MR Microinsurance_2012_03_29.indd - International Labour ...

Th ird-party payment mechanisms in health microinsurance
Box 6.1 Understanding the vocabulary: “cashless” and TPP mechanism
Synonyms or related expressions used in the HMI sector to refer to a TPP
mechanism include cashless HMI schemes, cashless claims arrangements, cashless
systems and cashless benefi ts.
Th e term “cashless” refl ects the perspective of an insured client, and not that
of the HMI scheme or the healthcare provider. Cashless arrangements are made
by HMI schemes to enable the insured to access healthcare services with no (or
relatively rela relatively tively little) out-of-pocket costs. Th e term cashless can apply regardless of
whether the insured patient’s access is truly cashless or whether it involves some
cost- sharing, e.g. co-payment or deductible.
Source: Authors.
Table 6.1 Summary of case study information
Africa Asia Latin America
Name of
scheme 3
Microcare 1 UMSGF 2 Yeshasvini CBHI GRET- FMiA
SKY
3 Sol salud (Zurich
Bolivia and BancoSol)
Country Uganda Guinea India Lao PDR Cambodia Pakistan Bolivia
Type of HMI Commercial CommuCommuCommuCommu- Insurer + distri- Insurer + distri-
scheme insurer nity-basednity-basednity-basednity-basedbution partner bution partner
No. covered
(end 2008)
29 000 16 120 3 060 000 65 000 39 000 19 000 13 000
Provider payment
method4 Africa Asia Latin America
Name of
scheme
Fee for serv- Case-based Case-based Capitation Capitation Fee for service Capitation payice
with fi xed payment payment
and case- with fi xed fee ment/fee for
fee schedule and drugs
basedpay- schedule service and casementbased
payment
Funds transfer Electronic Cash Cheques Electronic Cash Cheques n.a.
method transfer or
cheques
transfer
Health HospitalizaHospitali- Surgery HospitaliHospitali- Hospitali zation Hospitalization
services tion and zation and
zation and zation and and voucher and primary care
covered primary care primary
primary primary for one consul- (drugs excluded)
care
care care tation
Number of 150 53 295 24 63 4 hospitals and n.a.
providers
25 fi rst line
contracted
health facilities
Member cost- Claims in Small Claims in None None Claims in Co-payment and
sharing excess of deductible excess of
excess of claims in excess of
benefi ts
benefi ts
benefi ts benefi ts
Claims No No Yes (Family No No No Yes (PROVID)
administration
Health Plan
outsourced?
Limited)
3
Microcare 1 UMSGF 2 Yeshasvini CBHI GRET- FMiA
SKY
3 Sol salud (Zurich
Bolivia and BancoSol)
Country Uganda Guinea India Lao PDR Cambodia Pakistan Bolivia
Type of HMI Commercial Commu- Commu- Commu- Commu- Commu- Commu- Commu- Commu- Insurer + distri- distri- Insurer + distri- distri-
scheme insurer nity-based nity-based nity-based nity-based bution partner bution partner
No. covered
(end 2008)
29 000 16 120 3 060 000 65 000 39 000 19 000 13 000
Provider pay- pay-
ment method method4 Fee for serv- serv- Case-based Case-based Capitation Capitation Fee for service Capitation pay- pay-
ice with fi xed payment payment
andcase- with fi xed fee ment/fee for
fee schedule and drugs
basedpay- schedule service and case-
ment
based payment
Funds transfer Electronic Cash Cheques Electronic Cash Cheques n.a.
method transfer or
cheques
transfer
Health Hospitaliza- Hospitaliza- Hospitali- Hospitali- Surgery Hospitali- Hospitali- Hospitali- Hospitali- Hospitali zation Hospitalization
services tion and zation and
zation and zation and and voucher and primary care
covered primary care primary
primary primary for one consul- (drugs excluded)
care
care care tation
Number of 150 53 295 24 63 4 hospitals and n.a.
providers
25 fi rst line
contracted
health facilities
Member cost- cost- Claims in Small Claims in None None Claims in Co-payment and
sharing excess of deductible excess of
excess of claims in excess of
benefi ts
benefi ts
benefi ts benefi ts
Claims No No Yes (Family No No No Yes (PROVID)
administration
Health Plan
outsourced?
Limited)
1 Th e acronyms stand for the following organizations: Union des Mutuelles de Santé de Guinée
Forestière (UMSGF), community-based health insurance (CBHI), Groupe d’échange et de recherche
technologique (GRET), and First Microinsurance Agency (FMiA). SKY is a Khmer acronym for
“Sokhapheap Krousar Yeung”, which means “Health for Our Families”.
2 Microcare ceased operations in late 2009 due to a mixture of political and regulatory reasons.
Nevertheless, the lessons from this scheme are relevant for this chapter.
3 FMiA ceased operations in 2011, having failed to achieve fi nancial sustainability or to attract new
funding. Th is does not aff ect the value of the lessons they learned.
4 Th ese payment methods are defi ned in section 6.2.2.
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