Indu Bhushan (57) is at the helm of what is pegged as the world’s largest government-funded health scheme — Ayushman Bharat, which provides health cover to well over 10 crore families in India.

Until a few months ago, Bhushan, a former bureaucrat and East Asia head of Asian Development Bank, was a fit man. Only recently, his blood pressure shot up all of a sudden and he wonders why, as he straps on the testing apparatus to his arm to take a daily reading.

Bhushan and his team had been working late into the evening, even 12 hours at a stretch, to make the scheme a reality. “I would not have had it any other way,” says the CEO of the National Health Agency. Yet, there are a volley of concerns about the cashless health insurance scheme that remain to be addressed.

A growing line of worried private doctors has been knocking on government doors, seeking joint meetings with government think-tank NITI Aayog’s member, (health), VK Paul and Indu Bhushan to complain about the rates at which they are being asked to perform surgeries and other medical procedures.

Girdhar Gyani, director general, Association of Healthcare Providers (AHPI), India, leads the pack. Barely 10 days back, Gyani met Paul and Bhushan to illustrate how different States, which already run State-level government insurance schemes, have radically divergent rates for performing the same surgery that Ayushman Bharat demands be carried out at a lower rate.

Centre’s rates vs the rest

Gyani explains with an example. For a hysterectomy, Telangana allows for a charge of ₹62,000 while Karnataka has pegged it at ₹50,000. Tamil Nadu charges ₹34,000 and Maharashtra ₹35,000, for the same procedure. Ayushman Bharat package rates put the amount at ₹20,000, which is not agreeable to the States already running their schemes. The package rates drawn up by the Central government then remain a mere ‘guideline.’

Prices were drawn up unrealistically, says VK Monga, Finance Secretary of Indian Medical Association. “A surgery requires an anaesthetist, a surgeon, specialists like paediatricians if we are dealing with child issues. A hospital has to pay their fees, supply medicines to patients for, say, five days in the hospital, supply another set of drugs on discharge. How is all this possible with a low package rate?” questions Monga.

VK Paul, in an internal presentation, stated that six States — Gujarat, Karnataka, Rajasthan, Telangana, Maharashtra and Tamil Nadu — will continue to charge varied rates for surgeries according to their old schemes. Majority of the reimbursement, 60 per cent, is being borne by the Centre while 40 per cent is paid by the State. Asked if differential pricing will put pressure on Central coffers, Bhushan says that while initially ₹10,000 crore has been set aside for the scheme, more will be provided if and when required.

Even after the prices have been harmonised according to States’ demands, none of the big private hospitals in Mumbai is on board, says Joy Chakraborty, CEO of Hinduja Hospital, Mumbai. “We cannot be on board at such low rates. We already provide free beds under the Charity Commissioner’s direction,” says Chakraborty.

In Delhi, letters have been sent by the Centre to 140 private hospitals to come on board, but only three have agreed, so far. “Even as Delhi State has not come on board Ayushman Bharat, we are wanting to empanel private hospitals for portability purposes, so that a patient from another State can take the benefit of the scheme in Delhi, if s/he falls ill and requires hospitalisation in Delhi,” says Bhushan. The crux of the controversy, Bhushan says, is in the way costing has been was drawn up in the package rates for 1,350 procedures. package rates. This should ideally have been taken care of before the launching of the scheme.

Towards appropriate pricing

While private doctors criticise the scheme saying the pricing is not scientific, Bhushan reacts, “How are we to devise appropriate pricing? The scheme is being criticised that pricing does not have a scientific base and does not represent cost structures across geographies. So we need meaningful participation of private stakeholders as we do not want to replace one unscientific pricing methodology with another, neither do we want to keep revising rates every few months.”

The crux of the issue, as was seen in the case of stents, is whether hospitals recover their targeted amount from other billing categories. Hence, even if a procedure is slated to cost ₹20,000 under Ayushman Bharat, the actual bill for the patient could be more.