MR Microinsurance_2012_03_29.indd - International Labour ...

116 Health insurance
expand member benefits in HMI. This can increase the ability of low-income
individuals to access medically necessary care at the appropriate time, thus reducing
financial catastrophe and promoting economic productivity and efficient use
of resources.
5.2 Demand and supply challenges for health microinsurance
5.2.1 Complexity of health microinsurance
The very nature of HMI differentiates it from other forms of insurance. Health
microinsurance is about service delivery rather than paying to compensate for a
loss. This fact makes it extremely difficult to control demand and ensure that the
services delivered are appropriate. The situation is complicated by the fact that
healthcare services covered by insurance are delivered by a third party, the healthcare
provider, whose motivation may be to maximize revenue. This creates
another distortion, encouraging fraud and irrational pricing.
HMI is further complicated by the intense demand for services thought to be
required for good health. Standards of care continuously evolve and are influenced
by factors such as technology and infrastructure, greater awareness and
improved partnerships. As a result, the frequency and number of types of service
is increasing (such as diagnostic radiology once equipment and providers are
accessible). At the same time, the cost of service is also increasing (e.g. CT scans
replacing x-rays), compounding the challenge to deliver appropriate and affordable
care. Low-income households suffer disproportionately from infectious disease
and the consequences of poor living conditions, and they are also increasingly
subject to chronic lifestyle-related diseases such as diabetes and heart
disease that are traditionally more common in higher-income populations.
Amidst such challenges, HMI programmes differ on many fronts: they differ
in programme design, including the degree of integration with healthcare providers,
distribution and servicing approaches in relation to cover or benefits. This
complexity exists for a reason; different programme configurations address different
needs in the operating environment. Communities vary in relative wealth,
health and exposure to health risks, as well as proximity to healthcare providers,
pharmacies and laboratories. For example, some programmes attempt comprehensive
cover (in-patient and outpatient), while some offer catastrophic (hospitalization)
cover only. Further variance relates to whether a product covers preexisting
conditions, maternity, preventive or chronic care, as well as the
maximum benefit amount and the degree to which members are required to
share in costs.