Aswin, Pillai K Rajasekharan, D'souza Brayal, George Anice
Manipal College of Nursing, Manipal Academy of Higher Education, Manipal, Karnataka, India.
Manipal Institute of Management, Manipal Academy of Higher Education, Manipal, Karnataka, India.
J Educ Health Promot. 2024 Jul 5;13:174. doi: 10.4103/jehp.jehp_34_24. eCollection 2024.
Eliminating financial barriers and improving healthcare accessibility pertain to be key elements of the United Nation's sustainable development goals. These have directed health policymakers to advocate private health insurance as a health promotion strategy to enable patients to obtain absolute and affordable medical care when needed. Against this backdrop, the current study investigates the coverage trend and financial risk-protective nature of private health insurance plans.
We examined 12 months' hospital billing data of private health insurance holders with cancer, cardiac, neurological, and renal diseases. The billing and insurance claim data of 5002 patients were extracted from the billing section of a tertiary care teaching hospital located in southern India from April 2022 through March 2023. Five per cent of patients from each disease condition were selected through proportionate random sampling for analysis ( = 250). The cost incurred and reimbursement trend under various cost heads were investigated by examining the cost incurred by the patient during the hospitalization and comparing it with the amount reimbursed by the insurance company.
The scrutiny exhibits that private health insurance fails to provide comprehensive coverage, resulting in under-insurance among subscribers. Reimbursement received for each cost category is also discussed. To the best of our knowledge, this is the first study that has used institutional data instead of large survey data or patient data.
The research concludes by soliciting policymakers, healthcare providers, and insurers to develop strategies to enhance the affordability and accessibility of healthcare to promote health and wellness.
消除经济障碍和改善医疗服务可及性是联合国可持续发展目标的关键要素。这些目标促使卫生政策制定者倡导将私人医疗保险作为一种促进健康的策略，以使患者在需要时能够获得全面且负担得起的医疗服务。在此背景下，本研究调查了私人医疗保险计划的覆盖趋势和财务风险保护性质。
我们检查了患有癌症、心脏病、神经病和肾病的私人医疗保险持有者的12个月医院账单数据。从位于印度南部的一家三级护理教学医院的账单部门提取了5002名患者的账单和保险理赔数据，时间跨度为2022年4月至2023年3月。通过按比例随机抽样从每种疾病状况的患者中选取5%进行分析（n = 250）。通过检查患者住院期间产生的费用并将其与保险公司报销的金额进行比较，研究了各种费用项目下的费用发生情况和报销趋势。
审查表明，私人医疗保险未能提供全面覆盖，导致参保人保险不足。还讨论了每个费用类别的报销情况。据我们所知，这是第一项使用机构数据而非大型调查数据或患者数据的研究。
该研究最后呼吁政策制定者、医疗服务提供者和保险公司制定策略，以提高医疗服务的可负担性和可及性，促进健康和福祉。
