以医院为基础的社会弱势群体医疗保险计划适用模式研究

青岛市卫生局（266071） 王振合董宏伟

青岛大学医学院第二附属医院（266042）崔爽

    【摘要】医疗保险是为补偿因突发疾病带来的医疗费用的保障制度。作为解决高昂而不可预见的医疗费用的一种有效方式，其特有的主要原则是可以分担风险。建立医疗保险的主要目的是可以防止因意外健康问题造成的财产损失，缓解患者的焦虑和紧张情绪。出于为社区周围弱势群体提供医疗保健的需要，印度高等教育集团马尼堡学院（Manipal Academy of Higher Education Group）推出了被称为“马尼堡医疗卡”（Manipal Health Card）的综合性医疗津贴项目。

    本文试图对“马尼堡医疗卡”的显著特征和适用模式进行研究。

    通过查阅和分析所有五家参与医院的财务和医疗数据，可以得出“马尼堡医疗卡”持有者使用医院医疗服务和设施的情况。研究数据表明，“马尼堡医疗卡”确实有助于增加弱势群体享受医疗保健的机会。分析显示，由于得到组织者的资助且资助额度接近45%，让项目参与者得到了实惠，使得该项目很受他们的欢迎。据观察，以老年男性和急需就医人群使用“医疗卡”最频繁。很明显，当前仍然需要唤起社区对医疗和医疗保险的关注，并通过提供质优价廉的服务吸引更多的人参与到该项目当中来。

作为项目的发起者，高等教育集团马尼堡学院的最终目的是使“健康就是财富”的理念深入到印度的社区中。

【主题词】以医院为基础的医疗保险计划 适用模式

 

【背景介绍】身体健康的人可能想不到疾病给人带来的痛苦，当突然生病并陷入医疗债务危机的时候，才想起要为健康保险，为时已晚。

为防止疾病风险影响财政，几个欧洲国家在18世纪末为产业工人建立了医疗保险制度，以后又实行了对工伤、养老和残疾的保险制度等（例如1893-1889年的德国）。在发展中国家，社会保险仅局限于一小部分人，主要是政府雇员、军队人员和大公司的雇员，且养老金和医疗保险金还需要从个人收入中扣除。

在印度，大量的农村和城乡结合部人口被排除在疾病和事故的保护之外。他们主要通过以家庭或家族为基础的稳固组织支付医疗费用。如果有人需要金钱资助，家庭或家族成员就共同帮助，一起分享有限的资源。私有或商业医疗保险机构将这两部分人排除在外的原因是他们不具备金融偿还能力。不管是政府还是自由的市场体制都不能保证社会弱势群体享受到适当的紧急医疗风险保护。

弱势群体不受保护的原因不仅是由于私营保险公司缺乏商业利益的驱使，而且在于他们缺乏与保险公司谈判的能力。这些群体中的个人资金不足、社会地位低下，无法要求商业保险公司提供必要服务满足他们的要求。然而，较低的需求并不意味着无力支付。相反，关键是提供的服务是否适合，条件是否有利于保险费用筹集（比如：他们如何、何时进行支付）。

这就意味着，对于这样一个彼此熟悉易于管理的群体，可以依据当地居民的收入水平，采取用现金或实物的方式进行投保。如果群体中的某个人生病，保险协会（比如：群体全部成员）就可以部分或全部报销其特殊的治疗或药品费用。这足以改善贫困家庭的医疗条件，防止高额医疗费用带来的冲击，降低因病致贫或贫困恶化的风险。因此，建立微观医疗保险组织对解决当地的因病致贫问题，也是很有帮助的。

当政府举办的社会保险受到组织、制度或财政条件的限制，不能全面实施的时候，世界卫生组织就把所谓的“资金预付项目”作为一种有效方式，使发展中国家贫困人口能够享受到医疗保健服务。

然而，不管那些迄今仍未享受到医疗保险待遇的人们是否真想联合起来成立一个当地的医疗保险组织，在他们当中就出现了一些不同的看法。他们可能会发现，生病时靠个人或家庭积蓄资金可能更加经济，而不是投资形成共同基金，那样他们只能在未来很长一段时间才会受益，而且要为别人的治疗出钱。但是从长远的角度和非功利模式进行考虑分析，印度大约有70%的人口在农村居住，95%的劳动力在非正规部门工作，这些人口很大一部分都生活在贫困线以下，因此，急需为这部分人口建立社会保障机制。

医疗保险是可以补偿或有卫生保健费用的保障制度，能够支付部分或全部费用。作为解决高昂而不可预见的医疗费用的一种有效方式，其主要原则是可以分担风险。建立医疗保险的主要目的是可以防止因意外健康问题造成的财产损失，缓解患者的焦虑和紧张情绪。因此，称医疗保险为“卫生保健保险”也很合适。目前，只有约占印度人口0.25%的200-300万中产阶级可以享受到某种形式的医疗保险，因为他们有能力支付每年至少500至1000卢比的保险金额。如果我们要达到既定的健康目标，可以扩大保险覆盖范围向贫困人群和农村人口提供服务，这样就能从总体上有利于社会，特别是有利于弱势群体。一个由卫生保健提供者或医院、救助组织或医疗保险提供者等三方组成的充满活力的制度在印度已经开始运转。除此之外，医疗保险将对私营机构开放，并将制订《印度保险许可规章》(Insurance Regulatory Authority of India)。

在印度，医疗保险主要由追求利润的卫生维护组织（HMO）举办，他们主要通过为富人或社会精英提供各种专门的健康查体项目，以达到他们赚取利润的唯一目的。由于穷人过于贫困，没有正式工作不能定期交纳费用，无法轻易满足他们获取利润的目的，因此最有可能被排除在医疗保险之外。出于为社区周围弱势群体提供医疗保健的主要目的，高等教育集团马尼堡学院推出了被称为“马尼堡医疗卡”的综合性医疗津贴项目。

【研究目的】

1、研究马尼堡医疗卡的特点。

2、研究马尼堡医疗卡的适用模式。

【研究方法】

1、采取追溯的方法，对2002年7月15日至8月15日“马尼堡医疗卡”使用期间涉及的方案和行为进行了梳理。

2、从数据库中提取医疗卡持有人的详细简历，并进行了分析。

3、通过查阅所有五家参与医院的财务和医疗数据，得出了医疗卡项目会员使用医院医疗服务与设施的情况，并进行了分析。

4、组织马尼堡医疗卡项目管理人员和有关医院工作人员进行了分析讨论。

【适用范围】

    马尼堡集团发起的这个无与伦比的医疗保险计划，主要针对住在印度卡纳塔卡（Karnataka）和卡拉拉（Kerala）沿海地带的居民和临近达什.卡纳达（Dakshin Kannada）、卡萨高（Kasargod）和乌杜匹（Udupi）地区的居民，其主要目的是向社会中的贫困阶层提供医疗保健服务。医疗保险卡对卡的持有者确实有帮助，可以向其提供所属教学医院医疗服务与设施的使用情况。这包括3家三级医院、2家两级医院和9家基本医疗中心，共计约2500张床位。这些医院同样提供像心脏病、心胸外科、泌尿、肾脏、儿外科、胃肠病、整形手术、神经学和神经外科等所有专科和特色专科服务。有一个专业肿瘤研究中心，配备了肿瘤放射设备，也可以提供肿瘤内外科、放射线治疗和核医疗等服务。此外，还可以提供其他诊疗服务，如X光断层扫描、核磁共振、透析、多学科重症监护、结核病洁净隔离、计量药物实验室、血库和24小时药房等，和一支敬业守纪的可以随时处理任何紧急事件的专家队伍。

【项目宣传】

采取如下方法使该项目深入到社区：进行大规模广告宣传以引起上述地区居民的关注。召开新闻发布会并通过印刷媒体与群众沟通。通过Udayavani、Matrubhoomi、 Malayala Manorama和Madhyamam等主流报纸进行广告宣传。以广播电台和电视台，横幅和传单为辅助手段进行宣传。从社区中选拔包括专职雇员在内的项目代理人，以便在社区居民中引起良好反响并使其参加健康保险项目。

【项目特征】

该项目的显著特征是：

1、普通床位费、会诊费、外科医生费用、挂号费、麻醉费、手术费、专家费、分级会诊费、服务费全部免收。

2、包括放射、X光断层扫描、核磁共振、X光摄片等在内的实验室检测费用以及护工费、查房费、重症监护费、急诊费、外伤诊治费、透析费、空调使用费、监护仪使用费、雾化器使用费和牙齿诊疗费用按照70%收取。

3、覆盖住院病人和门诊病人。

4、覆盖参加项目前发生的全部疾病。

5、没有使用周期限制。

6、没有年龄限制。

7、全额产期津贴。

8、全天候诊疗服务。

9、另计价项目仅收取耗材费、药费和植入管费。

10、医保卡拥有者可到上述参加“马尼堡医疗卡”服务协议中的任何一家医院看病。

【医疗卡发行】

“马尼堡医疗卡”项目从2000年11月起投放市场接受申请，到2001年2月8日截止。医疗卡从登记注册之日起一年内有效。

【医疗卡注册】

所有住在印度卡纳塔卡（Karnataka）和卡拉拉（Kerala）沿海地带的居民和附近达什.卡纳达（Dakshin Kannada）、卡萨高（Kasargod）和乌杜匹（Udupi）等地区的居民都可以进行登记注册。登记注册需要提交象定量供应卡、驾驶证和护照等证明身份的资料，在该地区不同地方共设立了100个接收中心负责资料的收取。医疗卡从项目截止之月起发放给会员，一年内有效。

【保险费缴纳】

考虑到项目的意图和针对的群体，“马尼堡医疗卡”需要缴纳的年度保险费很低。个人会员每年140卢比；4口之家的家庭会员（孩子18岁以下）每年300卢比。

【注册会员数】

登记注册为“马尼堡医疗卡”项目的会员数如下：

1、个人会员卡8639个；

2、家庭会员卡4952个；

3、项目覆盖的人口总数23495个。

参加项目的会员数与预先估计的10万会员人数相比较低。

医保卡会员的年龄情况如下所示：

表1：会员年龄分布情况

年龄组（岁）	占会员总数的百分比（%）
1-20岁	8.8
21-38.5岁	38.5
41-60 岁	31.5
>60岁	20.8

上表显示出20岁以下年龄组登记为会员的比率很低，而老龄人群的登记入会的比率很高。

医保卡会员的家庭收入分析如下所示：

表2：会员家庭收入分类情况

年度收入(卢比)	占会员总数的百分比（%）
25,000 卢比以下	72.6
25,000 - 100,000 卢比	22.3
100,000 - 300,000 卢比	4.9
300,000卢比以上	0.2

    上表显示出72.6% 的会员年度收入低于25000卢比。这与医疗保险提供者为社区经济弱势群体服务的目的是一致的。

    医保卡会员的性别情况如下所示：

    表3: 会员性别分布情况

性别	占会员总数的百分比（%）
男	62.3
女	37.7

    尽管该地区的男女比例是女性高于男性，但女性会员的比例与男性相比非常低。

    【门诊情况】

    在23495个会员中，有18102个会员在项目参与医院使用了门诊服务，这意味着每人每年看了0.8次门诊。这在印度几乎是预期每人每年看0.3次门诊的3倍。

    【住院情况】

    在23495个会员中，有2174个会员因各种疾病在项目参与医院住院，这意味着每人每年住了0.09次院。这在印度几乎是预期每人每年住0.015次住院的6倍。

    上述数据显示出“马尼堡医疗卡”确实有助于社区居民享受医疗保健服务。

    研究显示：在医疗卡有效期前三个月内提供的服务约占整个医疗卡有效期内提供服务的40%，这意味着那些急需内外科治疗的人申请使用了医疗卡。

    “马尼堡医疗卡”项目发起人用在每位会员医疗和项目宣传上的平均费用是200卢比，而收取每位会员的平均保险费用是114卢比。

    数据显示，由于得到组织者接近45%的资助，使得该项目很受会员的欢迎。除此之外，由医疗卡引起的反响较小说明：如果要招募更多会员使用医疗卡提供的服务，就要做大量工作吸引社区居民的注意力。因为社区居民想得到更多的实惠，而要资助更多的资金对项目组织者来讲是不现实的。

    【研究结论】

为向社区周围的弱势群体提供健康保健服务,使他们能够用到该地区最好的医疗设施,马尼堡医疗集团以较低的保险金额推出了医疗保险卡,个人会员每年仅交140卢比,家庭会员仅交300卢比即可. 研究表明，医疗卡会员年龄百分比分布中老年群体高于青年群体，这意味着需要提供更为优惠的政策以打开青年群体的市场。研究表明，该项目符合为社会弱势群体提供医疗保险的目的，因为大约73%的会员处在年收入少于25000卢比的低收入阶层。通过研究会员的性别分布情况，可以发现对女性有明显的偏见，而且社会并未意识到关心女性家庭成员身体健康的重要性。数据表明，该项目门诊量和住院情况是全国平均水平的3-6倍。

根据以上分析，我们可以计划和改进未来的工作方法：

1、唤起社区居民关心自身健康的意识。因为，在人们没有任何健康问题的时候，健康消费在人们的意识中处于末位。这种意识将导致健康消费的延迟，不到万不得已不会花费。

2、要尽量改变人们对医疗保险的固定思维模式，加强与社区居民的互动，向他们解释健康保险的优点和不足，用健康保险花很少的资金就可为家庭成员提供专门健康保障的优点说服他们。

3、项目发起者的根本目的是要在社区居民中实现观念的根本转变，树立“健康就是财富”的意识。

4、加强与政府的联系，争取政府对医疗机构高价设备和其他需购物品的资助，促使私营医疗机构向社会提供更加高效、实用和经济的服务。

 

 

 

 

 

JOURNAL OF

THE ACADEMY OF HOSPITAL ADMINISTRATION

Vol. 16, No.1, January - June 2004

JAHA VOL 16, No.1, 5-9
Study of the utilisation pattern of hospital based health insurance plan targeted towards lower socio-economic group

VP Bhaskaran, Satyashankar P, Rajendra P Patankar

Abstract :

Health Insurance is a system of assurance to meet the contingencies of health care expenses. The main principle underlying it is ﾁesharing riskﾁf as an advantageous way of meeting high and unpredictable costs. Its primary objective is to protect against financial losses caused by unforeseen health problems and at the same time relieving anxiety and mental tension. With the prime motive of providing healthcare to the weaker and poorer sections of the surrounding community, the Manipal Academy of Higher Education Group had come up with a comprehensive health benefit scheme, called the Manipal Health Card (MHC).

The purpose of this study was to study the salient features of the Manipal Health Card and to study its utilization pattern

Utilisation of the facilities by the MHC members was done by going through the financial and medical record data of all the five participated hospitals and the same was analysed. The statistics deduced from the study show that the MHC has helped in substantially improving the access for health care to the community. The figures also show that the scheme was highly customer friendly and was subsidized by the organizers to the extent of nearly customer friendly and was subsidized by the organizers to the extent of nearly 45%. The analysis showed how beneficial it was for those who had opted to enroll themselves for this health insurance scheme. It was observed that old aged predominantly males and those in immediate need of treatment were utilizing the services most effectively. Also from the study it was clear, how there is still a need to create awareness among the community about ﾁeHealthﾁf and ﾁeHealth Insuranceﾁf and the need for the healthcare provider group to attract more & more interested and convinced people in order to provide the best of their services at the most economic costs.

The ultimate aim for us as a healthcare provider would be to bring in this turn-around of the perception in our community as justified by the saying ﾁgHealth Is Wealthﾁh.

Keywords : Hospital based health insurance, utilization pattern

VP Bhaskaran
Professor and HOD of Hospital Adminstration, Medical Superintendent, Kasturba Medical College Hospital, Manipal- 576 104, Karnataka, India
Ph.: 91-820-2570201, Extn: 22587, Fax: 91-820-2571934
E-mail: [email protected]

Satyashankar P
Associate Professor, Dept. of Hospital Admn. & Asstt. Medical Superintendent, Kasturba Medical College Hospital, Manipal- 576 104, Karnataka, India
Ph.: 91-820-2570201, Extn: 22587, Fax: 91-820-2571934
E-mail: [email protected]

Rajendra P Patankar
Asstt. Manager-Medical Operations, Kasturba Medical College Hospital, Manipal- 576 104, Karnataka, India
Ph.: 091-9845384319
E-mail:[email protected]

Introduction

A person in good health may not remember sickness and its implications, but when he falls sick and simultaneously into the debts of treatment, he regrets why he had not insured his health.

In order to provide protection against the financial effects of health risks, a few European countries at the end of the 19th century introduced health insurance systems for workers ﾖ later followed by accident, old age, and disability insurance provisions (e.g. in Germany between 1883 and 1889). In the developing countries, social insurance is still confined to a minority of the population, e.g. through contributions to pension and health insurance funds that are directly deducted from the pay. This minority mainly consists of state employees, members of the armed forces, and employees of large companies.

It is primarily the rural population and the population in the informal urban sector who are excluded from protection against disease the accidents. They try to pay for health treatment mainly through solidarity structures based on family or ethnic allegiances. The members of these family or ethnic groups help each other mutually and pool resources when one of their members is in (financial) need.1 Private, commercial health insurance organizations exclude these two segments of the population from their services, as they are not regarded as being financially ﾓsolventﾔ. Neither the state nor the free market ensures adequate protection against critical health risks for the socially excluded population²

The population groups excluded are unprotected not only due to a lack of interest on the part of private insurance companies, but also because of their poor negotiating power. Individuals in such groups lack the money and status to be able to ask for an offer from commercial insurance companies tailored to their needs2. However, low demand is not necessarily equivalent to an inability to pay. Instead, what matters is the appropriateness of the services offered to these population groups and the conditions, which apply for the payment of premiums (i.e. how and when they are to be paid).

At the local level, this means that a manageable group of people, most of whom know one another, pay a contribution in cash or in kind to the insurance scheme, from which specific treatment costs and/or drug costs can be fully or partially borne by the insurance association (i.e. by all the members) if one of the members falls ill. This can sustainably improve the health situation for poor households and prevent them from the shock of very high treatment costs that would otherwise reduce them to poverty or even deepen it. In this way, setting up micro-health insurance organizations also helps to fight poverty at the local level.

The World Health Organization (WHO) regards so-called ﾓpre-payment schemesﾔ as a way of enabling poor people in developing countries to obtain access to health care services when state-organized social insurance has not (yet) been universally introduced due to inadequate organizational, institutional, and financial conditions³

However, the question arises as to whether the population hitherto excluded actually wants to join together to form a local health insurance organization. They may find that it makes more sense economically to save money as individuals or as families in case of illness, instead of paying into a common fund from which they may only benefit a long time in the future, while in the meantime paying for other peopleﾒs treatment. By not focusing on such a short sighted view and by adopting a utilitarian mode of thinking it may be analyzed that, with 70 per cent of population in Indian living in rural areas and 95 per cent of work-force working in unorganized sectors, and disproportionately large percentage of these populations living below poverty line, there is strong need to develop social security mechanisms for this segment of population⁴.

Health Insurance is a system of assurance to meet the contingencies of health care expenses. It is a way of paying some or all the costs of healthcare. The main principle of insurance is sharing risk as an advantageous way of meeting high and unpredictable costs. The primary objective of health insurance is to protect against financial losses caused by unforeseen health problems and at the same time relieving anxiety and mental tension. Hence it can be appropriately called as Health care insurance. Currently in Indian only 0.25 percent of population is covered under some form of health insurance, with about 200-300 million population of middle class who can be brought into this ambit⁵, given their capacity to spend at least Rs. 500-1000 per year as insurance premium. Also if we intend to achieve our target health goal, by expanding our services to the poor and rural population we can benefit the society in general and the weaker sections in particular. A dynamic tripartite system comprising of healthcare providers or hospitals, managed care organizations or health insurance providers have already set the momentum in our country. Added to this, is the opening up of the health insurance to the private sector and the setting of IRDA (Insurance Regulatory Authority of India).

In India Health Insurance is started mostly by the for-profit HMOﾒs, their only aim being to make business out of it, mainly by catering to the richer or elite class of our society with all kinds of special to executive health check-ups. The poor are the ones most likely to be excluded from insurance because they are too poor to pay, do not have regular employment for meeting regular payments, and may not be easily accessed for purposes of collecting payments. With the prime motive of providing healthcare to the weaker and poorer sections of the surrounding community, the Manipal Academy of Higher Education Group had come up with a comprehensive health benefit scheme, called the Manipal Health Card (MHC).

Aims and Objectives

• To study the salient features of the Manipal Health Card.
• To study the utilization pattern of the Manipal Health Card.

Methodology

Type of Study

1. A retrospective study was conducted during 15th July 2002 15th Aug 2002, to understand the scheme and the activities involved during the implementation of the Manipal Health Card.
2. Cardholdersﾒ detailed profile was obtained from the database and the analysis of the same was done.
3. Utilization of the facilities by the MHC members by going through the financial and medical record data of all the five participated hospitals and the same was analysed.
4. Discussions were held with the Manager- Operations of MHC, the staff involved at all the constituent hospitals and analysis was done.

Observation

Applicability

With the prime objective of providing healthcare to the poorer sections of the society the Manipal group launched this unique health insurance plan mainly directed to the people living in the coastal belts of Karnataka and Kerala and primarily in the areas adjoining the districts of Dakshin Kannada, Kasargod, and Udupi. This health insurance card made available, to the cardholders, provided state of the art treatment facilities at any of its teaching hospitals. These included three tertiary care, two secondary care hospitals and 9 peripheral primary health centres with total bed strength of nearly 2,500 beds. These hospitals also provided services in all the specialized as well as supper specialized disciplines like cardiology, cardiac- thoracic surgery, urology, nephrology, paediatric surgery, gastro-enterology, plastic surgery, neurology and neuro-surgery. A specialized cancer research centre with facilities in radiation oncology, surgical and medical oncology, radiotherapy, nuclear medicine were also provided. Other services included Diagnostic services like CT scan MRI, Dialysis-unit, Multidisciplinary ICUﾒs, Ultra clean OTﾒs with HEPA systems, Digital Cath Lab, Blood Bank and 24 hours pharmacy services. A disciplined team of dedicated and expert staff was available to take care of any and every emergency.

Promotion of the scheme

Approaches adopted for reaching out to the community
In order to reach out to the community a massive advertisement campaign was launched to create awareness among the people living in these areas. Press Conferences were organized to communicate to the masses through the print media. Advertising was done through leading newspapers like Udayavani, Matrubhoomi, Malayala Manorama and Madhyamam. Radio and T.V. broadcasts, banners and handouts were others means utilized to reach the community. In order to get a good response ﾑAgentsﾒ including MHCﾒs permanent staff were appointed from among the community to enroll people for this health insurance scheme.

Features

The highlighting features of this scheme were

1. 100% cover/discount on Bed charges (General Category), Consultation Charges, Surgeons fee, Admission Charges, Anaesthesia Fees, Operation Charges, Professional Charges, Sub Consultation Charges, and services charges.
2. 30% cover/discount on lab investigation including radiology, CT scan/MRI/X-Ray, attendant charges, observation charges, ICU charges, Casualty charges, Trauma charges, Dialysis charges, Ventilator utilization, Monitor utilization, Nebulizers utilization, Dental treatment.
3. Coverage for both In-Patients & Out-patients
4. All pre-existing diseases were covered
5. No lock in period.
6. No age restriction.
7. Full Maternity Benefits.
8. Round the clock treatment facility at all the constituent hospitals.
9. Only extra charges payable were those on consumables, drugs and implants.
10. Cardholders could access any of the hospitals mentioned above.

Launch of the MHC

The Manipal Health card scheme was launched in December 2000 and applications were invited till 8th February 2001. the card was valid for a period of one year from the date of enrollment.

Enrolment of MHC

Enrolment was open for all people residing in the coastal belts of Karnataka and Kerala and in the adjoining areas, including but not limited to the districts of Dakshin Kannada, Kasargod, and Udupi. Enrollment required any document for identification like ration card, driving license, passport etc. to be submitted at any of the 100 listed collection centres identified in various areas of this region. The cards were issued to the members on month from closing of the scheme and were valid for one year from their date of registration.

Premium

The annual premium for the Manipal health card was kept very low taking into consideration the purpose and the customers to whom it was to be targeted. The premium was:
Rs. 140/- For Individual Card Members.
Rs. 300/- For Family Card Holders with family of four (Children being under 18).

Subscription

The subscription of the MHC was as follows-

• Individual card - 8639
• Family card - 4952
• Total Individuals covered under the scheme - 23495

The subscription was comparatively low when compared to the estimated expected subscription of 1 Lakh population.

Age wise subscription of the MHC is as shown below:

Table 1: Showing the age distribution of subscriptions for MHC

Age Group (years)	%
1 - 20	8.8
21 - 38.5	38.5
41 - 60	31.5
>60	20.8

The above table shows that among the population below 20 years, the rate of subscription was very low whereas, among geriatric age group the subscription rate was very high.

Family income of the Health Card population were analysed as given below-

Table 2: Showing the classification of the Health Card subscribers based on their family income.

Annual Income (rps)	%
Below rps 25,000	72.6
25,000 - 100,000	22.3
100,000 - 300,000	4.9
Above rps 300,000	0.2

The above table shows that 72.6% of the subscribers had annual income less than Rs. 25000/-. This conforms to the objective of the health insurance provider to serve the economically weaker sections of the community.

Sex wise distribution of MHC subscribers were analysed as shown below.

Table 3: showing the sex wide distribution of MHC subscsribers.

Sex	%
Male	62.3
Female	37.7

Though the male : female ratio in this region is in favor of female population, percentage of female subscribers was very less

Out-patient Service Utilization

Among the 23495 subscribers, 18102 members availed the Outpatient services from the participating hospitals, thus implying that there were 0.8 Outpatient visits per year per person. This is a almost three times more than the estimated 0.3 visits per year per person in India³.

In-patient Service Utilization

Among the 23495 subscribers, 2174 members got admitted in the participating hospitals for various ailments, thus implying that there were 0.09 admissions per year per person. This is about six times the estimated 0.015 admissions per year per person in India³.

The above statistics shows that the MHC has helped in substantially improving the access to health care for the community.

The study showed that the concession given during the first three months of the validity was approximately 40% of the total concession given for the whole period of the card, thus indicating that those who were in need of immediate medical or surgical treatment subscribed for the card.

The average amount spent by the sponsors of the MHC per subscriber in terms of Hospital service as well as on promotion of the scheme was Rs. 200 and the average amount received per subscriber in terms of premium was Rs. 114/-.

These figures show that the scheme was highly customer friendly and was subsidized by the organizers to the extent of nearly 45%. In spite of this, the low response for the card, shows that a lot needs to the done to create awareness among the community as subsidizing the cost further would not be feasible for the provider as well as the benefits realized by the community will be more if they utilize these services by enrolling in larger numbers.

Conclusions

A health insurance card was introduced by the Manipal Healthcare group at very low premium of Rs. 140/- for individual and Rs. 300/- for family with the prime motive of providing healthcare to the weaker and poorer sections of the surrounding community and at the same time making available to them the best treatment facilities in this part of the country. The study showed that the percentage age distribution of the subscribers of the card was favoring the middle to old age group as compared to the younger age group, thus implying fort the need to market the benefits of the card to this group in particular. The study conforms to the objective of providing health insurance to the economically weaker sections of the society as approximately 73% of the subscribers were under the low-income bracket of less than Rs. 25000/- per annum. As far as sex distribution among the subscribers was concerned it was found that there was a clear bias against the female sex and that our society has still not realized the importance of caring for the health of the female member of the family. The statistics for our outpatient and inpatient utilization showed that there was a three to six times more utilization than the average figures for our country. This makes us to analyze and plan our methods for future by:

1. Creating of Awareness among the community about he need to care for their health. This is because spending on ﾑHEALHﾒ is last on the peopleﾒs minds, especially when they are free of any health problem. This leads to expenditure on health to be deferred till such time that it becomes an absolute necessity.
2. To try to change the mind set of the people regarding Health Insurance. Interacting with the community and explaining to them the pros and cons of having their health insured and convincing them of the advantages of having a minimum budget earmarked for their familyﾒs health.
3. The ultimate aim for us as healthcare providers would be to bring in this turn-around in the perception of our community as goes with the saying-ﾓHealth is Wealthﾔ
4. Liaising with the government to get subsidies on certain high cost equipments and such other purchases to enable the private healthcare providers to deliver more efficient, effective & economic services to our society.

References

1. Cf. Hans Gsanger, Soziale Sicherungssysteme fur arme Bevolkerungsgruppen (Berlin: Deutsches Institut fur Entwicklungspolitik, 1993), pp. 36-48.
2. B. Cf. David D. Dror and Christian Jacquier, Micro-Insurance: Extending Health Insurance to the Excluded (Geneva: Social Security Department, ILO Planning, Development and Standard Branch), pp. 2-3.
3. C. Cf. World Health Organization, World Health Report 2000-Health System: Improving Performance (Geneva: WHO, 2000), p.98.
4. Health Insurance in India, Report of the one day workshop organized on 30th Oct. 1999 at IIM, Ahemdabad.
5. Express Healthcare Management Publication. Issue August 1-15th 2001. Page no-14.
6. Catherine P Conn, Veronica Walford. An Introduction to Health Insurance for Low Income Countries. The health Systems resource Centre, Health Sector Development U.K., 1998