Six months ago, a young couple from Bihar could not get their infant with congenital heart disease treated in Mumbai despite having an Ayushman Bharat (AB) card. Their plight, when reported in the Pulse page of BusinessLine , saw the AB machinery kick in and support the baby’s surgery. Tragically, the baby did not survive.

But as the Centre’s flagship health insurance scheme rolls into its second year, hospital corridors still abound with incidents of patients slipping through the cracks of multiple jurisdictions, just as was reported months ago. The Government needs to push for a seamless health coverage of patients between States and across different schemes, say doctors, who didn’t want to be identified.

Awareness on the scheme also needs to be scaled up, specially in the population it targets, they point out. Despite the high-profile mention of the scheme at the United Nations General Assembly (UNGA) by Prime Minister Modi, awareness on AB, its entitlements and how to be a beneficiary remains quite low.

When the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PMJAY) was rolled out last September (see box for details), there were concerns about its insurance model. Public health experts suggested that the scheme gravitate to a more universal model of health coverage. The scheme also saw concerns on funding, frauds even.

In its second year, access and financial protection need to be clearly addressed, says Indranil Mukhopadhyay, a health economist and Assistant Professor, OP Jindal University. Access involves the problems of portability as patients continue to fall outside the ambit of coverage despite having the AB card. And financially, patients still end up paying for some services, despite falling under the scheme.

Health experts say the scheme should widen its scope and make it universal, rather than just reimburse hospitalisation.

Mukhopadhyay also red-flags the referral system by the small wellness centres. While they play their role in primary-level screening, the worry is if they send patients only to private hospitals. There should be a system where patients are referred to a private hospital only if they were sent by a Government hospital that did not have the facility. The Government also needs to engage more with local bodies.

Union Health Minister Dr Harsh Vardhan, in his statement on PMJAY, said poor and migrant workers had been able to seek treatment outside their States. “So far, there have been more than 40,000 portability cases”, the note said. “The game is still open,” says Mukhopadhyay, as private hospitals push for higher rates for medical procedures.

Pandora’s box

There is some discontent on a “double payment” for Government hospitals that are funded by the central Budget and get a payment again as reimbursement, he points out.

In fact, pricing may well open Pandora’s box, as private hospitals will then be asked why they cannot charge all patients at the AB rates — a reason why private hospitals are pushing for higher rates. Apollo Hospitals’ Managing Director Suneeta Reddy lauds the programme but adds that it needs to have low-cost infrastructure, etc, available to support the scheme. Apollo is supporting the scheme in Tier 2 and 3 cities, she says, adding that the industry was in discussions with the Government on pricing.

There needs to be a comprehensive pricing regulation for hospitals that would cover services and quality, stresses Mukhopadhyay, with greater accountability on data, which should be available in an anonymised format for outside scrutiny.

PMJAY clocked a year this month as discussions were under way at the UNGA on Universal Health Coverage. In fact, on the eve of the high-level meeting, the World Health Organization said, “Countries must increase spending on primary healthcare by at least 1 per cent of their gross domestic product (GDP) if the world is to close glaring coverage gaps and meet health targets agreed in 2015.”

A sobering thought for Governments as they grapple with different models to provide healthcare to citizens.

Related Topics
comment COMMENT NOW