Insurance and Healthcare Financing

This book provides an up-to-date overview of healthcare financing, and the role which health financing plays in achieving universal health coverage and broader goals of the health system. It includes a detailed examination of revenue collection and risk pooling methods that are essential for managing financial resources effectively. Additionally, it covers the strategic purchasing of healthcare services, focusing on ensuring that funds are allocated and utilized efficiently to maximize the value of healthcare services delivered. Advanced topics such as setting provider payment methods, pricing, and the role of Health Technology Assessment (HTA) in strategic purchasing are discussed. The book also provides the context of healthcare financing in India, including publicly financed health insurance schemes and the associated challenges of demand-side financing. Fraud management and the importance of robust governance, capacity building, and monitoring and evaluation systems are also covered in detail with lucid examples. The chapters in the book are supplemented with an executive summary, definitions of key terms, learning objectives, and provides recommendations for additional readings for better understanding. The book is relevant for students in public health, hospital administration, community medicine, economics, and health economics; as well as for insurance professionals, including claims managers and policy analysts, who are directly involved in health insurance and financing. Additionally, it is useful for policymakers and government officials responsible for designing and implementing health financing and insurance policies; as well as for health economists and financial managers seeking to improve healthcare financing and ensure effective resource management.

Dr. Shankar Prinja is a health economist, a public health professional, and formerly a senior administrator within the Government of India. He has published over 300 articles in peer-reviewed national and international journals. Dr. Prinja’s research on costing of healthcare services has led to revision of prices under the national flagship health insurance scheme - Ayushman Bharat Pradhan Mantri Jan Arogya Yojana. His research on health technology assessment has led to several policy and program developments and reforms at both state and national level. Dr. Prinja was the executive director of the National Health Authority, Government of India in 2022-23, where he led the design of several important policies for Ayushman Bharat Pradhan Mantri Jan Arogya Yojana, including the major revision of its health benefit package and pricing, and introducing several important policy reforms for provider payments and value-based care. He was also a member of several high-level international and national expert groups, which have contributed significantly to both development of research methods, policy and programs. Dr. Prinja has also developed several online courses in basic and advanced health economics, and health systems, which have been running since past more than 12 years, and contributed to the design of master’s course in health economics and technology assessment which has been approved by the Indian Council of Medical Research (ICMR) and University Grants Commission (UGC).

Chapter 1: Universal Health Coverage: How to Finance It?.- Chapter 2: Revenue Collection for Healthcare Service Delivery.- Chapter 3: Risk Pooling for Healthcare Financing.- Chapter 4: Purchasing of Healthcare Services: An Overview.- Chapter 5: Healthcare Financing in India.- Chapter 6: Publicly Financed Health Insurance Schemes in India.- Chapter 7: Challenges of Demand Side Financing.- Chapter 8: Strategic Purchasing in Healthcare.- Chapter 9: Healthcare Provider Payment Methods and Pricing.- Chapter 10: Health Technology Assessment (HTA) for Strategic Purchasing in Insurance.- Chapter 11: Fraud Management in Health Insurance.- Chapter 12: Governance, Capacity Building, and Monitoring and Evaluation for Health Insurance.