Dr Neeraj Nagpal, a noted gastroenterologist and the convenor of MLAG (medio-legal action group) shares his views about the recently launched National Health Protection Scheme (NHPS).

 

 

 

 

 

 

 

 

Since the rollout of the grand NHPS in the budget I have been transfixed at the brilliance of the scheme and its design.

Let us for a moment assume “x” number of surgical procedures are needed to be done for this 40 % population over 1 year. Let us assume another “y” number require to be hospitalized for medical reasons lasting an average duration of 5 days. The question which arises is how will the total expenditure on treatment change from actuals and become restricted to Rs. 25000 crore the Government has decided to spend on this insurance scheme by paying Rs 2500 for each of the 10 crore families to public sector insurers.

If Rs. 25000 crore was all that was needed to provide free inpatient healthcare to all below poverty line individuals plus those covered under RSBY, CGHS and other Government schemes totaling some 50 crore population, then India should offer to provide inpatient healthcare to the entire world because this would be the cheapest quotation ever at less than 500 Rs per person per year.

This is financial jugglery at its best. What would cost lakhs of crores is being projected to be available in 25000 crores when actually the cost burden is simply being pushed on to the insurance companies which will take on a massive loss. Even this 25000 crore is not budgeted in the current dispensation. Ultimately the insurers will not be able to pay hospitals for services rendered and in the chaos will be the ubiquitous “Doctor” who will be blamed for the mess. Hospitals will have to refuse to admit patients and the government will arm-twist them and blame them for not giving the services promised. Doctors will be further maligned and incidents of violence against them, from those who are denied services promised by the honourable Prime Minister, will increase.

It will be interesting to see this gamechanger unfold as nearly all hospitals empanelled earlier in Bhai Ghanya Sehat Scheme, RSBY, CGHS, ECHS lost money due to bills not being paid. Many surgeons did not get paid for surgeries done in these hospitals under these schemes. Only those hospitals which indulged in some kind of billing fraud in collusion with authorities could make money from these schemes in the past and the experience will be replicated manifold again.

The entire credit of this scheme will accrue to the politicians in terms of votes while the entire blame will be placed on the shoulders of doctors for its failure if the above assessment is correct.

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Why I will not participate in Ayushman Bharat NHPS

Current ranking India has got in the World Health Statistics 2018 published by WHO in terms of healthcare indices, is a serious matter of concern not only for India but also the world. India is among the worst laggards and with its population burden of nearly 130 crores it drags down the entire world’s progress towards Sustainable Development Goals (SDG) 2030.

With a Maternal Mortality of 174 at least partly contributed by ham-handed suppression of ultrasound use under PCPNDT Act, it will take decades before India can match even Iran. The problem aptly highlighted by the WHO report is that the commitment a government shows towards improving healthcare indices is directly related to the spending it does whether per capita ($63 India) or as the percentage of GDP (3.4% India).

Countries which are committed to improving healthcare spending much more than the countries like India where token measures and slogans supplant hard currency. Wishing India into 21st-century development goals by gimmicks is again what is being attempted through this Ayushman Bharat scheme.

Unfortunately, there is no audit or accountability fixed in such schemes and though the basic structure of the scheme is flawed, and it is being inadequately funded the blame for the failure to provide services promised by the Government will be laid at the door of the medical professionals.

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Let us look at the nitty gritty of the tendering process for insurance companies being undertaken for this Grand healthcare scheme.

As per the document, certain rates have been finalised for various procedure cost of the package for a caesarean delivery (Sr No 11) inclusive of medicines, disposables, 5 days hospital stay and investigations if any is princely Rs 9000.

Laparoscopic Cholecystectomy (serial no 182) has been fixed at Rs 15000 and Appendicectomy with Appendicular abscess drainage (serial no 201) has been pegged at Rs 12000.

These rates are unrealistic, politically motivated, and will make healthcare establishments unviable. Low rates coupled with delayed payments have been the reason for the failure of previous such schemes. Also keeping the recent trend of flagrant generosity shown by consumer courts towards complainants one award of 1 crore plus in a caesarean death will cause many hospitals to close.

These rates and the premium that the Government is negotiating with insurance firms for this scheme ranging around 1250 to 2500 per family reveals a massive political gimmick and fraud with the public. Assuring approximately 50 crore population that their healthcare needs will be taken care of free of cost by the Government but actually spending only 12500 crore which works out to 250 Rs or 3.6 USD per capita is a fraud of gargantuan proportions.

People are being assured that just by showing cards without even a preauthorization their emergency needs will be taken care of by empanelled centres. This will lead to unrealistic expectations, worsening of doctor-patient relationship and increase in violence. What then is the difference between the Government and the scamster who collected crores by claiming to sell smartphones at 251 Rs. It is outright fraud If a service which cannot be provided for less than 1.5 lac crore is claimed to be provided in 12500 crores through impressive bureaucratic jugglery all the while knowing that the service being promised will break the Insurance Company’s back and Doctors will be blamed for not providing services which the Government promised.

Also, the strident claims of corruption in healthcare also has genesis in the low rates provided by insurance companies and such schemes. Hospitals are forced to do fraudulent billing for procedures not needed, drugs not used in connivance with the insurers and implementing authorities simply to break even for procedures which cost more than what is paid for them.

Given its current form, it is not wise to participate in it.

Disclaimer- The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of M3 India.