Question

Pick a real healthcare organization or create your own. Think about the reimbursement types that organization is basing the financial sustainability on. List the organization type (e.g., for profit, not-for-profit etc., a hospital, a minute clinic etc.). List the income streams appropriate (e.g., out of pocket, capitation, fee-for-service etc.). Discuss how we can use epidemiology to assess served population healthcare risks that will affect cost of care and financial sustainability of your organization. Give an example.

Answer 1

* To begin with the answer, let's take an example of one of the most reputed healthcare company in India " Max Healthcare"

It comes under private company category. First of all let's understand how the reimbursement works and what are the benefits covered under it.

Healthcare reimbursement typically means the payment which the concerned healthcare provider ( say doctors, hospitals, diagnostic center etc) receives upon giving you the treatment from the insurance/ healthcare company. Say for example, the company for which you work for, has insured you from max healthcare then there would be some limit of the medical bills you can claim and get the reimbursement of. This is typically called the reimbursement of the medical expense. It usually takes some time.

On the other hand if you are covered under some health insurance policy scheme, say from max healthcare itself, and you are required to get admitted to a hospital for treatment then all of your medical expense are taken care by the healthcare company itself ( say max healthcare in this case). They would give instant approval for some initial amount that you may admit the patient we would pay you the bills. If suppose the limit of the initial amount granted exceeds, then the hospital would again put a approval for more limit.

This works well if you are covered for full coverage. In some policies, you are not fully covered i.e out of the total expence, a part of the bill will be paid by the patient and rest by the healthcare company.

Now, let's understand what healthcare companies take to cover you ?

There is something called as the premium for the healthcare coverage which either is deducted from your annual ctc or if you cover yourself from outside then you need to pay on annual basis. Now, from here the healthcare companies makes profit.

If suppose, you took a policy for which you paid 20,000 INR for a year, and there was not any need arised to get hospitalised, then the premium is the profit for them as lakhs of people take the scemes and out of them few thousands require to get the claim initiated or say they need the hospital assistance. The crores of amount which is collected from the consumers by the healtcare companies are invested into various sectors of the market and a huge interest is incurred and thus high profits are earned by the company.

The company, follows capitation scheme. Since, when we reimburse medical bills, then the company rechecks them and initiates the amount to us for the medical service we availed from the doctor or diagnostic labs. In case of hospitalisation, the company provides the direct transfer to the hopsital for all the medical expense bills. Hence, capitation is followed.

Following epidemiology, we can take a great advantage of these reimbursement schemes provided to us by the company. for example, It's often said, prevention is better than cure. If we are insurred and by chance we fall ill and the medical bill is around 50 k. then the healthcare company would be taking care of it from scratch from end and if we are not insured then we have to pay from our pocket. In this era, there are n number of diseases, and one can get affected by any of them anytime So, it's better to get insurred yourself at the earliest.

Hope this helps !!