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On designing and conducting action research to understand health insurance claims patterns or developing health education tools


Emerging Project Lessons

A survey must be carefully tested and piloted before household interviews commence. Based on the experience of VimoSEWA, it is critical to test a range of methods to define and measure illness, particularly minor illness.  Local individuals who are familiar with the culture and available services should be trained to administer the survey.

A grassroots organization has a particular advantage to design and carry out action research.  VimoSEWA researchers and their implementing counterparts (i.e. CHWs) benefited from working together to develop systematic processes and standard materials for use in each of the health prevention and promotion interventions. The teams collaborated to effectively deal with small, ongoing challenges which emerged as the interventions were tested. As a result, researchers’ understanding of the intervention tools and processes, seen through the lens of the community was enhanced. They could analyze data and adapt tools and processes more effectively.

It is essential to analyze health claims on a frequency and cost basis per member (or per 1000 members) to uncover what is really driving results.  Instead of analyzing total amounts, VimoSEWA segmented and analyzed several years of claims data on per unit basis (e.g. number of hospitalizations per 1000 members).  By looking at claim incidence, cost and diagnosis per 1000 members, trends can be more easily observed, and the “noise” coming from change in membership and in the insured population reduced. For more details, see Emerging Insight 10.

Hysterectomies are a leading source of expenditure and claims.  One outcome of the detailed per unit claims analysis was that hysterectomy emerged as a primary driver of claim costs.  The findings raise concern about clinically indicated hysterectomies versus those that are medically unnecessary but perhaps are performed to generate revenue for providers, provide an expensive method of sterilization, etc.  As a result, VimoSEWA decided to create a specific health “intervention” to educate women as to when hysterectomy may be necessary and when it’s not.  To support this effort, a second opinion feature was implemented to encourage clients to validate with a government physician or a SEWA health worker supported by an in-house doctor if a hysterectomy recommended by a provider was supported by medical evidence. 

Epidemiological statistics can help interpret claims data.  Epidemiology is the study of the distribution and determinants of disease.  Epidemiological data can help guide the design of health interventions or other value added services, as well as support accurate pricing (based on more accurate prediction of expected claims) and optimal product design. VimoSEWA sees a high rate of hysterectomy in women below the age of 40, yet it is a challenge to interpret this finding (or others like it) without data on the expected incidence and cause of illnesses, and accompanying guidelines which can help to establish the medical indications for procedures like hysterectomy.

Hospital claims data require significant time and effort to sort and code to obtain more useful analysis.  VimoSEWA realized once it dug into claims data that there is a high degree of inconsistency with how claims are reported, particularly for diagnosis and procedures/treatments.  One of the greatest challenges is to be able to group like diagnoses and like procedures together, as they can be documented inconsistently, e.g.:  at least 16 types of fever were documented in the claims data sample using various terms such as fever, acute malaria, viral fever, etc., making it challenging to create a comprehensive count of admissions due to fever.  One solution implemented in more developed health care delivery environments is to use standard codes and definitions, such as the ICD10 diagnoses and procedure codes.  In many developing countries such as India, claims data are very challenging to accurately assess. For more details, see Emerging Insight 12.

Urban clients have more claims and the cost per claim is higher than their rural counterparts. VimoSEWA observed different health seeking behaviour in Ahmedabad city compared to the rural district locations.  Reasons for this will be analyzed further, but hypotheses include:  1) drug use per claim is higher in urban settings, and 2) access to hospitals on a “cashless” basis might encourage hospitalizations, though it’s not known if this creates a positive outcome for clients’ health.

Drugs are another key driver of claims costs.  In India, government hospitals are free to clients, but due to corruption, leakage, etc. Often drugs are not available and patients must purchase them out of pocket.  VimoSEWA’s plan covers drugs as a part of hospitalization, so in fact 50% of all claims costs are generated by purchasing drugs.

Implementing guidelines on how to conduct health education sessions can ensure consistent quality. VimoSEWA observed that maintaining uniformity and consistency of health education sessions led by community health workers is a challenge. Guidelines for the education sessions were developed following the observation of ten meetings (six urban and four rural):

1.       Each education meeting should cover only one of the three topics.

2.       CHWsare to inform the members in the community about the session in advance.

3.       The CHWs should start a game as soon as four to five members arrive. By the time all the women arrive, the game should be over and the CHW can begin the discussion using posters.

4.       The CHWs should focus on key messages during the meeting and have members repeat the messages at the end of each session.

5.       To ensure that meeting participants memorized the key messages, each participant should repeat the messages before she took the soap given out at the end of the training.

6.       If the education topic is diarrhoea, the CHW should do a practical demonstration of preparing oral rehydration salts (ORS). The demonstration involves boiling water, cooling it, measuring the correct amount using the measuring cup that was given to each CHW and mixing ORS powder. The CHW should remember to carry a packet of ORS.

The guidelines were discussed during regular monthly meetings to review issues and share best practice techniques.


 Date of last Learning Journey update: August 2011