Uplift Health Mutuals
SAURABH SHARMA
Uplift Health Mutuals
 Community based health fund (CBHIs, MHOs)
 Uplift Mutuals: Group of Social Sector Organisations
 Based in Maharashtra & Rajasthan
Uplift Health Mutuals: A Case Study
Purpose of Study
 Document the Uplift Model & Processes
 Review Key Performance Indicators, Sustainability, and Client value
Method of Study
 Qualitative and Quantitative




Literature review
Interviews with process managers, clients and senior management
Secondary Data Analysis
Observation of key procedures
Flow of Presentation
 Community Based Health Insurance
 Uplift: Timeline, Model & Product
 Growth & Impact
 KPIs
 Client Value
 Program Sustainability
 Cost model
 Program Costs
 Way Forward
Outreach of Community Based Insurance in India
Outreach
More Than 1 Million
2
100,001-500,000
5
10,001-100,000
15
5001-10000
5
1000-5000
10
Less than 1000
4
0
5
10
15
20
Challenges for community based risk solutions
Source: ILO, MIF
 Low community participation
 Lack of professional management
 Small size of risk pool
 Incomprehensive product
 Isolation from formal insurance mechnisms
Uplift: Timeline, Model & Product
A Decade for Uplift
2003
Uplift
Mutuals
established
2004
Registration
of Uplift
India
Association
PSW Pune
Joined
2007-08
Product
Modification
Arogyanidhi
2 Launched
2010-11
Enrollments
crossed
100,000
3 More
partners
Joined
2012-13
125,000
Members
Expansion to
Rajasthan
Partner Members
S NO
Name
Location
Year of Joining
Primary Activities
1
Swabhimaan
Pune,
2003
Microfinance & Health
2003
Supporting Development Activities
2011
Microfinance & Health
2004
Microfinance ,Enterprise Development & Family
Maharashtra
2
Inter Aide (Technical partner France
and Grant Provider)
3
Navnirman Samaj Vikas Kendra
Mumbai,
Maharashtra
4
Parvarti Swayamrojgar
Pune,
Program
Maharashtra
5
Annapurna
Parivar
Vikas Pune
Samvardhan
& 2003
Microfinance , Enterprise Development & Health
Mumbai,
Maharashtra
6
Disha Kendra
Pune,
2004
Microfinance
2003
Credit Cooperatives
2010
Microfinance, SHG & federation promotion
2012
SHG & federation promotion
Maharashtra
7
8
Annapurna
Mahila
Mandal Mumbai,
Credit Cooperative Society
Maharashtra
Chaitanya
Pune,
Maharashtra
9
PEDO supported Federations
Rajasthan
Arogyanidhi: the product
Feature
Uplift Mutuals
Compulsory/Voluntary
Compulsory for MFI credit customers
Payment Type
Reimbursement
Eligibility Criteria:
No age limit
Premium Contribution
For a family of four: Rs. 400 (approx. USD 8) per year
For individuals: Rs. 150 (approx. USD 3) per year
Period of Cover
12 months from the date of issue of policy
Sum Insured
Rs. 15,000 per person per year subject to policy
exclusions

In patient hospitalization expenses for treatment in
general ward

10 days of pre and post hospitalization cover
including expenses for one time diagnosis of the
ailment and the cost of medicines prescribed during
this period

Pre-existing diseases covered from 3rd year onwards

100% : Public Hospital

80% : Networked Private Hospitals

No reimbursement : Non Networked Private
Hospitals, except emergencies
Benefits Offered
Stipulation Pertaining to Health Care Providers
Value Added Services: Reducing Health Risk
Service
Details
Outpatient care
Beat doctor
Discounts on drugs and Diagnostics
Networked pharmacy and diagnostic centres
Free generic medicines
Health awareness sessions
Health camps & Talks
Client education
24/7 helpline
Access to Uplift’s network of HCPs
Referrals/guidance
Sessions about insurance and the HMF
program
Helpline for guidance or referrals
Uplift has established a network of more than
300 healthcare providers for better quality of
care, and to control cost. Uplift signs MoU
with these HCPs with negotiated medical
costs.
Assistance by a service executive
Health Education: Reducing Risk
Awareness Material
Awareness Sessions
How it Works
Uplift Mutuals
InterAide
Uplift As TPA
Uplift as
TPA
Managers/
Astt Managers
Negotiated Rates
Monitoring
HCPs
Networked
Health Care
Providers
Claim Processing
Arogyasakhis
Arogyasakhis
Arogyasakhi
Health seeking
Guided by Arogyasakhis
Final Claim Settlement & Disbursement at
community level
Growth & impcat
Reviewing Growth: Number of Ongoing Members
Reviewing Growth: Renewals Ratio
80%
70%
60%
50%
40%
30%
20%
10%
0%
72%
55%
51%
53%
56%
55%
58%
49%
43%
40%
37%
PSW
APVS Pune,
54%
APVS Mumbai, 54%
39%
29%
21%
7%
0
2003
0%
2004
2005
2006
2007
2008
2009
2010
2011
Uplift: Efficiency & Client Value
 24% Reduction in Out of Pocket expenditure
 Remarkable impact
 Service Ratio at 56%
 Proportion of clients using IP/OP insurance Services
 Claim rejection Ratio at 2%
 Initial high rate at 10.5%
 Key for Community Based Models
 Voluntary enrolment at 8-10%
Client Value: PACE Analysis
Source: ILO, MIF
Reducing Out Of Pocket Expenditure
120%
100%
100%
90%
80%
35%
23%
51%
27%
80%
Cost reduction due to
networked HCPs
70%
Claim amount
reimbursed
60%
60%
27%
37%
50%
40%
30%
Out of pocket
expense
65%
49%
20%
40%
Out of Pocket expense
50%
20%
36%
10%
0%
2008
0%
2008
2009
Claim amount
reimbursed
2009
Improving Client Value
 Challenges in improving client value
 Reimbursement based product
 High OP Care expenses leading to high OOP
 Challenges in providing Cash less system
 Increase in negotiated prices
 Role of community diminished
 Increased chances of Fraud
Program sustainability
Costing Model
 100% Gross Premium Collected
 60%: Claim Fund



20%: Uplift




Claims Disbursed
Solidarity Fund
TPA Services
Value Added Services
Opex
20%: Partner Organization


Value Added Services
Opex
 Subsidy Provided by Inter Aide
 Opex
 Value added services
Total Program Costs
100%
90%
80%
41%
59%
70%
60%
50%
18%
19%
40%
19%
30%
20%
41%
Claims
Value
Added
Services
Opex
TOTAL
APVS
Pune
56.5
(41%)
24.3
(18%)
57.6
(41%)
138.4
APVS
Mumbai
60.4
(42%)
26.6
(19%)
55.9
(39%)
142.9
PSW
45
(24%)
31
(17%)
107.9(5
9%)
183.9
39%
42%
24%
10%
0%
APVS
Pune
APVS
Mumbai
Psw
Total Program Costs on Per Member basis for Partner Organizations
Source: 2009
Dependency on Claim Funds
140.0%
120.0%
120.0%
100.0%
108.0%
109.0%
105.0%
99.0%
107.0%
88.6%
88.0%
80.0%
86.0%
77.0%
72.0%
70.0%
54.0%
48.0%
40.0%
71.0%
75.0%
APVS Pune
APVS Mumbai
63.0%
60.0%
95.3%
58.0%
52.0%
PSW
43.0%
40.4%
Chaitanya
39.7%
20.0%
0.0%
0.0%
2003
2004
2005
2006
0.0%
2007
2008
0.0%
2009
2010
Claim Ratios for Partner Organizations
2011
Operating Expenses
120
107.9
100
93.7
80
73.6
57.6
60
2008
2009
45.5
40
31.2
20
0
Uplift
APVS Pune
PSW
Operating Expenses on Per Member basis for Partner Organizations
Dependency on Subsidy
80%
70%
68%
68%
60%
50%
46%
Uplift
APVS Mumbai
PWS
40%
30%
32%
31%
27%
20%
23%
10%
0%
2008
2009
2010
Way Forward
 High Operating expenses for partner organizations

Tripling the current outreach

Automation of routine functions
 Enhancing Client Value

Instant Cash Loan Product (Health Expenses)

Reinsurance facility to increase cover
 Structural challenges

Attrition of Service executives

Adverse Selection

Fund management at branch level
QUESTIONS?