India’s Healthcare system is fragmented, the country is too diverse and large for a single unified system. Each state has its own healthcare programs. The central government provides the majority of the funds but the implementation largely rests with the states. States that are better off are independent in their decision making and show better outcomes. However, India can still aim for standardized protocols and interoperability across states. Interestingly, digital technology is proving to be a binding force between the three important stakeholders of healthcare namely, payer, provider and people. The new Ayushman Bharat national health insurance program is becoming the melting pot for public and private healthcare and emerging as the biggest driver for digital health.
Healthcare in India has lagged in adoption of technologies, but digital technologies are now pushing the country in the right direction. Technology driven transformation has happened in many sectors like Mobile and Telecom, Aadhaar based eGovernance, Fintech and Banking. Healthcare is likely to go through a digital transformation now.
Technology has already taken its toll on the Hospital Information Systems [HIS] market. Large HIS vendors have exited the market. Either they have lost interest and exited or have been acquired. On the other hand, many tier-II incumbent players are not able to shift out to cloud because of their long term negotiated contracts in client-server model. The newer cloud-based players are comparatively smaller in size and yet to reach size and scale. The HIS market is ready for complete disruption by Digital Health!
Now is the Era of Mobile-First Apps. Small Data ^ = Big Data. The time has come when you don’t need big monolithic HIS software to run hospitals. Now you can do a lot with small mobile based Apps for every function. Clinical evidence-based medicine has got a new meaning with Digital devices run on Artificial Intelligence being introduced. These devices can automate Laboratory Reports, read Radiology reports better, do accurate differential Diagnosis, pin point relevant Order sets, send Referrals, drug refill alerts and follow-up reminders. Disease management has gone Digital and the devices are learning fast and outcomes getting better with every new patient.
However, the old HIS and EMR systems or even the new breed Digital Health Apps lack credible Global Digital Health Standards. Hence, they exist in silos and don’t interact with each other or the larger Healthcare ecosystem. The data cannot be referred for any meaningful analysis. For example, we still don’t know clearly the size, scale and depth of the Dengue, Chikungunya and H1N1, Flu epidemics that strike us every year. Hence, we are always left gasping for breath when the seasonal spike starts. India is already the Diabetes capital of the world with 70 million cases and counting. We still don’t have standard protocols based Digital Disease Management Platform.
The HIS/EMR market in India requires EHR and Meta Data Standards based XML/JSON wrapper/objects that can help the existing systems to communicate with the external world in a Standardized format.
We need centralized Registries for uniquely identifying the Patient, Provider and the Facility where the treatment was carried out. We need Reference data dictionaries for standardizing the Diagnosis, Prognosis, Procedures, Laboratory tests, Radiological examinations, Drug prescriptions. This should be the common lookup so that everyone can be interoperable. The need for such Central Registries and Lookup Dictionaries is of paramount importance. Though the vital question remains, as to who will build and manage it. Should it be privately owned and controlled or publicly funded and managed.
Health Insurance sector has similar challenges. Private Health Insurance covers about 3% of India Population. There are 17+ Private Insurance companies that also do business in Health Insurance. 4 Public Sector Companies also cover Health Insurance. Four Private Insurance companies whose core business is only Health Insurance.
Public Health insurance covers about 10-17% of India Population. 80+% is Out of Pocket expenses. About 2% of India’s population falls below the poverty line every year due to unaffordable hospitalization expenses. Now the Central Government Pradhan Mantri Jan Arogya Yojana (PMJAY) has come to the rescue of most of the uninsured population. PMJAY is set to cover 40-50% of India’s Population. In absolute numbers the market is set to expand from the current 150 million people and go up to 500 million people.
Obviously, the TPA business which has been servicing only the private health insurance i.e. 3% of India’s population, must gear up to support PMJAY covering over 40% of India’s population. Hence TPA business is ready for disruption. The number of daily claims is set to go up by multiple times.
All these claims pipelines cannot be processed manually. We need to use high end technology to process the claims. We need a Standardized Claims format. The TPA market in India requires XML/JSON based standard Claims wrapper/object that can help the existing systems to communicate with the Hospital HIS/EMR world and the Health Insurance world in a Standardized format.
Globally, winds of change are evident. Digital is totally changing the way Health Insurance business has been run in the past. CVS has been building retail Primary Care centers and Diagnostics in its Pharmacies. Now with CVS Purchasing Aetna! John Hancock is shifting from traditional Life Insurance model to incentivize longer, healthier lives. In brief, they will move away from Life insurance model to Disease management and Precision medicine. Blockchain based Unique Identifiers are emerging. AI based start-ups are working on meta data driven Discharge Summary, Hospital Billing and Claims, Intelligent Claims Adjudication and Fraud detections. The Digital Tech Giants are becoming Healthcare companies. The lines are beginning to blur.
Is India far behind? Not really, India has a habit of leapfrogging stages, specifically with regard to Telecom and FinTech sectors. It will now happen to Healthcare. A Digital Healthcare Ecosystem is already taking shape.