Health Insurance Service Utilization And Willingness To Adopt Health Insurance Schemes Among Admitted Patients In A Tertiary Hospital Of India

International Journal of Current Research and Review Scopus Research Article

DOI: http://dx.doi.org/10.31782/IJCRR.2020.121816

Health Insurance Service Utilization and
Willingness to Adopt Health Insurance Schemes
yerr Among Admitted Patients in a Tertiary Hospital of

Section: Healthcare

@
Sci. Journal Impact I n d la

Factor: 6.1 (2018)
ICV: 90.90 (2018)

© Ria Ganguly’, Lipilekha Patnaik?, Trilochan Sahu?

Copyright@IJCRR

PG Student, Community Medicine, IMS and SUM Hosp ital, Siksha ‘O’ Anusandhan Deemed to be Univers ity, Kalinga Nagar, G hatikia,
Bhubaneswar-751003, Orissa, India; "Professor, Community Medicine, IMS and SUM Hosp ital, Siksha ‘O’ Anusandhan Deemed to be Uni-
versity, Kalinga Nagar, Ghatikia, Bhubaneswar-751003, Orissa, India; ’Professor & Head, Community Medicine, IMS and SUM Hosp ital,
Siksha ‘©’ Anusandhan Deemed to be University, Kalinga Nagar, Ghatikia, Bhubaneswar-751003, Orissa, India.

ABSTRACT

Background: With technological advances, new procedures and more effective medicines, the costs of healthcare have driven
up. So, taking health insurance is more affordable.

Aims: To know health insurance service utilization and willingness to adopt a health insurance scheme among patients admitted
in a tertiary hospital.

Materials and Methods: The study was conducted during September - November 2019 among 126 patients admitted in a ter-
tiary care hospital using a predesigned and pretested schedule. The study design was cross-sectional. Non-probability sampling
method was used. Data were entered to an excel sheet and SPSS software version 20 was used for analysis.

Results: Among the persons interviewed, about 20% were admitted under the health insurance scheme, 71% were aware of
health insurance. Around 60% of the respondents gained knowledge about health insurance from radio and television followed
by agents and friends (31.1%) and print media (8.9%). Among those insured 72% had ESIS, 24% had CGHS and 4% had taken
private insurance. Among participants, 55% were not willing to join any health insurance scheme but if given a chance,61%
preferred Government health insurance. 84 % of participants who were admitted under insurance belonged to upper socioeco-
nomic status. This association was statistically significant (p=0.002). Government health insurance was preferred by 80% of
participants.

Conclusion: Health insurance coverage will further increase by increasing awareness about different schemes and the initiative
taken by health care personnel will be more effective.

Key Words: Health insurance, Awareness, Out of pocket expenditure, Inpatients, Willingness to pay, Social security

INTRODUCTION systems are financed on the wellbeing of households, par-
ticularly poor households.!”

The prevalence of lifestyle diseases is rising due to chang-
ing lifestyles which in turn is increasing the demand for
healthcare. With technological advances, new procedures
and more effective medicines the costs of healthcare have
driven up. While these high treatment expenses may be be-
yond reach, taking health insurance is much more afford-
able.' Health insurance has been acknowledged as a valuable
tool in health financing. The design of health systems and
insurance schemes in countries like USA, Australia, Indone-
sia and India is based on the potential impact of how health

The insurance system works on the basic principle of pooling
of risks of unexpected costs of persons falling ill and needing
hospitalization by charging premium from a wider popula-
tion base of the same community.’ despite its significance,
the subscription is very less. People who can afford or aware
of health insurance are also found to be ignorant towards it.
According to the 71st round of surveys, the National Sample
Survey Office (NSSO) published the report “Key Indicators
of Social Consumption in India: Health” in 2016. In the re-

Corresponding Author:

Dr. Lipilekha Patnaik, Professor, Department of Community Medicine, Institute of Medical Sciences and SUM Hospital, Siksha‘O’ Anusandhan
deemed to be University, Kalinga Nagar, Ghatikia, Bhubaneswar, Khordha, Odisha-751003, India;
Mobile: +91-9437322268, E-mail: drlipilekha@yahoo.co.in

ISSN: 2231-2196 (Print) ISSN: 0975-5241 (Online)
Received: 15.07.2020 Revised: 24.08.2020 Accepted: 05.09.2020 Published: 22.09.2020

Bieta onan eee Se ————————— 7a
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Ganguly et al.: Health insurance service utilization and willingness to adopt health insurance schemes among admitted patients...

port, it was observed that more than 80% of people were not
covered under any health insurance plan. The majority were
covered by government-funded health insurance. Just 18%
of the urban and 14% of the rural population were covered
by some type of health insurance policy.*

A report from World Bank in 2002 showed that an enormous
proportion of individuals borrow money or sell assets for
hospitalization. Out of pocket health care expenses account
for more than 80% of total healthcare expenditure in India.°
People of lower socio-economic groups usually spend a
higher proportion of their annual income on health than high
socio-economic groups.° Once admitted to the hospital, the
poor usually undergo a severe financial crisis.

The health insurance schemes for the poor were introduced
to relieve their financial burden. Keeping in mind the health-
care needs of different strata of the population, insurance
companies design innovative products with optimal pric-
ing and comprehensive coverage. Plans funded by central
government are Employee State Insurance scheme, Central
Government Insurance Scheme, Rashtriya Swasthya Bima
Yojana. In 2018, the Government of India has introduced
Ayushman Bharat Yojana (Pradhan Mantri Jan Arogya Yo-
jana), which aims to help economically vulnerable citizens
for their health care need. Presently many private insurance
companies like Star Health, ICICI Lombard, Reliance, Apol-
lo Munich, Max etc. have come forward to offer health insur-
ance. People have to pay premiums as per conditions of the
policy, which vary according to medical care benefits. With
so many features in different policies, the demand for health
insurance has grown at a rate of 25 % per year, driven by
rapidly increasing awareness, and is going to rise even more
rapidly in the future.’

In Odisha, service delivery is mostly dominated by the
public sector. The state still struggles with high levels of
out of pocket expenditures and poor accessibility and qual-
ity of healthcare services in hard to reach areas. There is a
tremendous opportunity for private sector investment to
boost healthcare in this state, but private sector investment
should go hand in hand with strong private sector regula-
tion.’ People are not purchasing health insurance because of
low awareness, lack of finance and high premium charges in
India.’ In some studies in Maharashtra, India, lower levels
of awareness (11—30%) and utilization of health insurance
were reported,'° whereas higher levels of awareness (64%)
were reported from a South Indian population.'' The most
important reason for low coverage might be vast geographic
and economic variation. Therefore, it was necessary to un-
derstand the awareness, utilization and willingness in buy-
ing health insurance among people in hospital inpatients of
Odisha. So this study was conducted to assess the aware-
ness of health insurance service among admitted patients in
a tertiary hospital and to assess utilization and willingness to

adopt a health insurance scheme among them.

MATERIALS AND METHODS:

This study was cross-sectional and was conducted from Sep-
tember to November 2019 among 126 admitted patients in a
tertiary hospital of eastern India. The sample size was calcu-
lated taking prevalence of awareness of health insurance in
the urban area as 64% concerning a study by B. Reshmi et
al.'’ with 10% allowable error and 20% non-response rate.
The sample size was estimated to be 110. Bed numbers were
chosen by simple random sampling method and the inter-
view was done in 126 admitted patients by a pre-designed
and pre-structured schedule. The schedule consisted of ques-
tions on sociodemographic characteristics and awareness,
utilization and willingness to join insurance scheme. Before
the start of the interview, informed written consent was taken
from the participants. Privacy and confidentiality of the in-
terviewer were maintained. Those who did not give consent
for the interview were excluded.

Statistical analysis: Data were entered in the excel sheet
and analysed using SPSS software version 20 licenced to the
institute. The level of awareness about health insurance in
the study population was calculated in percentage. The as-
sociation between various factors with awareness and enrol-
ment were evaluated by Chi-square test. P-value < 0.05 was
considered a significant association.

RESULTS

13.3 years. Majority of respondents (48.4%) were in the
age group 41-60 years. Among them, 63.5% were male and
36.5% were female. Majority of the respondents were Hindu
(96.03%). Overall 50.8% population had education till High
school and below. Most of the respondents (82.5 %) were
married and69% belonged to the nuclear family. Majority of
participants belong to the upper class (57.14%) and upper-
middle class (38.88%) according to B. G. Prasad classifica-
tion 2019. (Table 1)

Out of 126 participants, 25 (19.8%) were enrolled in any of
the health insurance schemes. Awareness about health insur-
ance was 71.4% (n=90) and among those who were aware,
only 28% were enrolled. In comparison, males (69%) were
more aware of Health insurance than females (54%) but the
difference was not significant. (Figure 1)

Among insured patients, 72% were enrolled under the ESIC
scheme, 24% CGHS and 4% private insurance policy. Insur-
ance scheme was adopted to meet unforeseen expenses by
68% of the enrolled and 40% of those enrolled were satisfied
with the benefits. 16.7 % of the insured find it easy to access
the network hospitals and 10.3% find it easy to file a claim.

128 Int J Cur Res Rev | Vol 12 + Issue 18 » September 2020

Ganguly et al.: Health insurance service utilization and willingness to adopt health insurance schemes among admitted patients...

The main barriers for the subscription of health insurance
were not commensurate benefit (38%), lack of awareness
(36%) followed by financial constraint (12%). (Figure 2)

The main factors that motivated for the subscription of
health insurance found were — cashless benefit (12%), lack
of finance (20%), to meet medical emergencies (68%).

It was observed that, awareness insurance scheme was sig-
nificantly associated with the education of participants, and
enrolment was significantly associated with education, oc-
cupation and socioeconomic status (p<0.05) (Table 2)

Among the respondents, who were aware (n=90), the major
source of information of health insurance was from mass me-
dia like radio, television (60%) followed by friends/ agents
(31.1%) and print media (8.8%). When the participants who
had enrolled in health insurance scheme(n=25) were asked
about their satisfaction with the health insurance, it was
found that 12% were very satisfied, 40% were satisfied, 12%
were neutral and 36% were dissatisfied. (Figure 3)

Majority of patients (74%) wanted the government to pro-
vide total health care starting from the out-patient care to
the provision of drugs. 54% of the respondents were will-
ing to subscribe to insurance schemes in future. Only 25%
of the respondents preferred a private insurance scheme and
thought private insurance may provide a better and hassle-
free coverage.

DISCUSSION

It is necessary to know the awareness of health insurance
and reason for non-enrolment and thus this study was con-
ducted to assess the awareness of health insurance service
among admitted patients in a tertiary care hospital and to
assess utilization and willingness to adopt health insurance
scheme among them. Most people in India don’t seek treat-
ment in India due to financial insecurity resulting from out
of pocket health expenditure. Thus, it emphasizes the need
for awareness about health insurance and its benefits to be
made easily available to the citizens, more so to the elderly
and with comorbidities.'* The awareness among respondents
in the current study is 71.4% which was fair. In a study by
Madhukumar S et al. 35.3% of the 331 houses surveyed had
heard of health insurance." The difference might be because
the study was done in a rural setting. The higher awareness
in our study might be because of extensive media advertise-
ment and the efforts to market schemes by different private
as well as public health sector in the urban population. It
might also be because it 1s a hospital-based study among re-
spondents who might be having a chronic illness and finan-
cial burden due to health events. In this study, 29% of the
participants were not aware of health insurance. Therefore,
efforts are needed to aware the entire population regarding

various health insurance schemes Everyone regardless of the
socio-economic class should be educated about the necessity
for health insurance.

In this study 72% of those who were aware, also did not sub-
scribe to any insurance schemes. 80.2% were not enrolled in
any insurance schemes. Similar observations were found in
other studies conducted by Bawa SK where 71.9% had no
health insurance.'*

Educational status was the main socio-demographic vari-
able which affects the awareness and enrolment regarding
different schemes. Similar results were observed in a study
by Joseph N et al. Awareness increases with an increase in
the educational qualification were also observed in another
study from Hyderabad. Another case study from Guyarat
reported that there is a need for similar information to be
provided for the rural and urban population on the concept
of health insurance to improve awareness about health in-
surance on a large-scale.'® It is reported that socioeconomic
status and education play an important role in awareness of
ehealth insurance. Effective health financing measures like
information, education and communication (IEC) activities
will improve the understanding of the people unaware of so-
cial security schemes and provide financial risk protection.
In this study, enrolment was significantly more among the
upper socio-economic class and in respondents with high-
er education. In a study by Jathanna PNR et al. 99.5% of
the literates group were covered under insurance and 89.9
% were literates in non — enrollees group. This difference
was significant. The socio-economic results showed major-
ity enrollees (total of 77.7%) belonged to class HI and class
IV and it was significant at 0.01 level.” Only 16-18% of the
population of the country avail Central Government Health
Scheme, Employee State Insurance Scheme, and employer-
based schemes, therefore a large segment of the population
is left without any financial protection in case of health risks.
Thus, it was suggested by S.N. et al.!® to expand the ESIS
scheme, hence allow larger numbers and all grades of wage-
earners into the risk pool. It is opined by Virk AK and Atun
R that a balanced approach and evidence-informed policies
guided by morbidity and health spending patterns are needed
for financial protection mechanisms.” In this study, enrol-
ment was significantly associated with education, occupa-
tion and socio-economic status. Thus, it is likely that due
to the financial burden and stress of existing loan the poor
and low socio-economic population are reluctant to avail
any government or private health insurance schemes. In the
last decade, the private health sector has made several inno-
vations and improvisations giving them the advantage over
the government-issued public health sector. It is bothersome
for the poor and underprivileged masses to afford the cost
of specialised medical care provided by the private sector.
Moreover, public health care remains challenged with a
shortage of manpower and finance. Most people in India are

Int J Cur Res Rev | Vol 12 + Issue 18 - September 2020

Ganguly et al.: Health insurance service utilization and willingness to adopt health insurance schemes among admitted patients...

not financially secure by health policy because of low aware-
ness, lack of finance and high premium charges.”

In this study, the insurance scheme was adopted to meet un-
foreseen expenses by the majority that is 68% of the enrolled
and also 68% of them said they subscribed to meet medical
emergencies.

The results are similar to a study by Indumathi K et al., where
the majority of the respondents 96.2% had taken health in-
surance to cover their medical expenses. In the same study
86.6% of them reported benefit of health insurance to be re-
ducing healthcare expenditure, better coverage of the entire
family (18%), for the emergency health care(2.5%).”°

40% of those enrolled participants in this study were satisfied
with the benefits. Though in a study by Bhaisare RG et al.
in Maharashtra majority participants were satisfied with the
benefits by public health insurance schemes.’' In the present
study the respondents who were aware, the major source of
information of health insurance was from mass media like
radio, television (60%) followed by friends/ agents (31.1%)
and print media (8.8%). Similarly, a study conducted by
Reshmi B et al. showed 34% were aware through television
advertisements. Thus media do play an important role in the
dissemination of information.” In our study, 74% of patients
preferred government schemes similar to the study where
74% were willing to enrol to government policy.

The main barriers in this study for the subscription of health
insurance were not commensurate benefit (38%), lack of
awareness (36%) followed by financial constraint (12%).
An another study by Madhukumar S et al. observed that the
main barriers for the subscription of health insurance were
low income or uncertainty of income (43%) followed by oth-
er reasons.” In this study, 54% of the respondents were will-
ing to subscribe to insurance schemes in future. In another
study by Netra G et al. 77% of the households were willing
to subscribe for health insurance schemes.”

AS we can see respondents who were better aware and en-
rolled in any scheme were significantly more in those who
obtained high school certificate. Lack of education is the
biggest challenge for low utilization of health insurance
schemes. With the rise in health care cost, and high out of
pocket expenditure for funding healthcare, the only way for-
ward for financing healthcare is a robust health insurance
mechanism.

CONCLUSION

The findings of the study highlight the current status of the
fair prevalence of awareness toward health insurance in the
hospital setting was fair in this study but low enrolment was
observed among the participants. Health insurance cover-
age can further be increased by increasing awareness about

different schemes. Thus at every healthcare facility advisor
could be appointed to aware patients about the health insur-
ance policy. Information, Education, Communication cam-
paigns can be organized in villages and cities explaining the
importance of health insurance which is essential to cope up
with the rising medical challenges in India.

Limitation

The study is conducted in one healthcare setting and in only
two wards in the selected region hence results cannot be gen-
eralized.

ACKNOWLEDGEMENT

We extend our sincere thanks to the study participants for
their support and involvement in the study.

Funding: Self-funded
Conflict of interest: Nil

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Table 1: Socio-demographic characteristics of participants

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Characteristics Number (%)

Age (Years)
25-40
41-60

>60

Gender
Male

Female

Religion
Hindu

Muslim

Education

Primary
Middle
High school

Intermediate or Diploma

Graduate

Occupation

Semi profession/profession

Skilled worker

Semi-skilled

Unskilled worker

Unemployed

Socioeconomic status

Upper
Middle
Type of family

Joint

Nuclear

Int J Cur Res Rev | Vol 12 « Issue 18 - September 2020

46 (36.5)
61 (48.4)
19 (15.1)

80 (63.6)
46 (36.5)

121 (96.03)
5 (3.97)

9 (7.1)
34(26.9)
21(16.7)
38(30.2)

24(19)

35 (27.8)
48 (38.2)
10 (7.9)
8 (6.3)
25 (19.8)

72 (57.1)
54 (42.9)

39 (31)
87 (69)

Ganguly et al.: Health insurance service utilization and willingness to adopt health insurance schemes among admitted patients...

Table 2: Association of Socio-demographic variables with awareness and Enrolment of Health Insurance

Variables Awareness (%) Significance Enrolment (%) Significance
Aware Not aware (P-value) Enrolled Not enrolled (P Value)
Gender
Male 56 (70) 24 (30) 0.639 20 (25) 60 (75) 0.055
Female 34 (73.9) 12 (26.1) 5 (10.9) 41 (89.1)
Religion
Hindu 87 (71.9) 34 (28.1) 0.563 24 (19.8) 97 (80.2) 0.992
Muslim 3 (60) 2 (40) 1 (20) 4 (80)
Education
Intermediate or above 53 (85.5) 9 (14.5) 0.000* 19 (30.6) 43 (69.4) 0.002*
High school or below 37 (57.8) 27 (42.2) 6 (9.4) 58 (90.6)
Occupation
Professional/Semi-professional 28 (80) 7 (20) 0.186 18 (51.4) 17 (48.6) 0.000%
Others 62 (68.1) 29 (31.9) 7 (7.7) 84 (92.3)
Socioeconomic status
Upper class 49 (68.1) 23 (31.9) 0.333 21 (29.2) 51 (70.8) 0.002*
Middle class 41 (75.9) 13 (24.1) 4 (7.4) 50 (92.6)
Type of family
Nuclear 60 (69) 27 (31) 0.361 18 (20.7) 69 (79.3) 0.721
Joint 30 (76.9) 9 (23.1) 7 (17.9) 32 (82.1)
100% 100.0%
50%
ago 0.29%
72 09%%

70%

60%

50%

40%

30%

20%

10%

0.0%
0%

Total

Not aware

Aware

E Enrolled E Not enrolled

Figure 1: Awareness and enrollment under health insurance.

129 Int J Cur Res Rev | Vol 12 + Issue 18 » September 2020

Ganguly et al.: Health insurance service utilization and willingness to adopt health insurance schemes among admitted patients...

Not commensuarte benefit 38%
Not aware of schemes — 36%

No Financial constraint

Not necessary

Lack ofillness
0% 5% 10% 15% 20% $255 S0% 35% 40%

Figure 2: Reason for not being insured (n=1071).

40%

32%

35%
30%

Percentage
bi M
=] Ln
aes

15%
10%
5% =
0%
VERY SATISFIED CAN'T SAY DISSATISFIED VERY
SATISFIED DISSATISFIED

Figure 3: Satisfaction with current scheme (n = 25).

ESS nn be mera
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