Digital Technologies for Government-Supported Health Insurance Systems in Asia and the Pacific

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• Publisher: Asian Development Bank
• Year: 2021
• Print ISBN: 9789292692537
• eBook ISBN: 9789292692544
• Topic: Ciencia de la computación
• Subtopic: Aplicaciones de escritorio

This report explores digital solutions that can support the core business processes of public health insurance operators in Asia and the Pacific. It draws on examples from low- and middle-income countries from the region and beyond to demonstrate how digital solutions have improved health insurance management and administration. To support decision-making on potential investments, the report identifies key success factors for integrating new technologies into public health insurance schemes.

IV Health Insurance Business Processes

This chapter examines the core business processes of government-supported health insurance with the view of presenting future digitalization possibilities for LMICs.

The core processes of the JLN framework,⁸ as described in previous chapters, were used. However, additional literature on social protection and e-government was also used, as it often provides hints on how to improve the interoperability of existing legacy software for health insurers.

The business process has been divided into three sections: First, a general background on the process and what it does. Second, key drivers, which can be seen as a set of critical factors for health insurers that provide a possible motivation for the use of digital technology. For example, a key driver can be a specific operational problem and a desire to save costs or improve customer service. Third, a few examples are presented to illustrate good practice. The focus for these examples is on LMIC contexts, but the authors also believe it is relevant to draw on experience from other contexts.

Beneficiary Management

Digital interventions can contribute to UHC in a variety of ways. For instance, they can remove financial as well as administrative barriers to access adequate and affordable health care.

There are three main barriers to the expansion of health insurance coverage:⁹

1. The inability to enroll in schemes. Complex or unclear communication on eligibility criteria creates potential challenges in enrollment, and complicated administrative mechanisms result in the exclusion of target groups.

2. The inability to use the system. After they have enrolled, participants in a health insurance scheme sometimes do not have access to the legally entitled benefit—and which may reveal the administrative inability of the public sector scheme to provide benefits for all those entitled to them.

3. Inability to receive appropriate and high-quality services. Members who succeed in overcoming obstacles to enroll may still not receive adequate protection. Health insurance coverage must be appropriate to the needs of each person, especially those from high-risk groups such as children, women, the elderly, or households exposed to other forms of discrimination.

In the case of health insurers, the admission of members and the verification of eligibility are categorized as beneficiary management.

Good digital beneficiary management in the insurance industry brings improvements in revenues, cost efficiency, and customer satisfaction. However, despite existing technology, the customer approach is still far from being consistently digitized and value-oriented in some cases.

Several technologies can aid the process of beneficiary management in developing countries. For example, an online eligibility check has extra advantages in countries with a high proportion of domestic migration or areas with many seasonal workers not covered via a formal health insurance scheme that runs for a whole year. Particularly when it comes to scheme portability, coverage gaps or double insurance issues should be avoided as much as possible, which online and real-time eligibility checks can help with. Decentralized information (e.g., on smart cards) that can be retrieved on the sport can as well aid beneficiary management processes in developing countries, though challenges with synchronization of decentralized data and cost of associated hardware are at times as well considerable. With improving internet connectivity, including in rural areas, the trade-off between centralized online retrieval and/or verification of data should be weighed against decentralized data storage options.

Very often, member database “silos” exist. A silo means that different health insurance operators each maintain their member databases without being linked. As a result, seamless tracking of a person throughout the entire health insurance landscape is impossible due to the lack of a uniform database or ID numbers.

Table 1: Key Drivers for Beneficiary Management

Challenge/Key driver	Digital support opportunities
Health insurers want to identify their beneficiaries	Ideally, the beneficiary database should be interoperable with other relevant national databases (e.g., CRVS system; Social Registry; National ID database)
Timely enrollment of beneficiaries and ease of use	Mobile enrollment apps Employee registration platform
Fraud and abuse should be prevented	Use of biometrics Online eligibility check
Redundant entries in the beneficiary database should be avoided	Use of biometrics

Source: Authors.

Addressing the Key Drivers and Solutions from Other Countries

This section takes a closer look at the areas of beneficiary identification, mobile enrollment apps, and portability of services.

Identification

At the basis of any government-supported health insurance schemes lies the challenge of person/citizen deification and the related role of Identification Numbers (IDs). Indeed, unique identification is a way of verifying or authenticating each person and aggregates data personally.

Gelb, A. & Clark, J. (2013)¹⁰ state that some countries provide a general identification mechanism for their entire population using foundational ID systems. These mechanisms may include a Civil Registration Database as well as a unique national ID. Other countries opt for functional ID systems for a particular service, such as health-care provisioning. Indeed, a 2014 Survey by the World Bank’s ID4D Working Group¹¹ provided evidence that, out of 198 countries, a majority still employ fragmented, single-purpose ID systems. This ID4D group Survey, together with several other reports, highlighted that it would be costly to introduce national identification mechanisms and that time would be needed to remove duplicates. Therefore, several authors recognized that the introduction, or upgrading, of identification mechanisms requires appropriate management structures and clear goals to enable interoperability among all health system operators.

The significance of identification systems and IDs has created a strong interest among many governments, particularly in developing countries, to understand better the advantages and disadvantages of linking existing IDs or creating a national ID covering full citizenship. Many studies note that different ID systems have been developed for different purposes:

A central identification system and one of the oldest is the Civil Registration and Vital Statistics System (CRVS), which records birth, death, marriage, divorce, adoption, and issues identification documents such as birth certificates.

Functional IDs are ID cards, numbers, or other systems created for specific government services, such as in the health sector, a health insurance card (Gelb and Clark, 2013).

Foundational IDs are not linked to specific services but serve as legal proof of identity for multipurposes, such as a National ID Card that can access health services and other sectors such as banking (Gelb and Clark, 2013).

Foundational IDs are essential for health insurance and other benefit programs within the health system, given the fact that to access health facilities and therapies, a person in a particular country must prove that they are insured and what their entitlement is against what they contribute.

Additionally, IDs are essential elements for tracking valid payments to health facilities. Failure to provide proper documentation can result in the denial of benefits. Similarly, insurers and health-care providers may find more fraud cases if there is a lack of identification of beneficiaries. In some cases where health information systems are fragmented, patients may be billed twice, providers may be paid twice, or patients may not be adequately reimbursed when they seek treatment at multiple facilities.

Review of literature also shows that the form of ID systems in the health sector has also been evolving—paper-based ID systems, for example, are now primarily digital.¹² However, this does not mean that the number of IDs has decreased. Digital tools provide the opportunity to store data centrally and thus limit the need for multiple data collection; however, since a beneficiary database can be installed so quickly nowadays, many identifiers are being generated in parallel.

With more countries moving toward digital health solutions, patients identification options are expanding at the point of care and include:

using national universal unique identity numbers (NUINs) and also use these as National Unique Health Identifier (UHI),

developing and implementing an ID number mapping system based on an existing UHI, and

developing UHIs independently of the development of national IDs and CRVS systems and linking them.

Ultimately, insurance systems require complete and accurate health-care service utilization to bill patients, pay providers, and sustainably make budgeting and business decisions. The integration of unique identification mechanisms (e.g., a unique health ID) into health insurance programs improves effectiveness and efficiency in increasing coverage.

It is expected that the use of a unique national ID for the proper administration of health protection will bring several benefits such as:

reducing operational costs for beneficiary management, as those who wish to participate in a scheme, will not be excluded,

enabling the registration of beneficiaries when they move within the country,

eliminating duplicate or incorrect beneficiary entries and hence reducing fraud,

facilitating electronic payments through the banking sector, and

cross-referencing from one program to another to improve program integration and impact for beneficiaries.

Two successful implementations of nationwide ID systems are presented in Boxes 5 and 6.

BOX 5

National Identification Systems in the Republic of Korea

A country that successfully established a robust CRVS system, which benefited the National Insurance Fund and other government institutions, is the Republic of Korea. Indeed, the government has a very structured approach and assig...

Table of contents

• Front Cover
• Title Page
• Copyright Page
• Contents
• Tables, Figures, and Boxes
• Acknowledgments
• Abbreviations
• Executive Summary
• Introduction and Methodology
• I Digital Health Ecosystem for Health Insurance Operators
• II The National Health Insurance Framework
• III Enabling Implementation
• IV Health Insurance Business Processes
• Conclusions
• References
• Footnotes
• Back Cover