P11 Round Table Mental health Act, 2017 Impact on health Insurance industry– a research s



this is about Mental Health Act in India what is its impacts on health insurance industry they reach a study by two young persons are going to make a presentation to you today Joan buckle kindly come Okwe these suits okay that's fine yeah I will just briefly introduce the speakers to you and I will give a time of about 20 to 25 minutes for the bridge a presentation together and later on we can have questions on that topic the first the speaker is up there is a principle of millions India GA practice at managing director of the Middle East Prak practice he has more than 20 years of experience and reinsurance experience and has worked with clients in Asia and the Middle East he has experience working on product design pricing valuation measures adequacy shion's risk management business planning and strategic consulting services he serves as a parent luxury in India also and he's also the apparent actuary for a number of companies in Middle East he also advises leading financial and healthy regulators in the region and the other speaker is John buckle of Kassim topic only she's a principal and managing consultant formal events health practice in London she is experiencing health markets from the US Europe to Asia and the Middle East she works on traditional actual works such as pricing capital modeling and deserving but also has significant experience in managed care analytics and advise her clients on calculation methods for assessing the value of health interventions she has significant experience in both the public and private sector in fact I widly remember apart from this mental healthcare act there is a Disabilities Act also in this country which is defined what is the ability in fact in insurance can be provided to these disabled persons also and some of the insurers have some products to address the disabled persons also in this country so I would request the speakers to go ahead Scheffer and let us understand this mental state students and I think it is it is going to give good opposite well the health insurers and also you are going to do should say good work to the society beneficial to the society thank you thank you very much ladies and gentlemen I know this is the penultimate session of the day so the few people here but hopefully we'll have a focused discussion just to introduce the subject in the context of the mental healthcare act of 2017 in India and the ramifications of that in the industry it's important to understand that mental health care is very topical the World Health Organization in a landmark report in 2001 gave a global attention to this subject because there is a social stigma when it when we talk about mental health this is a question of physical health where insurance takes care of that component when comes when we talk about mental health there is always a socio-cultural stigma attached to what it means what it entails in whether one should go to psychiatrists or or treatment for for such conditions so the World Health Organization put together a taskforce in 2001 that led to an action plan for 2013 to 20 they ensure that certain fundamental objectives are fulfilled as far as the universal right of every human being is concerned and that includes mental health care so the World Health Organization put together a proposition with four objectives number one was to strengthen leadership in governance as far as mental health care is concerned globally number two is to provide a comprehensive integrated approach to mental health and the social care that is required within community structures and number three was to implement strategies for the promotion and the prevention in mental health and last but not least was to strengthen the information systems and the research and the development around this issue because there is no data as such so it is with this spirit in mind that the government of India the Ministry of Health and Family Welfare put together a research which they published in 2016 the National Mental Health Survey of India this was a survey carried out under the Ministry of Al across 12 different states in India it is a comprehensive study available on the Internet it is a qualitative and a quantitative study where there was a taskforce that went out in 12 different states collected data spoke to the people on the ground understood ward mental health care is talk to those who are affected by this and these statistics that emerge as a result of this particular study were quite revealing in that almost 150 million Indians need some form of support in this area less than 30 million are actually seeking cure when it comes to mental health and less than 10 percent of those are effectively getting the treatment that they deserve and a lot of this is attributed to social stigma that the community should not know about it or we don't know who to go out and talk to and there were there were anecdotal evidence is within this report that suggests that people didn't even know that they could go for treatment or for psychiatry support or or if they were addicted to drugs or alcohol and so on and so forth so this study was quite profound and revealing that actually led to the Mental Health Care Act of 2017 so what I would like to do are together with John is to literally go through the the various components the key features of the Mental Health Care Act the IRD is circular as a result of that the mental illness to understand what mental illness is you know as we were talking this morning about health insurance in itself being nascent in in the maturity of our proposition in India motor insurance and other lines are sort of advancing this is where we are as far as health insurance is concerned particularly when it comes to mental health so understanding and appreciating what mental health is and how would that impact us in light of this actus it's critical so to understand the different components and different types of mental illnesses what is included within the scope of the Insurance Act and what is excluded and then we'll talk about some of the the prevalence is that that we see in India the the challenges as far as the supply side is concerned significant challenges and thereafter when we have sort of covered the the Indian landscape John is going to talk about some of the international market practices as far as mental health is concerned and last but not least Milliman carried out a survey after the act last year where we asked a series of questions to the industry as far as the Mental Health Care Act is concerned and the impact on the insurance industry so we will try and share some of those results and put some considerations as food for thought as I say this is very blurry Maneri and it is important that we are on a journey as we try to understand and dissect what mental health care is all about the act itself is concerned the act is to provide for mental health care and services for person with mental illness to protect not only to protect look at the wordings to promote and to fulfill the rights of such persons during delivery of mental health care and services and for matters connected they're in or incidental thereto so this act is profound and there was a previous act in 1987 this act in effect gates or extends the scope of what the mental healthcare requirements are going forward so effectively this is a right of every individual in the country that not only are you to be provided with the physical healthcare the mental component is equally important it attempts to protect the right of the mentally ill and enable citizens to decide on a method of treatment it's giving the choice for the method of treatment as well and as a result of this Act IRDA also issued a circular on the 16th of August directing insurance companies offering health insurance to cover treatment for mental illnesses so this is where the debate is what will be the potential impact on the insurance policies health insurance policies going forward and and because it has been excluded it was an exclusion and now it can no more be an exclusion as far as the Act is concerned so let's let's look at a few key features of the Act itself the rights of people with mental illness the right to advance directive this is where the preferred way of care is chosen and not only that the the the right of a person who is suffering from mental illness is that he can or she can nominate somebody to support him or her in the process the number two is the right to access accessibility both in public and private services and number three is the right to confidentiality the treatment that is given has to be absolutely confidential at every stage at every phase of the treatment as far as insurance provision is concerned yes it's explicitly states that light physical insurance is provided mental should also be provided so I the supply provision is concerned the integration of at all levels of health care it comes to public health the primary secondary and tertiary bringing in professionals and you will see that as far as the supply side is concerned later or in terms of the number of people who are available to support those who are suffering from mental illness the establishment of central and state mental health authorities throughout the country and last but not least the mental health review commission and health review boards who are supposed to assess and evaluate the effectiveness of this act going forth as far as admissions discharge and treatments are concerned admissions as independent patient in mental health establishments it is limited to 30 days if it goes beyond 30 days then you need referrals from at least two independent psychiatrists out there and the provision does not separate women and children below the age of three unless approved by the authority as far as public awareness is concerned wide publicity through the public media television and other channels to go out and educate the people that there is that availability or they have the right of getting the treatment in the country and last but not least is strictness amongst though especially on on the professionals out there ensuring that any unregistered establishment of health professionals are liable for a penalty so you need to be registered and professionally in this area of expertise now the key question is what is mental health what is included and what is excluded as far as the as the current health insurance policies are concerned now as I mentioned to you that you know this is very much of the nation stage and a level of maturity is very early on and we're trying to understand and appreciate the the scope of mental illness there's a pretty wide scope I mean if you look at the definition as per the Act mental illness is defined as the substantial disorder of thinking mood perception orientation or memory that grossly eBay's judgment behavior capacity to recognize reality or ability to meet the ordinary demands of life mental conditions associated with the abuse of alcohol and drugs but does not include mental retardation which is a condition of arrested or incomplete development of the mind of a person especially characterized by sub normality of intelligence so you can see the scope is pretty comprehensive and when you look at the landscape in itself the the numbers are quite scary in the sense that there is a significant population out there that requires the treatment according to a w-h-o reporting there's so many numbers floating around according to whe Oh report seven and a half percent of Indians suffer from major and minor mental disorders requiring expert intervention according to the report that that was presented in this study of to the ministry you find the numbers are even more but more importantly there are fewer people who are access to professional treatment or professional support when it comes to mental so it's it's a pretty comprehensive area to try and understand appreciate the different components and that's why to to be able to dissect this even as an actuary I need to work with the clinician and try to understand what are the international classification of diseases as far as mental health is concerned how do I classify them into different components within the inpatient or within the outpatient spectrum to understand what is the scope and what is the potential price out there so broadly speaking when it comes to this report that was issued by the ministry in 2060 and these numbers come directly from the report they are weighted prevalence rates across the board some of it as excluded but just to put it in perspective here you can see over here that you have the common mental disorders on the left-hand side with su DS STDs is referring to substance use disorder yeah and on the right hand side is the SMD which is the severe mental disorder that requires inpatient support and this is where you know you probably can broadly define as what is the right hand side is inpatient and the left hand side is outpatient but having said that there is some ambiguity around what is covered and what is not covered under the Act certainly as far as insurance industry is concerned but what's revealing in this is that that the the current prevalence is pretty pretty high and when you look when you look at the split into the severe components the severe medical disorder it's it's it's a smaller component of the overall proposition like life expectancy is expected to be a lot lower as far as that is concerned but if you look at the left-hand side and this excludes by the way tobacco when you bring in tobacco the numbers are literally sure up so the prevalence varies according to its a psychological as social atmosphere we look at some numbers the prevalence Peaks between the age of 40 and 49 and the common mental disorders identified between different genders and different components of that and then interestingly the urban metro has the highest prevalence rates out there so I think I think the point here now is to try and understand some fundamental features within that but let's look at the the numbers in the report itself and you can see there as far as the numbers are concerned the prevalence is highest within the middle age group by gender is higher amongst the male as far as marital status is concern is the probably higher amongst the videos and the divorced again implicit challenges as far as depression and other components are concerned when it comes to the challenges that an individual faces in that in that segment the prevalence by residents the urban metro interestingly has the highest the prevalence of my education is primarily around you those who have had primary education and as far as the income quintile is concerned it is at the lowest level so you can see even from a socio-economic perspective it is moving twas the lower end of the spectrum but having said that the urban metric component is critical and this is just providing some more details within the comprehensive study that was done by the Ministry of Health and Welfare so for example when I look at the psychoactive substance use disorder which is at twenty two point four four and you look at the graph at the bottom right hand side you can see almost twenty point eight nine the bulk of it is coming from tobacco use disorder when I look at the mood disorders and by the way those are the ICD coding F 30 F 39 if we look at the mood disorders you look at the right hand side upper upper graph you can see that the majority of that is depressive disorders so there is a whole spectrum you can see across the board and there is so much to understand and and and and and look into when it comes to understanding mental health and the coverage that we provide now as far as the supply side is concerned because it's important to understand that you have the demand component you look at the prevalence rates you say okay you know it's 10% let's do some back of envelope numbers these severe cases are almost one per se and the rest is 9% you know we try and try and understand the numbers but the critical pareil is a supply-side what facilities are out there to support those who really need that attention that the act is providing so according to WH o and according to the report as well you can see there's a whole spectrum of recommendations that our where support should be provided from the village level all the way to the Community Care all these different forms of support are required depending on the type of mental care that you require but what's interesting is there's the level oddity the supply side is is very very challenging we are talking of just three and a half almost close to 4,000 psychiatrists in the entire country versus the need to have eleven and a half thousand to meet the current needs out there based on the prevalence rates that we see and in all if you add up all the professionals out there effectively you find that there is a huge gap between the need and the availability are talking off for less than 7,000 people out there to support and and there is a need of almost fifty six thousand seven hundred and fifty based on the prevalence rate so there's a huge gap when it comes to the supply side and and this is where you can see for example when it comes to the government sector there's only half a dozen of hospitals that are literally available to support such patients there's a high variability amongst the states you know from point one two to ten per hundred thousand cases out there and you can see the challenges on the supply side so we need to appreciate and understand that yes there is this huge demand but then there is a major gap between the the demand and the supply I think I'll probably stop here and hand it over to Joanne to talk about international markets and in this survey that we have carried out and discuss it yeah okay right I don't have been tied to the to the podium so I'm gonna get some steps in steps are very good for your mental health as well as your physical health so I'm gonna get some steps in while I do this and hopefully it's not too distracting so mental health coverage in international markets is interesting we looked at a few international markets particularly UK USA Brazil South Africa UAE and and they each had slightly different ways of approaching the issue of mental health in law anyway so USA has a separate Mental Health Act it's very clear about expecting parity between mental and physical coverage of benefits in the UK and South Africa there's no separate Act but there are particularly in the UK there is a set of directives that say that the NHS should give parity between physical and mental health now that doesn't happen in reality for the same issues that it won't happen in reality here and that's because the supply side is much much more constrained so if you're looking for a physical intervention you might have a waiting list or a few weeks to a few months quite often if you're looking for mental health intervention you could have a waiting list of well over a year for certain mental health interventions so although in theory there's parity in practice it rarely plays out like that and then in Brazil there's no separate act in a UAE they're in the process of getting a mental health law this year so types of mental health mental illnesses covered tend to be pretty uniform so people tend to use the DSM V Diagnostic and Statistical Manual of diseases sorry of mental disorders and and typical icd-10 codes and then in South Africa they have a slightly different system and the plan benefits tend to be relatively uniform so we're looking at inpatient outpatient treatment and but the interesting thing in particular about mental health is that it's very very hard for insurers to manage and therefore most in tend to default back to number of days limits on inpatient treatment number of visits limits on outpatient treatment and/or some kind of monetary limit because it's extremely hard to manage so one of the things that's interesting here is is thinking about how you do underwriting and risk assessment so in those countries it's based on the discretion of the underwriter but there is no separate risk assessment for mental health and when I get to the bits about the India survey then I think that's important because one of the results that came out of that for me was slightly counterintuitive which I'll speak to in a second but the same thing challenges arise so lack of data pricing difficulties you can't allow risk selection and not enough doctors and the supply side issue again the risk mitigation strategies will tend to be fairly uniform so again got strict benefit limits sometimes you see things like limiting inpatient stays with rather than just a benefit limit where the action specialists unit setup within insurers and the UK went into this in a big way about 10 years ago and insurers realized that their psychiatric costs were getting to be a larger and larger proportion of their overall costs and in some cases were well over 10 to 15 percent for the more generous policies of their overall costs and they set up a lot of specialist case management around it now as you can imagine if somebody is in a psychiatric hospital it is very very very difficult for an insurer to be able to move them on from that setting because typically the benefit plants don't support other norm inpatient interventions there's nowhere for that person to go if that person doesn't have home support then it's extremely difficult to set these things up and therefore even if you have some quite specialist case management around it and a lot of insurers had psychiatrists on their staff managing the cases it's difficult to know how in reality is an insurer you can limit your financial exposure at that point if that person has major depression and is in a secure psychiatric unit and can't be released because they're not getting better and often with things like depression it takes many many many weeks of treatment for even basic drugs to start working what can you really in reality do in that situation to limit your risk and the answer is very little and after what you've got written in your policy terms and conditions so there was a lot of specialist case management and there's a lot of co-pays and those those kind of member coinsurance type issues and I'm gonna move on in the interest of time and talk a little bit about the industry sir so we sent out a survey to nine insurance well more than nine nine responded in the Indian market primarily underwriters responded although we had a few actuaries respond as well and and we asked a number of questions and I'm just going to go through some of the answers to those questions and and just give my comments on some of those answers so there was a lot of concern about mental illness definition people considering in the definition in their new product filings thinking about how they were going to set up a defined list of included or excluded mental illnesses I don't know how you do that in reality but a lot of people out there seem confident that they could do it so I'm fascinated to see what comes onto the market because I haven't seen anybody anywhere in the world managed to do this with much precision we took asked a bit about product design we had quite a few people who say there was some expected progress on product design so indemnity cover up to a sub limit standalone mental illness product so I was fascinated by this one I don't think I've ever seen one of these and you are in the world and yet half of the people in our survey said we expect to develop a standalone mental health product now one of the issues with that is that mental health and physical health are very very indivisible so if you have a mental disorder you have a very high probability of having a physical comorbidity and if you have a physical disorder you have a high probability of having a mentor comorbidity the other thing about it is if you have physical coverage in separate products with wellness benefits attached to those your ability to engage that person in your in the wellness part of that benefit is going to be severely limited if they also have a mental comorbidity and in some studies I've seen you will be better off treating that mental comorbidity and it will reduce the physical cost of illness then you would be to leave it alone so I think if you go down the route of thinking of them as totally separate things with separate products I can't see how you would make that work in reality and I'm not sure it makes much economic sense but just something to think about and treatment design options say there was lots of willingness to provide coverage for different types of treatment options so not just the sort of standard Western treatment if you like but a lot of other treatment options I think that's fine I think I would have a slight concern with some of those treatment options that what's to stop you funding a week in a spa for somebody who's mildly depressed I'd like I'd like a week in a spa if someone was gonna pay for it I'd be pretty happy I've seen that happen in other countries and these things are very difficult to control it's very difficult to be able to think about the definitions that you would put in place to allow people access to certain benefits risk mitigation people were going down the route typically of pre-existing exclusions deductible co-payments and your benefit limit so I think that all makes sense I'm not sure how you pick up some of those pre-existing things and and this sort of leads on nicely to underwriting process so I was fascinated to find the the vast majority of people in our survey we're looking at doing some kind of tele health underwriting or interview for mental health screening now if I have mild to moderate depression that I haven't yet admitted to myself and you put me in front of a tele house underwriting system so maybe something that's like a standard depression questionnaire and it spits out hey Joe you're mildly depressed I'm not gonna be very happy about that you're diagnosing me so I'm not sure how you ask those questions you can ask standard questions about have you ever been admitted for psychiatric treatment have you ever been diagnosed but given the prevalence of undiagnosed disorder I'm not sure how that really helps you as an underwriter so that's also something to think about quite carefully I'd love to be able to see these questions that are filtering out these people with mental illnesses because I couldn't get my head around how that was gonna work so there's lots of pricing challenges as we've already talked about lack of clarity and cover changes in consumer behavior initial low policyholder awareness I think the biggest pricing challenge is going to be that supplier size issue because we all know that the most important thing for your utilization rates is going to be access to the supply side and that initially is going to be severely constrained but that may change over time expected claims cost so we had a very very very broad range of results to there so we basically said what do we think will be the increase in claims costs due to inclusion of mental illness and we had answers ranging from less than one percent to over ten percent that's a pretty broad range I would be on the low side of that initially just because of the supplier and use demand issue but I could see it increasing quite significantly over time I think it will have a much higher inflation rate than a standard physical only product information about networks is very lacking so most people didn't know what kind of facilities were out there they didn't know what kind of mental health network they were going to be able to get they didn't have any information on the mental health facilities in particular areas so that's going to be a problem and then that came with risk and I've already talked about the fact that it's basically in Turin linked with physical disorder and therefore you really need a strategy to manage both of those at the same time they are not typically separate divisible things so I'm going to go through this very quickly because I'm aware of time I'm trying not to be the thing that everybody else has done have run over time so key considerations we've talked about some of these already product design and definition so clarity on definition you're likely to get very significant variation in interpretation across front insurers pricing we've we've talked about underwriting I think he's going to be extremely difficult particularly for a mental health only product I don't really know how that how that would work claims processing management say typical imagine you're going to get non-disclosure unless you write the magic questionnaire that can pick up lots of undiagnosed illness you're going to have to have trained claims Assessors and then those issues I think around data collection and then typical knock-on issues around reserving if this does turn out to be a relatively big deal with a with a fairly high inflation rate some of the other considerations to think about so rights of people with mental illness and the provision of advanced directives which SAFTA referred to already means patients might have greater control on the preferred choice of care and providers might have quite limited control on how they actually define that appropriate treatment typically what I've seen in other markets is that you as an insurer have almost no control over that treatment pathway so if you think you have very limited control over the physical or the surgical treatment pathway wait till you get to mental health you're going to have almost zero say in it insurance provision so not much clarity around what can be covered within the insurance cover there might be some innovative products I mean I'd like to see more innovation around the wellness bit and whether or not you could integrate the mental and the physical benefits and actually come up with a strategy that manages health overall I think potential there for much more comprehensive insurance products with outpatient cover a lot of mental health will be on the outpatient side so that's something to think about we've talked about supply provision already and and just just a point here on admission so as I said earlier these some of these things if you get very serious mental illnesses these people can be in hospital for a really really really long time a really long time months and months and months and months and months you've just got to think about how you're going to manage that a little bit and then lastly just a note to insurers so keep an eye on what the mental health review board are doing because some of those modifications of advanced directives are likely to have implications on the coverage that can be offered so keep them keep them close and keep an eye on it and see what's going on there okay I think I did kind of okay thank you mic here I always gotta let the gentlemen up the back go first just just a personal a personal which is one of the things that I make a point of saying here you mentioned stigma with mental health and it's an important point and one reason why these sorts of things still cause a lot of problems in the community is that there is that stigma and it's up to people such as myself to actually help to overcome that stigma because I suffer from depression because I'm able to be adequately medicated but yeah I'm not the sort of person who should suffer from depression I do I'm okay with it but when I first came down with it I had to take months off work and you're right that's that's though any an incredible cost luckily I was with a very good employer at that point of time but as professionals as people who were supposed to be rational about this you know suffering from depression is as bad as breaking away or having some other physical trauma which is obvious the thing is depression is not obvious to most people so we have to as a as a profession actually reduce the stigma in the general population and that will help all that we're doing there and it will actually reduce the cost to society as a whole even ignoring the cost of the insurance and so forth so that's basically what what I'm here saying reduce the stigma which means anybody who's suffering from mental illness should think very seriously about telling other people so what is the so they might have done already something can we just pick on those positives that they have done on do you have any insights on what they have done which we could pick up on it and build a framework around other than keeping so many open questions with us well I think that's that's part of the problem so if you look at their responses that insurers have made in other parts of the world they've been very rational responses from their perspective they said well we'll only pay for a certain number of days we'll only pay for a certain number of visits there's nothing outcome-based about that and therefore what tends to happen is people they have treatment for a period of time they run out of coverage they stop having that treatment they're then in a cycle of being sick again and then we qualifying for treatment and basically going in and out of the system and I see that in in many countries and that happens in the UK even with the National Health Service because there's such limited capacity for beds and in the spirit of sharing as the gentleman there did my I don't have depression myself but my mother has major depression on and off throughout her life and has spent many many months in various NHS hospitals and and I can tell you from a personal perspective there first of all they're not places that you get better they're places that you basically are held in in a holding pattern until the drugs work they're not there to give you comprehensive treatment they're just not set up in that way they're not anywhere that I would ever wish anybody to spend any time quite frankly and and they release you as soon as they possibly can because they need that bed for somebody else and and therefore three months later you're back in that bed when you've risen up the critical list than somebody else has gone down the critical list slightly so I don't I don't think there's any easy answers to that I don't think that I don't think insurers have the answers to that quite frankly I think insurance is going to play a part in this but but we from from a financial perspective the only way that we can really limit our risk at the moment is to put some very strict benefit limits around it and and we have to acknowledge that that is not going to solve the problem but but I don't have any great answers for how you can solve the problem because one of the other issues you have of course is that the benefits to managing somebody's mental illness are typically going to accrue to their employer through less workplace absence through all of those things and and that person is going to have a much happier more fulfilled life there's no benefit to use an insurer for that person having a much happier more fulfilled life but there is a benefit to society so I think you look at it the insurance only issue is only to look at very one small part of the picture add one more point to this the fact that this has very small questions I think in itself with the objective of this presentation that there will be more questions than answers at this stage because we are in the very early phases of understanding sorry but no what I was saying is that the fact that this has raised more questions than answers in itself meets the objective of this presentation it was meant to to to raise questions because we are in an evolving process way comes to mental health now there have been certain quick solutions in certain markets that has worked implicitly so for example trauma trauma is a big issue particularly after an accident – the person enters into trauma which leads to depression and mental issues then it can it can go on and and some of the jurisdictions do have some insurance fund social insurance fund where you would support people who go through trauma or certain major mental illnesses that get really prolonged to be met by some form of insurance fun but this is just one example of what some of the jurisdictions out there are doing but as Joan mentioned there is no easy solution to this and if we devolve the time okay I think questions are over thanks for the good presentation by speakers [Applause]

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