A big challenge we see with universal health coverage in India is the financeability of care and the corresponding implications for health related poverty – there is an inability to access meaningful care, especially for the missing middle in India. Where insurance exists, it is often reimbursement based, involves significant fraud risk and is costly to process with long lead times.

Swasth is a multi-stakeholder health sector alliance that leverages digital technologies and healthcare expertise to drive healthcare inclusion & better health outcomes for India.

A key area of work for Swasth is the Health Claims Exchange (HCX) which has the potential to become a transformative factor in reaching Universal Health Coverage (UHC) in India.

HCX is a set of standards created by an open community of volunteers convened by the Swasth Alliance that is now being used to build a national claims routing network that can be interoperably accessed and used by all payers in the system – from private insurers to public and community payers.

As one of the core building blocks of Ayushman Bharat Digital Mission’s architecture, HCX’s construct is inspired by the recommendations of the 2019 Joint Working Group convened by National Health Authority (NHA) and Insurance Regulatory and Development Authority (IRDAI).

By enabling payer-provider interactions irrespective of who the payers and providers are, it focuses on improving the efficiency of insurance and other health benefit payments in India – both for those who are already insured (public and private) as well as for those who currently have no insurance (the missing middle).

The same infrastructure can support the transfer/exchange of any kind of health related information between health system participants – from doctors and healthcare providers to pharmacists, insurers and patients. The exchange can carry information on the services rendered, value delivered and the corresponding payments made or claimed for.

The immediate goal for HCX is to transform the viability and scale of cashless claims processing by:

Improving patient experience & outcomes: By decreasing the 6-24 additional hours spent by patients in hospitals waiting for payments to come through.

Reducing risk for payers/insurers by reducing fraud: By enabling reduced fraud, support the evolution and entry of new payers and new kinds of payers.

Reducing the cost of claims processing: Today, the cost of processing a claim ranges between Rs. 500-2000. This makes paying for small ticket items like primary care impossible. HCX will drive this cost down and enable payers to efficiently cover a wider range of services for the patient.

Reducing the time of claims processing: HCX will mean faster resolution of claims, therefore reducing the financial burden for insurance holders.

Enabling health benefits interoperability between all health stakeholders: Standardisation will lead to ease of information transfer & improve interoperability which will enable patients and policy holders to explore new, less expensive options.

Hence, HCX will act as the foundation of a wider health information exchange (HIX) that will eventually underpin universal value-based healthcare in India – in line with SDG 3.8, which is to ‘achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all’.

We believe that Swasth is uniquely positioned as the prime mover of foundational infrastructure – governance infrastructure, collaborative infrastructure, technological infrastructure – and we look forward to working with them in pursuit of our aspiration for a genuine population scale health for all goal!