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|Year : 2019
: 61 | Issue : 10 | Page
|Health insurance and mental illness
A Sangoi Bijal1, C Naveen Kumar1, N Manjunatha1, Mahesh Gowda2, Vinay Basavaraju1, Suresh Bada Math1
1 Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
2 Department of Psychiatry, Spandana Healthcare, Bengaluru, Karnataka, India
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|Date of Web Publication||8-Apr-2019|
| Abstract|| |
One of the important provisions of the Mental Healthcare Act, 2017, in section 21 (4), is the inclusion of “mental illnesses” for health insurance coverage. This is a progressive step toward considering mental illness at par with physical illness, which will, in turn, ensure better access to mental health care. In this context, the article summarizes the concept of “health insurance” and then goes on to talk about various provisions for persons with mental illnesses in India. We also discuss some of the relevant concerns that may arise in this context. Whereas insurance for mental illness is a welcome step toward achieving universal health coverage, there is a need to deliberate on various issues before we can achieve that.
Keywords: Health insurance, insurance, mental illness
|How to cite this article:|
Bijal A S, Kumar C N, Manjunatha N, Gowda M, Basavaraju V, Math SB. Health insurance and mental illness. Indian J Psychiatry 2019;61, Suppl S4:791-7
| Introduction|| |
One of the important provisions of the new legislation in mental health, the Mental Healthcare Act (MHCA), 2017, in section 21 (4), is the inclusion of “mental illnesses” for health insurance coverage. This is a landmark moment that has come at an opportune time in which India is looking at achieving universal health coverage for all her citizens. In this context, the article summarizes the concept of “health insurance” and then goes on to talk about various provisions for persons with mental illnesses (PMI) in India. It finally discusses the various questions that can arise during the implementation of insurance for mental disorders.
| Health Insurance|| |
Health insurance can be defined as insurance for future medical or surgical expenditure. In simple terms, it is a contract where an individual or group of people purchase, in advance, health coverage by paying a fee called the “premium.” Based on the type of insurance plan, usually, the insured person is either required to pay for the health expenses from his/her pocket, which is then reimbursed by the insurance company, or the expenses are directly borne by the insurance provider who pays it to the service provider (the so-called cashless facility). The service provider in this context refers to the clinic, hospital, physician, laboratory, or any other establishment where the health care was provided to the insured and to whom the insured is expected to pay for the same. At present, in India, health insurance is available only for hospitalization or inpatient care. Outpatient services, which form the major part of health-care expenditure, are not covered. Broadly, health insurance can be divided into two types: private health insurance and public health insurance (government funded). This article critically evaluates the provision of health insurance in mental illness.
Private health insurance
Various private companies offer health insurance policies (for example, HDFC ERGO Health Insurance and ICICI Lombard Health Insurance). Here, the individual has to pay a fixed amount of money (known as “premium”) at fixed intervals of time (monthly/quarterly/annually) to an insurance company that pools similar risks and insures them for health-related expenses. The main distinction is that the premiums are set at a level that is based on an assessment of risk status of the consumer (or of the group of employees) and the level of benefits provided, rather than as a proportion of consumer's income.
Public health insurance
These are funded by the government and aimed at providing health insurance coverage to certain sections of the population, mostly the underprivileged and vulnerable. These insurance programs are financed through tax and typically do not require premiums or user fees from beneficiaries. In some programs, the insured persons may have to pay a minimal amount as premium to avail the benefits. The major burden of premium in these cases is borne by the central and/or state governments. Some examples include Rashtriya Swasthya Bima Yojana (RSBY), Employment State Insurance Scheme, Central Government Health Scheme, Aam Aadmi Bima Yojana, and Ayushman Bharat.
In addition, in the public sector, the General Insurance Corporation (GIC) and its four subsidiary companies (National Insurance Corporation, New India Assurance Company, Oriental Insurance Company, and United Insurance Company) provide voluntary insurance schemes. The most popular health insurance coverage offered by GIC is the mediclaim policy.
The mediclaim policy
It was started in 1986. It reimburses the hospitalization expenses incurred due to illness or injury suffered by the insured, regardless of whether the hospitalization is domiciliary or otherwise. It does not cover outpatient treatments. The government has exempted the premium paid by individuals from their taxable income to various extents (not that the entire premiums are exempted). In addition to the general insurance companies, several life insurance companies also offer health insurance.
| Impact of Health Insurance on Outcomes|| |
There is limited evidence from the developing countries on the impact of health insurance on the health and economic well-being of beneficiaries. Published reviews suggest that while insurance improves utilization and reduces personal expenditures, the evidence on health outcomes is mixed.
| Current Scenario in India|| |
Currently, India spends 1.15% of the gross domestic product (GDP) on health, which remains one of the lowest in the world. Over 80% of health financing is private, much of which is out-of-pocket payments and not by any prepayment schemes.
High out-of-pocket costs make health services inaccessible to a significant proportion of Indian households. Among those who decided not to seek medical care for an ailment, nearly 20% of urban and 28% of rural households cited financial constraints as the limiting factor.
In India, central, state, and local governments together contribute only 20% of the total health expenditure while individual households contribute 71% of the total, through out-of-pocket expenditure at the time of treatment. According to a World Bank report published in 2012, health expenditure by the government is only 3.6% in India. This high level of out-of-pocket expenditure by individual households is one of the highest among low- and middle-income countries, thus ranking India low in terms of financial protection.
As of 2017, only 44% of the 1.3 billion people in India have a health insurance policy, according to a report by actuarial and consulting firm Milliman. As a consequence, a large proportion of the country's population has to bear health-care expenditure from their own pocket.
| Universal Health Coverage in India|| |
India, being a member state of the United Nations, is bound to implement the United Nations' Sustainable Development Goals (SDGs) agenda by 2030 and Universal Healthcare Coverage (UHC) is one of those goals. In fact, UHC cuts across all the health-related SDGs. UHC essentially means that every person can use the promotive, preventive, curative, rehabilitative, and palliative health services they need, of sufficient quality, while also ensuring that the person does not get exposed to financial hardships while achieving this. UHC brings the hope of improved health and financial protection of the poorer sections of the society. Governments now have an obligation to make such health services available.
| Health Insurance and Mental Illness|| |
Economic burden of mental disorders and its consequences
Data from the National Mental Health Survey (NMHS) reveal that mental disorders are significantly higher in households with lesser income, low levels of education, or limited employment, thus making it evident that these individuals have a greater vulnerability to mental disorders. At the same time, these same factors also limit their access to and utilization of mental health services. Assessment of the economic cost of the care of a person with mental disorder showed that the median out-of-pocket expenditure per month was approximately INR 1000–1500. This indeed is a huge burden, particularly for those belonging to the lower socioeconomic strata. This is a big challenge in addressing the pressing issue of the wide treatment gap for mental disorders. Furthermore, many a time, the task of caring for those with psychiatric disorders is a lifelong affair, given the chronicity and disability associated with severe mental disorders. Often, the families get entwined in the spiral of relapses (due to financial crises) and disabilities, leading to disastrous consequences including social drift, suicides, and homelessness.
In a systematic review, Roberts et al. noted that having health insurance was frequently, but not consistently, correlated with health service utilization for common mental disorders. In another study, there was an inconsistent association between treatment seeking and other enabling factors such as being in employment or having good social support.
Need for health insurance in Psychiatry
According to the recently concluded NMHS 2015–2016, common mental disorders including depression, anxiety disorders, severe mental disorders, and substance use disorders are a huge burden affecting 11% of the population anytime. Despite the availability of effective treatment for these disorders, a huge treatment gap exists for common mental disorders, the highest being 86.3% for alcohol use disorders. Treatment gaps for major depression and neurosis were identified to be 85.2% and 83.2%, respectively. Among the various factors thought to have an impact on treatment gap, affordability of care was identified as one critical factor influencing treatment utilization.
In this context, the inclusion of psychiatric disorders under the ambit of insurance will no doubt contribute toward reducing the treatment gap by covering for the financial risks that families need to endure. Although traditionally psychiatric disorders have been kept out of the health insurance schemes, the enactment of MHCA 2017 has brought in a welcome change in the scenario. Over the next few paragraphs, we would give a glimpse of the positive developments in this area.
Recent developments in the area of health insurance for psychiatric disorders
- MHCA 2017 section 21 (4) says, “Every insurer shall make provision for medical insurance for treatment of mental illness on the same basis as is available for treatment of physical illness.” Soon after the enactment of the said act, the Insurance Regulatory and Development Authority of India (IRDA), issued a notice directing all insurance providers to include psychiatric illnesses under the ambit of medical insurance. The IRDA is the governing body under whose purview the insurance providers come. These developments are really welcome. However, a couple of issues need to be kept in mind (a), unlike the physical illnesses, mental illnesses do not have an assured way of “risk-based calculation.” (b) Inpatient care in psychiatry involves interventions which may not fit entirely into the category of medical interventions (e.g., a session of psychoeducation, a family therapy session, etc.). These issues need to be sorted out before insurance covers expenses for those with psychiatric disorders
- Swavlamban Health Insurance Scheme: Even before the National Health Protection Scheme (NHPS), The New India Assurance Company Limited, in association with the Ministry of Social Justice, the Department of Empowerment of Persons with Disabilities had launched this scheme on October 2, 2015. The aim was to provide affordable health insurance to persons with blindness, low vision, leprosy cured, hearing impairment, locomotor disability, mental retardation, and mental illness. This scheme is made available for persons with disabilities with an annual family income of Rs. three lakhs or below, on declaration basis in the proposal form. There are no premedical tests. Uniform premium of INR 357 is collected from the insured person. Although the total premium for a sum insured of Rs. two lakhs per annum comes to Rs. 3100, the remaining amount is absorbed by the government. Another aspect of the scheme is the Out Patient Department (OPD) cover up to Rs. 3000 per annum. Preexisting illnesses are also covered under the scheme. An initiative at the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, was undertaken in the year 2016–2017 wherein about 350 patients were enrolled in the scheme. Officers from the New India Assurance Company Limited would come to NIMHANS on a predesignated date where a group of people (and their families) would be present. The premium would be collected from all of them on a single day, and the policies delivered to their houses, after due processing. However, during mid-2017, the scheme was stopped, and the current status of the scheme is not clear
- NHPS of the Ayushman Bharat: The NHPS which will subsume the ongoing centrally sponsored schemes – RSBY and the Senior Citizen Health Insurance Scheme – was launched in 2018 by the Government of India. It targets deprived rural and urban families as per the latest socioeconomic caste census data. This “Ayushman Bharat Yojana” has a two-fold strategy. The first is to provide comprehensive primary care accessible at a center near the community through strengthening and upgradation of existing facilities. It also aims to provide guidance on healthy lifestyle practices, including yoga, through health and wellness centers across the country.
The second is the introduction of the Pradhan Mantri Jan Arogya Yojana, which provides cashless health insurance cover up to Rs. five lakh per family (no restriction of family size) per year. This scheme aims to cover over ten crore families across the country, reaching about 40% of the entire Indian population. The magnitude of this endeavor makes it the largest publicly funded health insurance scheme in the world. Benefits of the scheme are portable across the country, and a beneficiary covered under the scheme will be allowed to take cashless benefits from any public/private impaneled hospital across the country. To control costs, the payments for treatment will be made on a package rate (to be defined by the government in advance) basis.
At the national level, an Ayushman Bharat National Health Protection Mission Agency would be put in place. States/union territories (UTs) would be advised to implement the scheme by a dedicated entity called the State Health Agency. They can either use an existing Trust/Society/Not for Profit Company/State Nodal Agency or set up a new entity to implement the scheme. States/UTs can decide to implement the scheme through an insurance company or directly through the Trust/Society or use an integrated model.
The expenditure involved
The expenditure incurred in premium payment will be shared between the central and state governments in a specified ratio as per the Ministry of Finance guidelines in vogue at present. The total expenditure will depend on actual market-determined premium paid in states/UTs where Ayushman Bharat-National Health Protection Mission will be implemented through insurance companies. In states/UTs where the scheme will be implemented in Trust/Society mode, the central share of funds will be provided based on actual expenditure or premium ceiling (whichever is lower) in the predetermined ratio.
States have also started rolling out their versions of the Ayushman Bharat schemes under various names. For example, the one in Karnataka is named ” Arogya Karnataka:” Arogya Karnataka, the health assurance package initiated by the Government of Karnataka in March 2018, merges all the ongoing insurance schemes together to form a universal health coverage package with assured coverage to below poverty line patients and co-payment mode for above poverty line patients. The scheme applies to residents of Karnataka only.
Packages for mental disorders are to be included in the NHPSs/Arogya Karnataka [Table 1].
In order to be eligible to provide services under this domain, the provider needs to qualify for the basic essential/minimum criteria as mentioned under the empanelment guidelines provided for NHPS provider network.
- Preauthorization: Mandatory for all packages for progressive extension of treatment/hospital stay
- Preauthorization remarks: Prior approval must be taken for all mental health conditions/packages under this domain for progressive extension of treatments
- All clinical test reports, diagnosis, mental status examination, case sheet/clinical notes, and discharge summary need to be submitted for extension of packages and during claims submission
- Legend of bed-day charges [Table 2].
- Complex secondary and tertiary cases
- All high-dependency unit (HDU) admissions would be considered complex secondary cases
- All sectioning cases (supported admission as per section 89 or 90) would be tertiary cases
- All high-risk population would be considered tertiary cases.
Criteria for admitting patients to the HDU
- Catatonic symptoms
- Violent/dangerous behavior resulting in harm to self or others
- Suicidal/self-harm ideas or attempts
- Delirium of all causes
- Severe adverse effects of psychotropic medications
- Severe substance withdrawal states
- Severe intoxication resulting from substance use.
The following facilities should be present in the center to get itself impaneled as HDU (for admissions other than HDU, the criteria for empanelment would be to possess a valid license for mental health establishment (MHE), issued by the state/central mental health authority:
- Provision for two full-time psychiatrists or one psychiatrist and one medical officer
- Adequate provision of human resources to take care of assessments, counseling, and psychoeducation
- Provision for emergency psychiatric services round the clock
- Provision for bed-side laboratories/outsourcing to accredited institutions
- Provision for in-house pharmacy
- Provision for in-house kitchen/canteen
- Provision for adequate documentation of processes
- Provision for adequate security measures for preventing violence/escapes
- CCTV facilities in public places
- Registered under MHCA 2017 (meaning, qualifying under minimum standards according to the MHCA 2017).
- Criteria for supported admissions
- The criteria for HDU should be met
- Section 89, 90, or 94 under the MHCA 2017
- MHE should be compliant with MHCA 2017.
- Criteria for high-risk population
- MHE should be compliant with MHCA 2017
- Separate ward/facilities for admitting:
- Perinatal admissions
- Children and adolescents (aged below 18 years)
- Geriatric population (aged 60 or above).
- Basic minimum documents required for submission to insurance/assurance agencies
- Basic medical records as per the MHCA 2017.
| Discussion|| |
Ushering the era of health insurance for psychiatric illnesses is a welcome change that the MHCA 2017 has brought about. This step is no doubt a boost to the rights-based approach for PMIs. However, the issue of insurance for mental illnesses brings in a host of clinical/social factors that need consideration. Some of them are discussed here.
Long duration of treatment
The treatment for most physical illnesses warrants hospitalization for a few days, while PMIs are often hospitalized for a few weeks to a few months. In some of the mental disorders, even after discharge from the hospital, the patient needs to be on medication for a long time, which is also an economic burden on families. Should the package then be decided by the number of days of hospitalization or should there be a predetermined package based on diagnosis? What happens if there are more than one diagnoses, which is not an uncommon situation in the practice of psychiatry? Should the maintenance treatment, which continues after the stabilization phase, be considered for coverage under insurance schemes, considering its long duration and economic burden?
Willful noncompliance to treatment by patients
The management of physical ailments is clearly defined and facilitated by the patient willingly agreeing to continue the same. In many PMIs, the treatment is given involuntarily, and it is complicated by issues of noncompliance, which may lead to multiple relapses and increased number of hospitalizations. Another dilemma which may arise in the context of MHCA 2017 is that PMIs now have the right to make an “advance directive” in which they may specify the way they wish to be treated as well as the way they wish not to be treated. What if a person wishes to be treated in a manner that is more expensive than the other equally efficacious alternatives available?
Preexisting mental illness
The insurance companies have a predetermined premium loading for standard medical conditions that are preexisting, usually based on the severity and chronicity. Applying the same to preexisting mental illness will be a challenge.
Preventive and rehabilitation services
Treatment of mental illness not only comprises medical or biological treatments but also includes other interventions such as psychosocial rehabilitation, psychotherapy, and counseling. These are likely to go on for months. Will the insurance cover these interventions for as long as they are needed? What all treatment interventions would be covered under insurance? Will stay in halfway homes be considered? What about long-stay options?
Suicide attempts are common in many psychiatric illnesses. However, should insurance cover them is not a simple enough dilemma. The MHCA 2017 section 115(2) states that to a person having severe stress and who attempted to commit suicide, the appropriate government shall have a duty to provide care, treatment, and rehabilitation to reduce the risk of recurrence of an attempt to commit suicide. Should all suicide attempts get insurance cover then?
Reimbursement for complications
MHCA 2017 places a lot of importance on the autonomy and rights of the persons with mental illness. It also gives them the option to refuse treatment. Should the illness go untreated and lead to other damages in the form of poor general health due to poor oral intake or poor personal hygiene as a consequence of untreated mental illness, should the insurance company pay for compensation? How should these issues be negotiated?
Providing medical records to the insurance company
The health insurance company gets access to medical records of persons with mental illness. The medical records such as procedure done, investigations, diagnosis, and treatment are specifically needed for payment of claims. The insurance company may request medical history related to symptoms and prior treatments in order to justify the insurance coverage. However, there are no guidelines or regulations regarding how much medical records should be shared or what information can be shared. If the medical records are shared with the insurance company, will it be the contravention of the MHCA, 2017 section 23, right to confidentiality? These issues need to be clarified for the proper implementation of health insurance for mental illness.
A lot of these queries do not have a straightforward solution. One-way forward is to follow the guidelines given by the state or central governments as discussed earlier. Furthermore, the Insurance Regulatory and Development Authority of India has notified a relevant policy. This states that the insurers are free to come up with their own packages for the initial few years. Data about their utilization will then be studied to guide further developments.
It may be concluded that, treating mental illness at par with physical illness by mandating provision of health insurance for mental illness is no doubt a welcome change; however a considerable amount of thought will have to be put into working out the details.
| Conclusions|| |
Covering families with health insurance is a necessary act if the financial risks are to be guarded, particularly for the poor. In India, now mental illnesses have been given equal priority with other physical ailments and have been included for consideration of health insurance. Consequently, they figure prominently in the state-sponsored health insurance/assurance schemes. This augurs well toward achieving the SDGs through universal health coverage.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sood N, Bendavid E, Mukherji A, Wagner Z, Nagpal S, Mullen P. Government health insurance for people below poverty line in India: Quasi-experimental evaluation of insurance and health outcomes. BMJ 2014;349:g5114.
Prinja S, Bahuguna P, Pinto AD, Sharma A, Bharaj G, Kumar V, et al.
The cost of universal health care in India: A model based estimate. PLoS One 2012;7:e30362.
National Sample Survey Organization. Morbidity, Health Care and the Condition of the Aged. New Delhi: National Sample Survey Organization, Ministry of Statistics and Programme Implementation; 2006.
Berman P, Ahuja R, Bhandari L. The impoverishing effect of healthcare payments in India: New methodology and findings. Econ Polit Wkly 2010;45:65-71.
Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, et al
. National Mental Health Survey of India, 2015-16: Summary. Bengaluru: National Institute of Mental Health and Neurosciences Publication; 2016.
Roberts T, Miguel Esponda G, Krupchanka D, Shidhaye R, Patel V, Rathod S. Factors associated with health service utilisation for common mental disorders: A systematic review. BMC Psychiatry 2018;18:262.
Wang PS, Berglund P, Kessler RC. Recent care of common mental disorders in the United States: Prevalence and conformance with evidence-based recommendations. J Gen Intern Med 2000;15:284-92.
Sivakumar T, James JW, Chethan B. Health insurance schemes for children and adolescents with psychiatric disability. J Indian Assoc Child Adolesc Ment Health 2017;13:1-9.
Dr. C Naveen Kumar
Department of Psychiatry, National Institute of Mental Health and Neurosciences, Hosur Road, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2]