Dvara Analysis Weblog | Can Leveraging Social Capital Improve Shoppers’ Expertise with Well being Insurance coverage?

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Introduction

Common well being protection (UHC) is a well being coverage purpose for a lot of creating international locations, together with India. UHC implies that “all folks have entry to the total vary of high quality well being providers they want, when and the place they want them, with out monetary hardship” (World Financial institution, n.d.). To realize this purpose, governments worldwide, together with India, are designing medical insurance packages that present various ranges of twin entry, i.e., healthcare and monetary safety (Forgia & Nagpal, 2012). Additional, a number of smaller and focused community-based medical insurance (CBHI) packages have taken form to supply such entry to poorer populations (Bhat et al., 2017). Nevertheless, for a lot of of those packages, the street to realizing these goals and translating them into improved well being outcomes is riddled with a number of challenges.

These challenges might originate from each the demand and provide sides, finally impacting the buyer. For instance, challenges on the demand aspect might embody behavioural biases impeding insurance coverage uptake (Ashraf et al., 2021). On the provision aspect, the design of medical insurance packages can also give rise to sure challenges. As an example, the kind of incentives supplied to healthcare suppliers might have an effect on the supply of healthcare providers, akin to beneath or over-provisioning, denial of providers, or the standard of healthcare providers supplied (Ashraf et al., 2021).

When considered from a shopper’s perspective, these challenges manifest at totally different levels of their journey with a medical insurance program, starting from the choice to enrol in a program and ending on the renewal stage. Whereas tweaks to the design of the medical insurance program or shifting to a extra built-in mannequin of healthcare provision might assist (Ashraf et al., 2021), on this weblog submit, we discover the function that social capital can play in circumventing a few of these challenges.

Social Capital and Well being Insurance coverage

The idea of social capital is carefully linked to the idea of a group. Social capital, the place it exists, could be traced to the existence of a group and social relationships amongst members of such a group. Not like an arbitrary group of individuals, a group represents a bunch with shared pursuits, targets, experiences, values, language, faith, and many others. For instance, migrant staff might turn out to be a part of a group at their office due to shared ethnicity, akin to coming from the identical Indian state and talking the identical language. Such commonalities can carry folks collectively, and interactions amongst them can result in particular person and group bonds creating. We are able to think about such particular person and group interactions occurring as a part of on a regular basis lives or as a part of deliberate makes an attempt to create a group. Within the earlier instance, migrant staff might work together with one another continuously on account of being on the identical job web site, or an occasion could also be organized to carry staff with a shared ethnicity collectively. Each types of interactions, repeated over a interval, can strengthen bonds, create a way of belonging and regularly result in a close-knit group forming.

Inside communities, member interactions, each deliberate and unplanned, might evolve into rituals that turn out to be markers of belongingness but additionally act to strengthen present bonds. Right here, rituals discuss with behaviours and actions that group members usually show or observe. Within the earlier instance of migrant staff, an instance of a ritualmay be staff coming collectively as soon as day-after-day to arrange and share meals. Over a interval, such rituals and the areas for interactions they create permit members to share their on a regular basis lives and experiences, producing a way of belief, reciprocity, and solidarity among the many members. These elements are what we discuss with as social capital[1].

In medical insurance, the idea of social capital has been acknowledged as a key determinant of the success of CBHI packages which are sometimes voluntary and require prepayment to entry providers. Particularly, emotions of belief and solidarity have been discovered to considerably affect the willingness of group members to enrol (Donfouet & Mahieu, 2012; Dror et al., 2016; Negera & Abdisa, 2022). Nevertheless, past enrolment into such packages, the potential of social capital in mitigating most of the different challenges customers might face with medical insurance packages stays largely unexplored. Whereas the discourse round social capital additionally cautions in opposition to its downsides (Moore & Kawachi, 2017; Donfouet & Mahieu, 2012), we prohibit our focus on this weblog submit to social capital as an enabler.

A Client’s Journey with Well being Insurance coverage

A shopper’s journey with a medical insurance program could also be broadly divided into 5 levels, as talked about beneath. We argue that there’s scope at every of those levels for leveraging social capital and the rituals integral to producing and sustaining it[2]. We establish group members, group well being staff, and group leaders as related stakeholders on this context. Common interactions amongst them, whether or not formal or casual, can present potential avenues by way of which social capital could be put to work to deal with most of the challenges customers might face in successfully benefitting from medical insurance packages.

1. Enrolment in a medical insurance program

A shopper’s choice to enrol in a medical insurance program could also be affected by a number of components, chief amongst that are consciousness of 1’s healthcare wants, consciousness and appreciation of medical insurance, and behavioural biases related to in search of healthcare and medical insurance (Ashraf & Nambiar, 2021). Even when these challenges had been resolved, customers would possibly nonetheless have program-specific considerations, akin to apprehensions relating to the potential misuse of premium cash. We see a job for social capital in addressing such considerations. As an example, when group members work together with these in the neighborhood which have skilled medical insurance advantages, they could come to see the worth of medical insurance and be persuaded to enrol in a program.

2. Utilization of healthcare providers

Accessing healthcare by way of the insurance coverage program can both contain solely inpatient care (as in lots of indemnity packages) or the complete spectrum of providers encompassing preventive care, main care, and hospitalization (as in managed care packages) (Ashraf, 2021). It needs to be apparent that higher well being outcomes are extra possible as a system strikes nearer to providing the complete spectrum of providers, or on the very least, a mix of preventive care and medical recommendation relating to, firstly, the even handed use of medicines and, secondly, acceptable ranges of secondary or tertiary care. In India, nevertheless, an built-in and holistic method to healthcare is generally absent because of the preponderance of indemnity insurance coverage. Subsequently, Indian customers don’t usually search preventive care, and after they require hospitalization, they typically face challenges in selecting and accessing acceptable care. Right here too, then, we see a vital function for social capital. As an example, interactions with trusted group well being staff and leaders might persuade members to avail acceptable preventive healthcare. Additional, belief and emotions of solidarity might immediate members to help one another in accessing time-sensitive details about healthcare suppliers coated beneath an insurance coverage program throughout well being shock.

3. Claims settlement course of

In insurance coverage packages that provide cashless therapy, customers ideally don’t incur out-of-pocket bills for therapy. Nevertheless, the place insurance coverage packages pay retrospectively for therapy bills, customers want to hunt reimbursement by way of a claims settlement course of that will contain a number of interactions with an insurance coverage program’s administration. With out consciousness of and entry to mandatory info, customers will discover the claims settlement course of to be cumbersome and difficult. Right here, social capital might permit group members to help one another, making the method extra accessible, easier, and fewer useful resource intensive for the aggrieved member.

4. Grievance redress mechanism

From their expertise of accessing and using healthcare providers, customers might endure grievances that want redressal. These might embody denial of healthcare, delay in receiving healthcare, poor high quality of providers acquired, overbilling, and even issues with the claims settlement course of. Once more, as with the claims settlement course of, a lack of understanding of grievance redress mechanisms and entry to mandatory info might make the redress course of difficult. Group bonds could also be leveraged to disseminate info on submitting a grievance, to supply periodic updates on the development of grievance processing, and to make group members conscious of obtainable avenues for escalation.

5. Renewal choice

On the finish of a shopper’s journey with a medical insurance program (in a single membership cycle), they could select to resume their enrolment or choose out. Broadly, two components might affect this choice. One, the absence of a well being shock in the course of the earlier subscription interval might trigger customers to query the deserves of renewing. Two, for customers who skilled a well being shock in the course of the earlier subscription interval, their expertise of using healthcare by way of this system can turn out to be dispositive.

Social capital may help handle a few of these considerations. As an example, interactions with different members who’ve skilled a well being shock and availed of healthcare beneath an insurance coverage program might persuade members who didn’t have to make use of the providers to nonetheless renew. Additional, group leaders could possibly be actively concerned in capturing and relaying shopper suggestions to program heads inspiring shopper confidence within the scheme regardless of remoted incidences of poor providers.

Conclusion

The function of social capital in medical insurance has been explored beforehand however to a restricted extent from a shopper’s perspective. On this weblog submit, we’ve tried to map customers’ journey with medical insurance packages, establish potential challenges they could face in successfully benefitting from the packages, and supplied examples of how social capital could be put to work to beat these challenges. To successfully leverage social capital on this means, some rituals that carry group members collectively might have to be formalized. As soon as absolutely developed, this framework can probably kind a helpful lens to judge medical insurance packages from a shopper perspective and assist in creating community-driven options to shopper challenges.

References

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[1] Students throughout disciplines view social capital otherwise; no single agreed-upon definition exists. Nevertheless, the present discourse broadly credit two sociologists, Pierre Bourdieu and James Coleman, for theorizing the idea. Whereas each think about social capital as a useful resource that emanates from and resides in societal relationships, there are specific variations of their respective conceptualizations. Bourdieu felt that social capital permits particular person entry to sources hitherto unavailable, the absence of which deprives one of many identical. However, Coleman regarded social capital as a high quality of the collective that garners the entire group larger entry to sources or goodwill (Claridge, 2017). Finally it was a political scientist, Robert Putnam, who popularised the time period and aggregated it to the belief that facilitates interpersonal cooperation.

[2] The buyer journey levels, processes concerned at every stage, and their sequence within the journey might differ based mostly on the insurance coverage coverage and the nation context.

Cite this weblog:

APA

Prasad, S. G., & Nambiar, A. (2023). Can Leveraging Social Capital Improve Shoppers’ Expertise with Well being Insurance coverage? Retrieved from Dvara Analysis.

MLA

Prasad, Sowmini G and Anjali Nambiar. “Can Leveraging Social Capital Improve Shoppers’ Expertise with Well being Insurance coverage?” 2023. Dvara Analysis.

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Prasad, Sowmini G, and Anjali Nambiar. 2023. “Can Leveraging Social Capital Improve Shoppers’ Expertise with Well being Insurance coverage?” Dvara Analysis.