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Journalism of Courage
Stating that there is a “trust deficit” among citizens towards private healthcare providers in past insurance schemes, Niti Aayog member Dr Vinod Paul said surgeries with “moral hazards” such as a hysterectomy or appendix removal may be kept out of the ambit of the National Health Protection Scheme (NHPS), to curb wrongful profiteering. He urged private healthcare providers to undertake self-regulation and work on self-conduct to make the insurance scheme a success.
Paul was delivering a lecture on implementation of NHPS, organised by the Confederation of Indian Industry on Saturday. He said discussions are underway to cover emergency medical care under the NHPS, which may include snake bite and dog bite cases that require brief hospitalisation. So far, he added, 1,300 procedures have been finalised to be included under the scheme. The state, he added, can include more procedures according to their requirement at their own cost.
“Our exercise is solely based on how to prevent fraud by doctors and hospitals, and to ensure insurance providers do not cheat. These are serious issues. I appeal to private hospitals to impose self-regulation,” Paul said. He added that false patient records, forceful admissions, unnecessary surgical intervention are frequent fraudulent activities Niti Aayog has noticed in the previous insurance scheme, Rashtriya Swasthya Bima Yojana. “We will have a state health agency that will monitor hospitals. Hospital admissions will be watched and clinical audit system will detect abnormal patterns. The NHPS will remain a state responsibility,” Paul said.
State health officials, however, said the scheme remains in planning stage. “We need to create a system where the existing scheme and new scheme will run together,” said principal secretary (health) Pradeep Vyas. While inviting suggestions from hospitals on package rates for the insurance scheme, Niti Aayog member Paul added that hospitals must curb profit margins for healthcare provided to the poor. On April 30, a nationwide exercise will be undertaken in village panchayats to update list of Socio-Economic Caste Census (2011), ones who will be beneficiaries of the new health insurance scheme. Data with Niti Aayog suggest 10.74 crore families will benefit under the scheme, including 8.03 crore under deprivation criteria in rural areas and 2.33 crore under occupational criteria in urban areas. The NHPS, announced by finance minister Arun Jaitley, aims to cover 10 crore families with a maximum cap of Rs 5 lakh per family. Under the scheme, emergency medical care will be included but only for hospitalised patients. The scheme so far excludes out-patient services.
Healthcare providers present at the event, however, raised concerns over existing low rates of insurance packages under existing schemes. “If a large number of patients come under the scheme but we are not able to get sustainable profit margins, we will not be able to continue the scheme for long,” said Dr Parag Rindani, associate vice-president at Wockhardt Hospital, adding that the government needs to devise a system where hospitals do not make massive losses under the scheme.
Currently the central government plans to have a premium of Rs 1,000 to Rs 1,200 for insurance providers. On Saturday, insurance providers, however, quoted a minimum premium of Rs 2,500 necessary to sustain the scheme. The scheme will have a 60 per cent funding from the Centre and 40 per cent from the state, except in north-eastern states where the Centre will contribute 90 per cent of the funds.
