In TN, 17% of claim proceeds must be ploughed back into Govt hospitals

At Chengalpattu Medical College Hospital, in Kancheepuram district, a whole body cooling unit and mobile incubators are standouts in an otherwise understated neonatal ward.

This is not only because they facilitate better neonatal care but also because the devices have been bought by the insurance claim proceeds under the State’s Chief Minister’s Comprehensive Health Insurance Scheme (CMCHIS).

In the slightly more upscale Government Kilpauk Medical College, in Chennai, the NICU, or Neonatal Intensive Care Unit, is on a par with those at private hospitals. The unit has been set up with the funds from the insurance claims under CMCHIS.

Wrapped in red woollens, a six-day-old baby, with clinical sepsis and hyperbilirubinemia, is being treated at the unit under the PMJAY-CMCHIS scheme for a claims package worth ₹14,000. The payments by the insurance company (United India Insurance is the insurance partner) for this infant, and many more in the ward, will again need to be ploughed back into the hospital, as laid down in the model agreement of CMCHIS.

Tamil Nadu’s CMCHIS has been dovetailed with the Centre’s Ayushman Bharat (Pradhan Mantri Jan Arogya Yojana – PMJAY). With coverage having been increased to ₹5 lakh under Ayushman Bharat from CMCHIS’s ₹1 lakh per year (₹2 lakh for specified procedures), the additional funding can be used to further strengthen infrastructure. The premium burden is also shared between the Centre and the State (60:40), and the additional financial assistance from the Centre will make fund flow easier for other health needs in the State.

Flexibility

“As laid down in the CMCHIS, the claim proceeds under various packages/procedures are given to government hospitals. The sharing of funds for the cost of consumables, infrastructure, special corpus, and incentive to operating team is mandated to be in the ratio of 40:17:28:15.

“Hence, 17 per cent of the insurance proceeds are to be invested back into the hospitals for improving infrastructure and equipment,” said Dhakshinamoorthy, Deputy Project Head, MDIndia TPA.

The special corpus is to be used for high-end procedures at government and private hospitals for treating poor families, adds Prema Mukilan, Chief Manager, United India Insurance.

At SRM Medical College Hospital, in Kancheepuram, a particular case of renal transplant that cost ₹4 lakh, was covered only up to ₹2 lakh under the earlier CMCHIS scheme.

“The additional ₹2 lakh was given to the private hospital out of the corpus (28 per cent of insurance payments) created by government hospitals, after approval by the State government,” explains SS Nathan, Deputy General Manager-Operations, SRM Medical College Hospital. Hence, the flexibility given to government hospitals to manage the insurance funds will not only help them improve their infrastructure but also provide additional assistance in certain high-end procedures in private hospitals too for the poor and deprived families.

While the insurance claims under PMJAY-CMCHIS can continue to provide a source of additional funding for government hospitals, reluctance on the part of patients to use the card in such hospitals is a concern.

Cards remain unused

Given that most procedures are done free of cost in these hospitals, patients are not keen to use the card and reduce their coverage. They want to reserve the coverage for use in private hospitals. This impacts the flow of funds into government hospitals that rely solely on these funds for infrastructure development.

Overall, 40 per cent of claims pertain to government hospitals, while 60 per cent go to private hospitals, according to past trends.

“Limited resources, relatively less trained and experienced staff (vis-à-vis private hospitals), and incomplete documentation at times, are some key reasons for higher rejection and lower flow of claims into government hospitals,” adds Prema.

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