Introduction
The ongoing Covid-19 crisis has necessitated, and thereby accelerated the digitization of services wherever possible. Even with the lockdown reaching a gradual end, the continued need to minimize human contact and external movement will sustain the demand for online services, including education, entertainment, financial services, purchase of essentials, etc. Healthcare is hardly an exception to this, particularly in a pandemic.
Health-tech has a crucial role to play, even as its full potential is still being explored. Governmental support via the National Health Stack (“NHS”)[i] is only at the development stage, and regulation is at a nascent stage[ii]. Fintech has support to offer, via the guidance that can be obtained from the fintech experience on the one hand and more direct technological support with the financial aspects of the healthcare on the other. The proposed infrastructure of the NHS, in particular, demonstrates how fintech can be leveraged here.
Fintech Guiding the Development of Health-Tech
The Account Aggregator Framework: Open Health Data and Consent Management
The government-provided backbone of ‘Digital India’ is India Stack [consisting of Account Aggregators (“AA”), Digi Locker, UPI, and other facilities],[iii] which is also an important tool for digitizing financial services and financial inclusion. The NHS, interestingly, borrows from this to create its underlying ‘Digital Health Infrastructure’.
Open financial data and services like open banking in India, for instance, are (officially) at the initial stages, but the regulatory framework is in place (the RBI’s AA framework[iv]) and the first AAs are expected to be operational soon.[v] A crucial component of the NHS, in fact, is a consent management system,[vi] analogous to the AA system, that enables open health data as well. The framework here will similarly consist of a health data consent manager, health information providers and health information users, a health locker (equivalent of the Digi Locker), etc., and will rely on electronic health records (‘EHRs’) and an API (Application Programming Interface) based exchange of data.
One advantage over the AA framework, which is restricted to regulated entities,[vii] is that in the NHS’s consent management system, health information users are to include private players. The NHS, in fact, calls for accountable private sector participation,[viii] for instance as a part of its ‘application layer’.[ix]
The actual regulations issued after the NHS is in place should clarify the extent of private sector involvement. Initial regulatory support is nevertheless coming in from different avenues – the mandate of EHRs for clinical establishments[x] or the issue of the Electronic Health Records Standards, 2016[xi] enabling inter-operability.
Merchant Onboarding/KYC Technology: Doctor Onboarding/Patient Identification Tech
Identification is critical for financial services, in particular to prevent say money laundering or tax evasion. This can take the form of KYC requirements for individuals (say while opening a bank account or accessing a digital wallet[xii]) or on-boarding requirements for businesses (say for merchants when utilizing a payment aggregator to enable digital payments[xiii]).
While the motivations vary, identification is equally crucial to healthcare, particularly with its digital delivery (eg. identify genuine medical practitioners, accurately access a patient’s health records, enable proper delivery of an individual’s health insurance facilities, etc.).
The recent Telemedicine Guidelines, 2020, for instance, thus require patients to be identified via data like name, age, phone number, registered ID, etc.[xiv] Similarly, only Registered Medical Practitioners or ‘RMPs’ can provide telemedicine services,[xv] and intermediaries like healthcare aggregators or telemedicine platforms are mandated to verify registration and carry out due diligence prior to on-boarding doctors.[xvi]
Thus, technology in use for KYC services or on-boarding in the financial sector, can be customized for meeting identification requirements here as well.
Fintech with Direct Uses in Healthcare
KYC Tech: Consent-based Identification/Insurance Delivery
Apart from such customized technology, KYC technology in itself can have direct uses in health-tech. For one, it in itself can be used as a consent-based identification tool in health apps. Next, the NHS also proposes the creation of a Digital Health ID, a unique system-wide identifier similar to Aadhaar, the generation of which will require an initial KYC process.[xvii] A last use is with the delivery of an integrated health insurance facility in a health-tech app, which will require initial identification. The NHS, for instance, proposes to include a ‘Policy engine’ enabling unified view and API based consumption of all of a family’s insurance plans.[xviii]
The Blockchain: EHR Management/Drug Supply Chains
While blockchain tech has use in almost every industry, its origin (as the foundational technology of cryptocurrency, which acts as an ‘open, distributed ledger that can record transactions between two parties efficiently and in a verifiable and permanent way’[xix]) makes it another form of fintech which can aid the digitization of healthcare. Its typical uses here include EHR management, healthcare claims management[xx], purchase or settlement of insurance claims[xxi] (which for example, avoids insurance fraud), drug supply chains (which for example, avoids counterfeit drugs entering the system), etc.
The use of blockhain and smart-contracts,[xxii] for example is also suggested for the ‘Claims engine’ of the NHS, which supports the ‘Policy Engine’ by managing insurance claims processing and related payment flows.[xxiii]
Fintech Aiding Digitization via Integration/Interoperability
Healthcare aggregators typically aggregate core healthcare services alone (for example- MyHealthcare[xxiv] is a technology partner for healthcare delivery for hospital networks, integrating EMRs, health trackers, emergency services, video consultation, etc.). Fintech and insurtech integrations are also known (for example- LifeMiles[xxv], an airline loyalty program, integrates with fintech and insurtech company ‘novae’ for protection from trip cancellation, purchase of advance care memberships like emergency medical expenses, accidental death, etc).
A particular demand today is to have a single point of access to several related activities, much like neo/challenger banks (entirely digital banks which often utilize open banking to provide a range of financial services through a single app[xxvi]) offer in the financial sector. In healthcare, a demand will, thus, be for integrated health-tech, fintech and insurtech services, allowing an integrated experience of everything from healthcare consumption to its financing. Efforts aimed at integrating these will encounter challenges, for instance, this would necessitate interoperability between NHS’s consent managers and account aggregators.
At present, the integrations can take the following forms:
Digital Payments Tech: Enabling Integrated Payments in Health-Tech
Medical expenses incurred by patients include consultation fees, lab payments, medicine costs, etc. Integrated digital payment technology in health-tech apps, thus, offers an advantage. While this includes wallet/payment aggregator integrations at a basic level, today dedicated healthcare payment service providers (like Simplee[xxvii] and Healthexpense[xxviii]) for integrated patient billing or aggregated medical reimbursements are also available.
Insurtech: Automated Medical Insurance Delivery
Much like the integrated insurance experience proposed by the NHS, digital healthcare which includes the facility to purchase, pay (instalments) and settle health insurance are convenient. For health-tech facilities targeting (say) rural areas or the urban poor like Gramin Healthcare,[xxix] such facilities should include the ability to integrate government insurance benefits like Pradhan Mantri Jan Arogya Yojana[xxx] or the Rashtriya Swasthya Bima Yojana.[xxxi]
Additionally, alternative data from such apps can also be used for alternative insurance underwriting (for example- Acko General Insurance[xxxii] uses deep-data analytics for personalized pricing for insurance products, while Vantis Life[xxxiii] uses a ‘real-time’ underwriting process, using data from public records and third party data providers).
Digital Lending: Medical Loans and Fundraising
A need for external financing for medical expenses can also arise. Integrations of digital lending service providers, P2P lending services and crowdfunding facilities (for example- ImpactGuru provides crowdfunding solutions for medical expenses[xxxiv]) for fundraising are, thus, also advantageous. Alternative data can be leveraged here as well for alternative credit scores.
Addressing Concerns with Digitized Healthcare Platforms and the NHS
An initiative of the scale of the NHS leads to concerns like privacy, surveillance and competition, to name a few.[xxxv] The proposed Digital Health ID leads to fears of another Aadhaar like ID.[xxxvi] The very aim of the NHS is to aggregate, generate and leverage vast quantities of data towards policy making, medical research, etc., making privacy a major concern as data is ‘democratized’ via such facilities. The same concerns extend to any large health-tech aggregator that may emerge, along with competition concerns via their ability to promote health-sector participants of their choice and exclude others.
It is important here to learn from lessons from the past and avoid a repeat of issues, like those highlighted in the Aadhaar case. The Digital Health ID, for instance must be non-mandatory, and must not lead to exclusion from healthcare services. The competition concerns can be addressed via laws defining a platform’s related liabilities (for example- a mandate to remain neutral and grant equal treatment to self-provided and rival services[xxxvii]), and via necessary assessments of the Competition Commission of India (for example- merger reviews). Lastly, there is now a recognized fundamental right to privacy[xxxviii], and any use of data must be consent-based, non-mandatory and within a prescribed legal framework. The need of a dedicated data protection law like the Personal Data Protection Bill[xxxix] is now stronger than ever
[i] NITI Aayog, “National Health Stack: Strategy and Approach”, 2018, available at- http://niti.gov.in/writereaddata/files/document_publication/NHS-Strategy-and-Approach-Document-for-consultation.pdf (hereinafter, “NHS”).
[ii] The Electronic Health Records Standards for India, 2016, available at-https://main.mohfw.gov.in/sites/default/files/EMR-EHR_Standards_for_India_as_notified_by_MOHFW_2016_0.pdf (hereinafter, “EHR Standards, 2016”); the Telemedicine Practice Guidelines, 2020, available at-https://www.mohfw.gov.in/pdf/Telemedicine.pdf; the draft E-Pharmacy Rules, The Draft Drugs and Cosmetics (__ Amendment) Rules, 2018, available at-http://egazette.nic.in/WriteReadData/2018/189043.pdf); the Draft Digital Information Security in Healthcare Act, available at- https://www.nhp.gov.in/NHPfiles/R_4179_1521627488625_0.pdf.
[iii] Vivek Raghavan, Sanjay Jain et al., “India Stack ? Digital Infrastructure as Public Good”, Communications of the ACM, Vol. 62, No. 11, 2019, available at- https://m-cacm.acm.org/magazines/2019/11/240375-india-stack-digital-infrastructure-as-public-good/fulltext.
[iv] Non-Banking Financial Company – Account Aggregator (Reserve Bank) Directions, 2016, available at- https://www.rbi.org.in/Scripts/NotificationUser.aspx?Id=10598.
[v] Saritha Rai, ‘Soon you can share income tax return, other details easily for bank loans, accounts’, LiveMint, January 2020, available at- https://www.livemint.com/money/personal-finance/getting-a-bank-loan-would-soon-be-easier-reliance-jio-has-a-role-to-play-11578891997913.html.
[vi] AaryamanVir, Siddhartha Shetty et al., ‘iSPIRT Open House Sessions on NHS: Summary & Next Steps’, iSPIRT, May 2020, available at-https://pn.ispirt.in/ispirts-open-house-on-nhs-summary-next-steps/.
[vii] Non-Banking Financial Company – Account Aggregator (Reserve Bank) Directions, 2016, Directions 3(xi) and 3(xii).
[viii] NHS, pp 40, available at- https://niti.gov.in/writereaddata/files/document_publication/NHS-Strategy-and-Approach-Document-for-consultation.pdf
[ix] The National Digital Health Blueprint, 2019, pp 20, available at-https://www.nhp.gov.in/NHPfiles/National_Digital_Health_Blueprint_Report_comments_invited.pdf
[x] The Clinical Establishments (Central Government) Rules, 2012, Rule 9(iv).
[xi] EHR Standards, 2016, supra note ii,
[xii] The Reserve Bank of India (Issuance and Operation of Prepaid Payment Instruments) Directions, 2017 (Master Direction), available at- https://www.rbi.org.in/Scripts/BS_ViewMasDirections.aspx?id=11142; Guidelines for Licensing of Payments Banks, 2014, available at- https://www.rbi.org.in/Scripts/bs_viewcontent.aspx?Id=2900.
[xiii] Guidelines on Regulation of Payment Aggregators and Payment Gateways, 2020, available at- https://www.rbi.org.in/scripts/NotificationUser.aspx?Id=11822.
[xiv] The Telemedicine Practice Guidelines, 2020, Guideline 3.2.2.
[xv] Id., Guidelines 1.1.3 and 1.2.
[xvi] Id., Guideline 5.
[xvii] NHS, pp 20.
[xviii] Id., pp 24.
[xix] Marco Iansiti and Karim Lakhani, “The Truth about Blockchain”, Harvard Business Review, January-February 2017 issue.
[xx] GemOS,available at- https://enterprise.gem.co/ .
[xxi] Ethersic, available at-https://etherisc.com/files/what_is_etherisc_1.0_en.pdf .
[xxii] NHS, pp 25.
[xxiii] Id.
[xxiv] MyHealthcare, available at- https://www.myhealthcare.co/.
[xxv] Pavithra R, ‘LifeMiles partners with FinTech & InsurTech company novae’, IBS Intelligence, available at- https://ibsintelligence.com/ibs-journal/ibs-news/lifemiles-partners-with-fintech-insurtech-company-novae/; Novae, available at- https://wearenovae.com/about/.
[xxvi] Crowdfund UP Team, ‘What is a Neo Bank and how are they disrupting traditional banking models?’, Medium, July 2018, available at- https://medium.com/crowdfundup/what-is-a-neo-bank-and-how-are-they-disrupting-traditional-banking-models-3c1b2fa5b8e1.
[xxvii]Simplee, available at- https://simplee.com/platform/.
[xxviii]Healthexpense, available at- https://www.disruptordaily.com/top-10-fintech-disrupting-healthcare/.
[xxix]Gramin Healthcare, available at- https://www.graminhealthcare.com/the-company/
[xxx]Ayushman Bharat Pradhan Mantri Jan Arogya Yojana, available at- https://www.pmjay.gov.in/.
[xxxi] Rashtriya Swasthya Bima Yojana, available at- https://www.india.gov.in/spotlight/rashtriya-swasthya-bima-yojana.
[xxxii] Acko General Insurance, available at- https://www.acko.com/.
[xxxiii] Neal Baumann, “A catalyst for change How fintech has sparked a revolution in insurance”, Deloitte, 2018, available at- https://www2.deloitte.com/content/dam/Deloitte/global/Documents/Financial-Services/gx-fsi-cataylst-for-change.pdf; –, “Low-Cost Protection For The Ones You Love – It’s That Simple.”, Vantis Velocity, 2020, available at- https://www.vantislife.com/sites/default/files/inline-files/velocity-term-life-insurance.pdf
[xxxiv] ImpactGuru, available at- https://www.impactguru.com/about-us.
[xxxv] Seema Singh and Arundhati Ramanathan,‘The elite VC-founder club riding AarogyaSetu to telemed domination’, The Ken, dated May 2020, available at- https://the-ken.com/story/the-elite-vc-founder-club-riding-aarogya-setu-to-telemed-domination/.
[xxxvi] K.S. Puttaswamy v. Union of India, (2019) 1 SCC 1.
[xxxvii] Trade and Development Board, “Competition issues in the digital economy”, UNCTAD, TD/B/C.I/CLP/54, 2019, available at- https://unctad.org/meetings/en/SessionalDocuments/ciclpd54_en.pdf
[xxxviii] Justice KS Puttaswamy v. Union of India, 2017 SCC OnLine SC 996.
[xxxix] The Personal Data Protection Bill, 2019, available at- https://www.medianama.com/wp-content/uploads/Personal-Data-Protection-Bill-2019.pdf.
By Ms. Asheeta Regidi, a lawyer specializing in tech, fintech and privacy laws, currently heading Fintech Policy at Cashfree. She was assisted by Aditya Vyas, a 3rd year student at RGNUL, Punjab.