Inclusion of dental packages in Chhattisgarh challenges wisdom of universal health cover

The large-printed words put out in Hindi that reads “Smart-card facility is available here”, outside a renowned hospital in Raipur, Chhattisgarh, should be reassuring. But oddly, the message that smart-card holders will be treated free of cost under the Ayushman scheme, at this dental hospital, does not evoke as much enthusiasm. Possibly because, a health insurance policy normally does not cover dental procedures in India.

Smart card holders treated free of cost under Ayushman at this dental hospital in Raipur

So why should the mega health insurance scheme that offers a cover of ₹5 lakh, cover small-ticket dental procedures at all? Interestingly, Chhattisgarh is the only State that has included dental procedures under Ayushman. There are as many as 32 dental packages covered! What’s more, aside from dental hospitals, dental clinics too are empaneled to provide treatment under Ayushman.

“Under Ayushman so far, 28-30 per cent of claims number is for dental (6-7 per cent in terms of amount) and about 9-10 per cent for eye, “ says Vijendra Katre, additional CEO of Ayushman in the State. This number is more or less similar to the figures under the State’s erstwhile RSBY (Rashtriya Swasthya Bima Yojna) scheme.

Chhattisgarh already had RSBY which was launched in 2009-10 for people below the poverty line (BPL). The cover under the scheme was up to ₹50,000. Aside from this, the State also has a Mukhyamantri Swasthaya Bima Yojana (MSBY) which covers all those who are not covered under the RSBY. With the implementation of Ayushman, the RSBY has been subsumed under Ayushman, while the MSBY continues for other beneficiaries. The smart-card holders under RSBY are entitled for coverage under Ayushman.

Flexibility or moral hazard

To ensure smoother implementation of Ayushman across States, the Centre has given some amount of flexibility to States to tinker with package rates. While the Centre has developed a list of approximately 1,400 packages across 23 specialties and finalised their rates following a rigorous consultative process, States have been given flexibility to modify the rates within a reasonable limit.

Further, States that are already implementing their own health insurance/ assurance scheme have been allowed to continue with their existing package rates.

Since dental procedures were already covered in Chhattisgarh, under its earlier health schemes, they appear to have been included under Ayushman, by design.

Chhattisgarh, has adopted the hybrid model to implement Ayushman, wherein a claim package of upto ₹50,000 is taken under the insurance model while a package of over ₹50,000 is processed under the trust model. According to officials, of the 1.6 lakh claims so far, less than 1000 are under trust. This is because, a chunk of the procedures are smaller ticket sizes, which are handled by the insurer for now.

Allowing small ticket dental procedures dilutes the intent of the scheme and may need a review sooner than later. While it is true that one of the key positives of the scheme is the flexibility it provides to states to implement the scheme, unwanted packages prone to misuse need to be curbed.

A sign outside a multi-specialty hospital in Chhattisgarh stating that Ayushman work is closed

Low package rate?

Across my visits to hospitals, particularly private ones, concerns over low package rates were common and plenty. For instance, the cataract package rate is ₹7000 in Chhattisgarh while private hospitals say that the cost is usually upwards of ₹20,000. Still, this did not seem to discourage hospitals from empaneling under Ayushman.

In Shri Ganesh Vinayak Eye Hospital in Chhattisgarh, a private hospital, 30-40 eye surgeries are done under Ayushman per day. A separate ward at the hospital caters to the low income earners who get treated under Ayushman.

So, why are hospitals keen on empaneling despite aberrations on package rates?

“At a broader level health insurance schemes are a volume game. If a hospital has 10 cases that come in, it may be able to recover significant surplus over its marginal costs in say 9 cases, but bear some loss in one case. So the hospitals that stay empaneled despite these aberrations are ones that also see increase in footfalls, explains Divyanshu Jha, the Executive Director of Jharkhand State Arogya Society, implementing Ayushman in the Jharkhand.

In one of the multi-specialty hospitals we visited in Raipur, at the entrance there was a clear sign stating, “as directed by IMA, Ayushman work is closed”. But the hospital continued to enroll patients under Ayushman, possibly unwilling to let go of the flow of cases.

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