Health Insurance Hospital Registry

This article was first published in the IIB Bulletin, Vol 1, Issue 4: Co-Author: Varsha, GS1 India
https://iib.gov.in/IIB/Articles/IIB%20Bulletin%20Q4%202014-15.pdf

Poor data impacts many areas in the healthcare system. One of the areas that has an impact on Healthcare Analytics is the way hospitals are identified and stored in the various databases. In the case of the Insurance Industry, each Insurer has their own naming convention for Hospitals. For example, Table 1 shows that five different Insurers can name the same hospital in 5 different ways in their databases.

Table 1

Database A	Database B	Database C	Database D	Database E
ABC Hospital	The ABC Hospital & Emergency Services	ABC Hospitals Pvt. Ltd	ABC Hospital Group	ABC Group of Hospitals

In the above illustration one cannot be certain if all the names are referring to the same entity or if they are all different entities, without painstaking manual intervention. Using the list as it is would not give a clear picture of the number of claims, average claims, top diseases in a period in a particular Hospital, total insurance claims paid per Insurer to the hospital, and many more such statistics.

To overcome this issue it is recommended to identify each entity (hospital) with a standard and unique number. Think of it as a mailing address: an identifier for a single location in the world that is globally unique to that location. No other organization, agency, or affiliate can use it to identify their locations, but all parties can and should use it to identify that location.

The Standard adopted globally to identify a location using a unique and unambiguous number is a GS1 Global Location Numbers (GLNs) based on the GS1 System of Standards. Utilizing a GLN can help improve data integrity. In turn, it will help reduce cost and time spent on data cleaning and making it more reliable.

Such a system enables global and unique identification of products and locations, as well as the continuous, automatic update (i.e., synchronizing) of standardized information across all stakeholders. Unique identification provide the necessary foundation for achieving the best results when using complementary applications like automatic data capture, e-commerce, electronic record management, etc.

Insurance Information Bureau of India has undertaken a project to identify each Hospital in the Health Insurance Providers Network. GS1 India would allocate a GLN to each hospital, which is a unique, 13-digit number for a specific location. Implementing GLNs simplifies the exchange of information and provides the opportunity to manage accurate and authenticated data more effectively.

The GLN, or the globally unique ID would not only identify a specific location, but also provide the link to the information pertaining to it (i.e., a database holding the GLN attributes such as postal address and GPS co-ordinates of the location, services offered at that location, key contact person at that location etc.). This is a key advantage of using a globally unique identifier because all information can be held and maintained centrally in a database or registry reducing the effort required to maintain and communicate information between multiple parties on a national or global basis.

This enables various stakeholders to simply reference a GLN in communications, as opposed to manually entering all of the necessary party/location information. Using a GLN to reference party/location information promotes efficiency, precision and accuracy in communicating and sharing location information.

Figure 1

Several countries like UK, Australia, Austria, North America etc. use GLN’s in their procurement processes to enable efficiency and transparency to deliver better patient care.

The use of GLNs provides a method of identifying locations that are:

·         Unique: with a simple structure, facilitating processing and transmission of data;

·         Multi sectoral: the non-significant characteristic of the GLN allows any location to be identified - regardless of its activity

·         International: location numbers are unique worldwide.

By identifying hospitals with GLNs enables interoperability with other GS1 Healthcare Registries in the world, building global visibility of Indian healthcare facilities, services and capabilities for international patients

However, the most immediate impact of the Unique Identification would be on the quality of Analytics. Only when hospitals are properly identified, logged and data generated on health aspects from them are reliable, can any meaningful analysis be carried out. A list of unique hospitals will be beneficial to Hospitals, Insurers, Govt. Agencies and also the Public.

·         Claims payment can be accelerated

·         Fast, reliable and relevant Analytics

·         Geography based trends, patterns of disease occurrence, cost patterns, etc.

·         Footprint is visible

·         Will aid in the Fraud Analytics efforts of IRDAI

Ministry of Health and Family Welfare is working on standardizing treatment procedures and costing templates. Efforts are being made by IRDAI-FICCI to categorize hospitals. Unique Hospitals would complement all of these projects as well.

A simple illustration may be seen in Table 2 where the outlier analysis throws out more meaningful results when the hospital is correctly identified.

Table 2

	Cost of treatment for Disease type Cholera
	Database A	Database B	Database C	Database D	Database E
	ABC Hospital	The ABC Hospital & Emergency Services	ABC Hospitals Pvt. Ltd	ABC Hospital Group	ABC Group of Hospitals
Claim Paid 1	16,016	2,093	33,115	24,299	39,113
Claim Paid 2	16,577	27,929	22,919	19,366	26,343
Claim Paid 3	12,122	23,767	30,916	29,279	26,000
Claim Paid 4	16,134	25,958	31,108	21,147	15,500
Claim Paid 5	10,280	15,981	1,99,400	26,828	25,000
Average claim paid per hospital	14,226	19,146	63,492	24,184	26,391
Overall Average claim paid	29,488
Highlight Outliers where Claim paid or amount claimed is above/below +/- 50% of the average for the hospital
	Database A	Database B	Database C	Database D	Database E
	ABC Hospital	The ABC Hospital & Emergency Services	ABC Hospitals Pvt. Ltd	ABC Hospital Group	ABC Group of Hospitals
Claim Paid 1	-	Outlier	Outlier	-	-
Claim Paid 2	-	-	Outlier	-	-
Claim Paid 3	-	-	Outlier	-	-
Claim Paid 4	-	-	Outlier	-	-
Claim Paid 5	-	-	Outlier	-	-
If the Hospital is identified as the same hospital in all databases, the average claim paid will be Rs 29,488/- across all 25 claims.
	Database A	Database B	Database C	Database D	Database E
	ABC Hospital	ABC Hospital	ABC Hospital	ABC Hospital	ABC Hospital
Claim Paid 1	-	Outlier	-	-	-
Claim Paid 2	-	-	-	-	-
Claim Paid 3	Outlier	-	-	-	-
Claim Paid 4	-	-	-	-	-
Claim Paid 5	Outlier		Outlier	-	-

Health Insurance vs Macro and Socio-Economic Indicators

This article was first published in the IIB Bulletin, Vol 1, Issue 4: Co-Author: Vishnu Vardhan, Syed Md. Ismail

https://iib.gov.in/IIB/Articles/IIB%20Bulletin%20Q4%202014-15.pdf

Inference

It may be inferred from the graph and the GLM analysis that higher the Literacy rate and the GDP per Capita, higher will be the Health Insurance Premiums in the State. In a research done at the Indian Institute of Management, Ahmedabad (Bhat & Jain, 2006) it was found that the purchase of health insurance is related to the awareness and knowledge about insurance and also the income of the household. Almost a decade later, our findings suggest the same.

Reference

Bhat, R. & Jain, N., “Factoring affecting the demand for insurance in a micro health insurance scheme”, Indian Institute of Management, Ahmedabad, Working Paper No. 2006-07-02, 29p

Underwriting in the Health Insurance Business

This interview was first published in the IIB Bulletin, Vol 1, Issue 4
https://iib.gov.in/IIB/Articles/IIB%20Bulletin%20Q4%202014-15.pdf

Dhanasar (Danny) Ramjit is the Chief Executive Officer of MediGuide America, which provides remote Medical Second Opinions to its Members and their local treating physicians. Danny is a seasoned Insurance Executive and Actuary with experience in diversified areas- Life, Accident & Health and in companies like AXIS Global Accident & Health, American Life Insurance Company, New York Life Insurance Company, Manulife Financial and Cigna, in various capacities.

With a bachelor’s degree in Physics and Mathematics, Danny believes that everyone should study Physics as it is principles based and makes logic and reasoning a habit. Originally from Guyana, Danny moved to the United States of America in 1980 and studied Actuarial Science. He is a Fellow of the Society of Actuaries (FSA) and a Member of the American Academy of Actuaries (MAAA). In addition, Danny became a Fellow of the Institute of Actuaries of India (FIAI) in 1999 and he is also a Fellow of the Actuarial Institute of Taiwan. In a career spanning more than 25 years, Danny has worked in the USA, Latin America, India, China, Japan, South Korea, South East Asia, the UK, Central and Eastern Europe, Western Europe and the Middle East.

In a conversation with Dr. Nupur Pavan Bang of the Insurance Information Bureau of India, Danny talks about Underwriting in the Health Insurance Business.

What are the factors that an Underwriter should look at before deciding to write a particular risk?

Is there a need to cover the particular risk and is it estimable? Can the risk have a catastrophic financial impact on people? To be insurable, either the “timing” or “Severity” must be beyond the control of the Insured.

In the Health Insurance space, do you see any major gaps in terms of the products being offered?

In India, Health Insurance plans generally only cover “In-Hospital” treatment. At this point, the person is already sick. With healthcare costs spiraling out of control globally and medicine extending lives, there is a very great need for “preventative coverage”. Keep people healthy rather than trying to cure them when they are sick. Outpatient care is therefore as huge gap in the health coverages available in India.

What type of statistics would help a Health Insurance Underwriter?

One must understand the cost drivers. Important statistics include Medical Trend (utilization and Medical cost Inflation), geographical variations (Urban vs. Rural) and other good data to support the rate table structure (Age Groupings, Sums Insured, Gender variations). In the end, the Pure Premium for any given “Age, Sum Insured, Gender” cell must be supported by credible estimates of “average claims costs” for each such cell.

It is important that the data must be for the “benefits covered” by the policy. If a new benefit is being added or an existing benefit is being enhanced, then the necessary research must be done to find credible estimates of the additional costs. For provider networks, it must be made sure that the right cost differentials are taken into account in setting cost sharing parameters.

There is increasing concern regarding the Individual Health Premiums being more expensive than the Group Health Premiums. What do you think are the reasons for it?

Group Policies bring together large numbers participants under a single policy. Participants in the group subsidize each other and if the group is large enough and homogenous enough by occupation and Industry, then it can be treated as a “self-contained or 100% Credible” group for rating purposes. Individual anti-selection is removed if participation is 100%.

For Individual health plans, it is almost impossible to screen out “anti-selection” and so the “average claims cost per Individual” can be higher than that for a group. So, assuming that all health policies are priced to produce combined ratios not to exceed 100%, an Individual Plan can be expected to cost more than that for a large group.

On the expense side, “bulking of administrative” costs in Group policies and differences in “Commissions and other acquisition expenses” can result in lower expenses per participant in a group vis-à-vis an Individual plan.

As per the IRDAI Annual Report 2013-14, the Net Incurred Claims Ratio for individuals is 83% and group is 110%. If expenses are accounted for, both the categories would not be profitable. Why do you think is this happening?

I am glad you chose to look at “loss ratios” here. The only answer is that competition is driving group pricing below the so-called appropriate “Burning costs”. If loss ratios are at 110%, think of how high the combined ratios must be!

Underwriting in the Group Health Business is considered a black box of sorts. How can this scenario be changed? How is risk assessment done in other countries for Group Health Business?

This should not be. In an efficient marketplace, groups would be rated using a combination of that group’s own experience history and the “universe of all similar groups”. A credibility weighted actuarial approach is used which blends each group’s own experience and that of its “universe”.

The least result that can be expected from such an approach would be combined ratios of less than 100% for the group industry as a whole, while still maintaining some balance between “pure actuarial equity” and “100% social equity”.

Of course, one can charge all groups the same rate per participant (100% social) and this rate can be calculated in such a way that a combined ratio of less than 100% is arrived at.

If you were to import a key learning from your experience globally in Health Insurance, to India, what would that be?

Products should be priced and underwritten to pricing parameters using the sound actuarial principles espoused by the Institute of Actuaries of India and Global Actuarial and Insurance standards. This requires good data capturing and analysis by companies. The IIB can serve a very good role here by publishing Industry averages in broad terms (so as not to violate confidentiality of contributing companies) as benchmarks.  IIB should also publish Medical trend even if it’s a simplistic “Crude analysis” of the historical data.

Need of the Hour for the Health Insurance Industry in India

This interview was first published in the IIB Bulletin, Vol 1, Issue 4
https://iib.gov.in/IIB/Articles/IIB%20Bulletin%20Q4%202014-15.pdf

Mr. Sanjay Datta is Chief - Underwriting & Claims, ICICI Lombard General Insurance Company Limited, the largest private sector General Insurance Company in India. With over 24 years of experience in General Insurance, Datta was a part of the startup team at ICICI Lombard in 2001 and has since then grown the business into a market leadership position.

At ICICI Lombard, Datta is responsible for underwriting and claims division across the organization. He heads customer service for all product lines of the business and spearheads underwriting discipline, operational excellence, product development and pricing across Wholesale and Retail products. Datta also drives company's foray for quality service delivery across all products.

In a conversation with Dr. Nupur Pavan Bang of the Insurance Information Bureau of India, Datta talks about the business of Health care in India, the role of the Insurance Industry and the things that the Industry as a whole needs to do to be able to serve the population.

An evolved Health care system in a way represents the quality of life in a nation. How evolved is India, relative to the developed and the developing nations, in terms of Health care system?

India has made significant progress in terms of economic growth and overall development. But not much has changed on the healthcare front. Basic measures of health standards remain at alarmingly low levels even today. India spends between 1-3% of its Gross Domestic Product (GDP) on healthcare which is among the lowest in the world. A large percentage of Indians are still deprived of adequate healthcare facilities.

Can you give a few examples?

Bed density or number of hospital beds per 1000 remains below World Health Organization (WHO) standards of 1.5 beds. Doctor density or number of doctors per 1000 patients stands at 1.8. Comparisons with other developed and many developing nations show that we are lagging far behind.

An average Indian still pays around 60% of his or her healthcare expenses from out of pocket, much higher than even Lower Middle Income countries where individuals pay not more than 37% of healthcare expenses from their own resources.

For the poor, this self-funding has a crippling effect - various studies including those conducted by the (National Sample Survey Office) NSSO have shown that 64% of the poorest population in India gets indebted due to health related expenditures. Still only a small percentage of the Indian population is insured.

Is there anything specific in any of the Developed nation, which you would like to highlight, that can be emulated in India?

If you were to look at Japan, you will realize the current issues and get a sense of what needs to be done. In India, the cost of treatment varies widely between public and private hospitals due to the lack of a regulating body. In case of Japan, a patient pays more only if he or she is not insured, thus promoting insurance purchase.

The other key difference is in terms of the insurance approach. While in India, primarily In-Patient Department (IPD) expenses are covered for the majority of population; Japan allows virtually all access to preventive, curative and rehabilitative services at an affordable cost.

In India, there is no metrics defined to assess quality of care provided, in Japan it is all about care. A doctor in India spends minimal time on each patient, there is no set protocol or pathway to report medical fraud or exaggerated bills and the country doesn’t practice evidence based medicine which is common in developed nations. Indian healthcare system has started using technology. However, it is leading to expensive treatments. The concept of telemedicine too is at the pilot stage.

In fact, the Japanese healthcare system is perceived as an exemplar by many countries. Hospitals, by law, are run as non-profit and managed by physicians in the country. Medical expenditures are strictly regulated to keep them affordable. Measures have been taken to promote insurance and price them depending on the family income and age of the insured. Also, models like activity-based funding, where hospitals are paid based on the services provided and Diagnosis Related Group (DRG) type financing have resulted in reduction in the days of hospitalization and total average claim size, thus reducing costs.

This clearly shows that it is time for India to take stock, improve access to and raise the service standards of its healthcare system to truly harness the power of its billion strong population.

Including the Government schemes, based on optimistic estimates, about 25 percent of India's population has access to some form of health insurance. But the balance 75 percent are yet not covered. Can the Insurance Industry do much in a country where nearly one million Indians die every year due to inadequate healthcare facilities and close to 700 million people have no access to specialist care?

India’s health insurance sector is growing at a CAGR of 25 -30 % for the past 8 years. Despite this there is a significant shortfall in terms of health coverage with majority of individuals struggling to meet their healthcare needs. As you rightly pointed out, a meager 25-26% of the population is covered through some form of pre-paid scheme, including General Insurance Companies, Employees' State Insurance Scheme (ESIS), Central Government Health Scheme (CGHS), schemes for Railways and Defense employees.

Amidst this low penetration, availability of wide variety of products and government incentives are key drivers. In India, providing affordable quality healthcare is a challenge with 80% healthcare centers located in urban areas and catering to only 30% of the population. To achieve the goal of Universal Health cover, efforts should be made towards developing an integrated system that ensures affordable, accessible and equitable care for all.

Encouraging public private partnership model to address these challenges can be the first step. Insurers can help by supporting the government in network management, cost control, data and analytics etc.

It may be argued that bringing Insurers in the fray would add a layer of intermediation, resulting in high healthcare cost inflation.

Yes, some may argue that. However, it must be understood that the interest of insurers and the individual is aligned, with insurers wanting customers to stay healthy and avoiding hospitalization, thus keeping treatment costs low. The starting point would be to customize diagnosis, care and cure while engaging patients before, during and after the ailment and its treatment.

There is a clear need to pursue a model which ensures operational efficiency and cost effectiveness. 

Here, it would be worthwhile to evaluate the framework adopted for certain mass health insurance schemes such as Rashtriya Swasthya Bima Yojana (RSBY).

In a brief period of time, social insurance schemes led by RSBY have made commendable progress and covered over 300 million people – mostly the poorest - of the population. RSBY, the flagship scheme of the Central government in particular has achieved tremendous success in terms of coverage and won international recognition for its design and architecture, including adoption of technology; paperless & automatic claims settlement processes, coverage of pre-existing diseases, competitive package rates for treatment, price discovery through bidding, customer choice, etc. 

Can you elaborate on the model adopted by RSBY and the role of Insurers?

Moving away from its traditional approach, the government, in the case of RSBY, focused on the role of ‘Payor’ while allowing private entities including Insurers to take up the responsibility of provisioning.

Without insurers, the government as a ‘Payor’ would have to ‘buy’ the services of the providers directly – a model fraught with obvious risks. Even if the procurement process was managed efficiently, it would be difficult for the government to control leakage and misuse without the fraud control and analytics capabilities of insurers, resulting in cost inflation in the long term.

Insurers can further facilitate specialist and adequate care by offering primary care and out-patient (OPD) benefits to help beneficiaries get essential cover at the diagnosis or early stage of ailment. Primary care facilities will act as a gate keeper to limit instances of high expense in-patient treatments.

Second, like the Government, it is in the interest of the Insurer to reduce the cost of treatment. This is because treatment expenses directly influence the quantum of claim. As such, cost effective treatments can help reduce amount of claims paid, the benefit of which can be passed on to consumers in the form of reduced premium.

Third, use of insurance will give flexibility to the Government to design different levels of financial support across economic strata of the society and over time as families move up the income brackets.

Insurers can also play a significant role in driving awareness and influencing change in terms of health status of the community at large. Finally, insurance will provide an individual choice without tying the patient to a provider.

Inadequate healthcare facilities are a bane in India. How can the Insurers ensure that a hospital meets the basic minimum requirements to treat a patient?

Insurers first and foremost should ensure that a hospital holds accreditation from a reputed association before empanelment. Quality Council of India provides the necessary accreditation. National Accreditation Board for Hospitals and Health care Providers (NABH) is another constituent board of Quality Council of India, which is set up to establish and operate accreditation and allied programs for healthcare organizations.

A large number of hospitals face challenges and difficulties in implementing all the Accreditation Standards. NABH has developed Pre Accreditation Entry Level Certification standards, in consultation with various stake holders in the country, as a stepping stone for enhancing the quality of patient care and safety. The aim is to introduce quality and accreditation to the Health Care Organizations (HCOs) as their first step towards awareness and capacity building.

Currently, accreditations are not necessary and are just add-ons to build trust amongst patients. National registry of hospitals can be another good initiative which can help classify the list of hospitals that meets minimum standards.

Insurers can evaluate them on the basis of factors like infrastructure (bed capacity, strength, speciality, age of the building, infection control, patient safety, staff and accessibility, laboratories, ambulance, dietary service, housekeeping, laundry and linen, fire safety, pharmacy, power backup, operation theatre etc.). In the long run, insurance companies can follow these standards and ensure that no hospital is empanelled without necessary certifications leading to quality healthcare facilities for all.

Apart from the basic facilities mentioned by you, what are the other attributes that the Insurers look for before empanelling a hospital for Cashless facility?

There are various other factors which insurers look for before empanelling a hospital for cashless facility. Features which help in reduction of medical inflation such as package rate for procedures, discounts offered by providers for various medical treatments and infrastructure costs for ICU, biomedical gases, laboratories, radiology etc. play a major role while empanelling a hospital. Location and demography is also considered as an important factor. However, these are not the sole parameters for selection of a hospital by insurers.

It is also taken into account that any of the above factors is not leading to increase in operational costs and grievance with regards to the hospital. Insurer’s internal teams empanel a hospital post sound background check and audit. Popularity, trust, group identity and background of the medical institution stand out to be the most important parameters for any health provider.

The Health Insurance Business in India is mostly unviable as of now, with claims and costs being higher than the premiums collected. What are a few steps that need to be taken to make the business more viable?

Increasing incidences and claim size is a challenge faced by the Health Insurance industry today. The Net Incurred Claims Ratio for FY 2012-13 and FY 13-14 has been as high as 97% and 101% respectively. While unregulated medical inflation and hectic lifestyle is the primary reason behind the increase in the claims size and incidence; the industry is also confronting the issue of predatory pricing.

Insurers will have to collectively take a step forward to stop such pricing practices. The Insurance Regulator’s step directing insurers to claim above previous year’s claim is an effort which when implemented will bring in some solution.  This proposition will also compel insurance companies to undergo regular reviews of their Health Insurance products.

The other viable steps will be to manage the network effectively and prevent leakage.  Efficient network negotiations can result in less claims outgo through cashless transactions, helping almost 55% cases. While, leakage - which is of two types’ leakage due to fraud and leakage due to inefficiency- can be prevented with strict control on operational efficiency.

Exaggeration of expenses like adding emergency visit, unnecessary doctor rounds, needless tests are soft frauds, which along with many hard frauds- where the case claimed is completely false- eat up approximately 20% to 25% of an organization’s premium. While soft frauds can be addressed by defining proper care procedure and protocols, hard frauds can be tackled with the help of data analytics and regular audits of the hospitals.

Preliminary leakages due to inefficiencies like approving claims above sum insured, providing claims to people who are not enrolled, missing a disease sub limit, paying for exclusions, paying above tariff, missing co-pay etc. can be controlled internally. Organizations can prevent such losses through prudent underwriting practices.

One way to make a business viable is to reduce costs. The other way is to price the risks better. What is the kind of data or analytics that can help the Insurers recognize and price the risks better?

Pricing risks better is indeed a prudent move towards the viability of the General insurance business.  However, risks can be priced better only at an industry level. Data analytics is the key and an anchor to better risk pricing. Industry data on claim experience with demography, disease with respect to age, incidence claim size, industry type and individual customer assessment for both retail and group health will help as parameters for the analysis.

While for the retail portfolio factors such as demography, morbidity tables and individual health profile will impact the pricing; for group health, past claim experience-generally considered as industry practice- will help in the evaluation. In case the group has no past experience, then data analytics on demography, industry category and related experience can be considered as an ideal practice.

The use of such data analytics will lead to defining and designing covers differently for the same premium as per the insured’s portfolio. Thus, pricing risks better. Analytics will also help insurers to offer exclusive provider network for cases such as cataract, chemotherapy or dialysis. It will also help in the selection of alternative and cost effective platforms - such as telemedicine for second opinion- for treating diseases and doing away with unnecessary treatments and procedures. This will have a huge impact not only in terms of risk pricing but will finally benefit the insured in terms of premium as well.

Lastly, According to Annual Report, to the people, on Health by the Ministry of Health and Family Welfare, Government of India (December 2011), about 71% of the total health care expenditure in the country was borne by households out of their pockets. Can the industry as a whole do something to increase awareness about the need for Insurance?

It is alarming that close to 71% of the total healthcare expense is still out of pocket in India. The expenditure can be bifurcated into in-patient department (IPD) and out-patient department (OPD). While, IPD can burn deep holes in ones pocket, OPD expenses makes it difficult to control finances on a day to day basis.

Industry, with the assistance of government, can play a major role to create awareness towards health insurance purchase. Introduction of Universal Health Care under the National Health Assurance Mission is a step in the right direction. While the government adopts the role of the ’Payor’, it will always face efficiency issues in view of the vast landscape and population of the country. Tax incentives linked to purchase and higher limit for senior citizens will propel insurance awareness and purchase. Along with the government, insurance companies can initiate activities like office on wheels creating community awareness on insurance and introduction of insurance in schools and colleges at a low premium, to boost insurance awareness.

As people buy insurance, more and more of the private healthcare space will be routed through insurance. Private insurance as the ‘Provider’ will thus have stronger control and thereby better chance of influencing the way healthcare delivery happens in India. It will be able to manage the healthcare space both in terms of quality as well as the cost of delivery. It will be in a better position to build a sustainable healthcare system which focuses on the preventive as well as curative aspects of healthcare.