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Part 1 Peoples HM Sundararaman T
Unpacking Ayushman Bharat and other Health Policy initiatives of the last one year (2018 -19): Part 1

The task before peoples’ health movements

I. Ayushman Bharat: PMJAY (Modicare)
II. Ayushman Bharat: Health and Wellness Centres
III. The Making of the Health Professional: Changing Policies in Healthcare Education and Professional Regulation
IV. Privatization, Public Private Partnerships and Growth of Healthcare Industry: The Niti Aayog at work.
V. Developments in Access to medicines, patents and innovation
VI. Gender Issues in Health and Healthcare.
VII. The Social Determinants of Health.

I. AYUSHMAN BHARAT:

This is the main health program initiated under the NDA Government. It was launched in 2018. This program has two components; the Health and Wellness Centres & the Prime Ministers Jan Arogya Yojana. The former is an approach to comprehensive primary health care and the latter is a publicly funded health insurance scheme to provide access and financial protection to BPL families requiring secondary and tertiary health care. We describe each of these schemes below, and the problems we have with the way these are designed and implemented, as also the way Peoples Health Movements, Peoples Science Movements and all democratic forces should respond to these policies and their implementation.

Prime Ministers Jan Arogya Yojana: (Modicare)

1. What is this scheme?
A description

This is a Government Funded Health Insurance Program. Those who are poor by the socio-economic caste census or identified as belonging to certain occupational categories are eligible for this scheme. An estimated 10.74 crore families (about 50 crore individuals) are estimated to be eligible.

Under this scheme, if any eligible individual needs what is called a secondary care or tertiary care treatment/procedure, they can go to any empanelled hospital. The hospital will admit them and provide them free care- no charges at all. All medicines, diagnostics and even some element of the transport are to be paid by the hospital without charging the patient. The government would then reimburse the hospital on the agreed upon rate. A family can utilize up to Rs 5 lakh rupees of such treatment in a year (called a family floater basis- since anyone defined and enrolled as part of the family can be paid for within this Rs 5 lakhs. All pre-existing illnesses are also covered, and some part of pre-hospitalization and post hospitalization expenses are also covered.

PM-JAY has defined 1,350 medical packages covering surgery, medical and day care treatments.

Both government hospitals and private hospitals are empanelled under this scheme. About 60 % of the number of claims and about 75% of the total value of claims is made by and paid to the private sector hospitals.

It will offer a benefit cover of Rs. 500,000 per family per year (on a family floater basis).

2. There is a wide welcome for this scheme in media, among providers and even in public? Why has this been so welcomed?

i. Free or subsidized care in the public hospitals was the main approach to ensuring that everyone received affordable and good quality healthcare. However, the capacity of the public health services to deliver services is very limited, and a majority of people are either forced to , or are choosing to seek care in the private sector. The high costs of such private healthcare leads to high levels of financial hardship and to impoverishment that affects the whole family. Insurance schemes are meant to protect against this. Hence there is a considerable welcome from the public

ii. Private Hospitals have considerable un-used capacity. There is no shortage of number of sick patients, but there is a shortage of those who can pay. Also, typically, much of the profits of the modern hospital comes from deployment of high-end technologies used in diagnostics, procedures and surgeries. The number of paying patients who need or can be persuaded to consume these procedures are limited. Publicly funded insurance is thus a boost to what is nowadays referred to as India’s private healthcare industry.

iii. Much of the media welcome and the welcome in civil society and academic circles is because shifting to private providers is seen as a desirable reform, in tune with the times. Private providers are perceived as better in quality and public providers as inherently of poor quality. This is not so much a perception of the poorer and weaker population, but it is very much the perception of the middle class. The differing perceptions are in part due to the considerable heterogeneity in the type of private sector encountered, and the influence of the pro-private, anti-public sector discourse in these sections.

3. Government has claimed considerable success in this scheme and it is considered as one of the big achievements of the Modi government. What is the truth and what is just hype?

i. Government claims “Modicare” is the largest health scheme in the world. This is far from true. In terms of budgetary outlay, it is one of the smaller schemes- less than even the National Health Mission- and certainly less than what most states are spending on health. In terms of insurance coverage also, it provides cover to much less diseases than most other comparable scheme in other nations. In terms of the population covered by an insurance scheme, it would be less than what China covers.

ii. The number of those actually enrolled is only 3 crores- though 12 crores are eligible for a smart card.

iii. In almost all the states where PMJAY is seen to be effective, the central government has merely added its name to a pre-existing state government run health insurance program. The central government in return is also committed to paying 60% of the costs- though for a number of reasons this has not fully happened. The state governments are also being persuaded to change some of the rules they have evolved, and many states which had reasonably effective schemes in place- like Kerala, are suffering as a consequence.

iv. The government’s claim to success is largely based on the number of claims they have received and paid, across the states. There is no evidence at all on whether health outcomes have improved or even whether the poor have been protected from financial hardships due to healthcare costs. A considerable number of studies have been conducted on the earlier government funded health insurance programs and they all have shown the following patterns:

a. Lack of Information: Most of those eligible do not know about the scheme, and therefore are unable to claim its benefits.

b. Denial of Care: Of those who are eligible and who know about the scheme, a large proportion are denied benefits on one or other technical grounds. The most common being to state that the scheme does not cover the illness or procedure that the patient has, or that the hospital does not offer that particular service.

c. Double Billing- Of those who successfully manage to seek care under the scheme, almost all are billed for some or all of the services, for which they have to pay out of pocket. Free, cashless services are almost a myth. At best they may have to pay about 20% less than those who do not have a card. Having charged the patient, the hospital goes on to get reimbursed from the government also.

d. Supply driven care: Quite often the private hospital tends to provide much more of those procedures, for which they have greater profits, and deny those where the profit margins are less. Sometimes they actively recruit those patients who qualify for the procedures that they wish to supply. Thus, if we examine the pattern of claims across districts, there is little correlation with epidemiology- but a lot with which private providers are enrolled and pushy.

e. Substituting, not supplementing, public services: The aim of bringing in private sector was to provide access to many procedures which are not currently available within the government hospital. However, if we examine the claims of each state, they tend to provide services in those same few areas where government already provides care. For example, in UP, Bihar, and Chhattisgarh, it would cater to normal deliveries and cataract surgeries, which are the few procedures that government provides. But when it comes to renal stones, or glaucoma, or acute abdomen or burns, there would be little contribution from the insurance scheme.

f. Inappropriate care and dumping: Earlier if a private hospital could not provide the care to a poor patient, it would refer the patient away. Now, the same hospital is likely to admit the patient, exhaust all the money that the patient has in the smart card, and then refer the patient away. The treatment gets delayed and is exhausted of all resources when he or she reaches the government public hospital. Dumping patients who have exhausted their insurance coverage into public hospitals is a common practice even in the USA.

4. Is not government aware of these problems? What is being done to address these? And why is it not doing more? If government seriously addresses these issues, can we then expect the insurance program to provide relief?

· Government is aware of these problems. The government has both a grievance redressal system and monitoring mechanisms. The grievance redressal system is under-used by beneficiaries who are not aware of their entitlements as also how to seek redress for it. Even those who seek redressal have a poor experience. The big problem is that it takes great effort to bring a grievance to notice, and then what the private hospital gets is a very token penalty. Similarly, monitoring mechanisms are weakly functional, but even to the extent they are functional, authorities are unable or unwilling to take action against errant hospitals. Underneath there is a tacit understanding that such cheating is alright, since otherwise the private sector hospitals will refuse to participate. The current rates for each procedure that government is paying to hospitals are said to be low- but that is not the case. That is merely a convenient excuse for double billing- an excuse that those monitoring the scheme accept too readily even if it is in violation of the contract and the law. Delays in payment also push out ethical small providers who cannot manage the delays and uncertainties in reimbursement.

· Were the government to be serious about preventing all of the above distortions, and plan for adequate monitoring and grievance redressal, the immediate result would be that the private hospital participation would drop. Even now private hospitals are unwilling to come in at these rates. This in itself is not a bad thing, because public hospitals would continue, and so would not- for- profit hospitals and ethical small providers who are able to manage within these rates quite well.

· However, in such a scenario, insurance and purchase from the private sector would be a supplement to a robust public sector- which because of ideological reasons the current policy makers are unwilling to accept.

· While better monitoring would address issues like double-billing and denial, none of these solutions, and not even tighter regulation would affect the problem of supply driven care- when decisions on what care is to be provided is influenced by the monetary/business model driven interests of the provider more than that of the beneficiaries.

5. There are many nations where insurance schemes are working well. How are these nations doing better? What prevents our government from adopting those strategies?

· Germany and Japan are examples of such nations, where providers are mainly private and payment is by insurance mechanisms. This is so in Canada and Australia also, though the proportion of public providers is much higher.

· The single most important feature of these is that these are built around the principle of solidarity. Great care is taken to ensure that the decision making by providers is ring-fenced from immediate monetary incentives. The Japanese, for example, have a law against making profits from health care and for that reason little foreign direct investment/corporate funding comes in- since dividends cannot be paid. Germany rules out profits for insurance companies, and the government steps in to pay part of the premium to prevent losses and ensure equity.

· All these nations which are insurance based have high degrees of regulation, where the prices of all healthcare services, even for those who are not insured, are regulated at the same prices as what the government allows. In Australia and Canada all payments are from the government. Along with taxes they collect different premiums from rich and poor, but the treatment for rich and poor, whether insured or not is the same. Families may purchase a second private insurance for higher quality of hospital care- but that is as much choice as is allowed.

· Health systems which are insurance based a sentence is incomplete.

· Thailand and UK are not insurance schemes in the conventional sense. They are much better and more flexible forms of public financing and public managing/ management by the public. Here again, clinical decisions are ring-fenced from monetary considerations. The market is kept out of the transaction.

· All national health systems that are largely based on purchasing healthcare from private providers spend much more than other systems which are dominated by public providers. Thus, Sri Lanka spends only 3% of the GDP, Thailand 4% of GDP, Cuba and Brazil 8% of GDP. In contrast, USA, which is free market plus insurance based, spends 19% of GDP on healthcare.

· In nations like India and the USA, the principle is of “making markets work for healthcare.” Which really means figuring out how to channel public expenditure on health through private sector, so that they are able to benefit from it. That leads to a huge over-consumption of care, much of which is unnecessary, while large proportions of population are excluded from the care that is needed.

· The classic example is USA, which spends 19% of the US GDP on healthcare, and yet close to 25% of the population are uninsured and another 25 % or more are under-insured- meaning that the insurance cover which they have fails to pay for their healthcare need. India’s PMJAY is rapidly trying to take us down the US type of health insurance model.

· If India was to achieve Universal Health Coverage based on purchasing care from a dominant private sector, it has to be ready to spend many times more than what it would need to spend in comparison to a public provisioning-based system.

6. How should peoples’ movements respond to this initiative? What should their approach be to mobilizing people for change, and in shaping the public discourse on these subjects?

The response has to be at many levels.

At the level of public discourse, Peoples Movements must disseminate a select few key messages- and this would have to be backed up by evidence:

a. The PM-JAY scheme is unable to deliver on its key promises, which are: providing financial protection for the costs of health care and increasing access to healthcare and improving health outcomes.

b. The PM-JAY is being projected as a great gain for the poor- but in reality, the main purpose it serves is as an economic boost to the private sector in healthcare. The poor would have been better served by increasing the quantity, range and quality of public services.

c. There is a need for much better monitoring of the PM-JAY and civil society organizations’ and people’s movements must be involved in such monitoring. If monitoring improves, many private providers would exit or have to be pushed out. But this is good, for it would leave only the ethical not- for- profit providers- and these could supplement the healthcare system. Furthermore, private providers may be encouraged only where public sector is unable to provide care.

d. Paying public providers using the current insurance mechanism brings the problems of private sector behaviour into the public sector. The insurance scheme can however be approached to top up the usual facility budget based on variety and quantity of cases managed in the previous months or year.

e. Payments to private providers must be made in a timely manner and without corruption, so that ethical players are encouraged to stay on. For both public and private providers, it is only the marginal capacity that should be paid for- (that is the running costs. It should not include the capital costs).

f. There has to be a substantial improvement in number of beds and range of services provided by public hospitals, along with improvement in quality of care. Quality of care should include all elements of patient dignity, comfort and satisfaction, and also access to timely care, polite behaviour, better patient communications and facilitation, fixing appointments for consultation etc. Public investment is best spent on achieving these objectives.

At the level of popular mobilization of those who are directly affected, peoples’ movements can undertake the following activities:

Ensure that patients know their entitlements under the scheme, and where it is denied, they bring it to notice of authorities. These should include at least the following:

The patients are consulted and informed of price of services before they are charged the same.

The patients can readily see how much money is on the card, and how much is being charged and they receive a bill for it- even though they are not paying in cash. It should be clear that the same bill that the patient has signed is the basis for reimbursement.

That a patient is not denied any service for which the hospital is empanelled. The services they are providing and those they are not providing should be clearly listed in the contract itself and be available to the public.

After gathering testimonies or other forms of data on breach of the contractual terms, forms of collective protest can be organized. These could take the form of a petition, or news statement, or meetings etc.

Gather evidence of double-billing and help both individuals and organizations to challenge it.

Demand right to anonymized data base of the PM-JAY claims for district level analysis to identify distortions and patterns of supply driven care

7. PM_JAY is limited to inpatient care and procedures. It does not cover out-patient care and primary healthcare. But greater proportion of health expenditure is on out-patient care. Also, by keeping outpatient care outside the PM-JAY package, does not healthcare get fragmented? Should we therefore demand inclusion of out-patient care in the PM-JAY package?

a. Out-patient care is far more difficult to monitor and regulate than in-patient care. When the PM_JAY platform is so prone to problems like double billing and inappropriate care, adding out-patient care will only exacerbate the problem. Also, much of primary health care and out-patient care at all levels is preventive and promotive- like screening for early detection, counselling and medication to prevent complications and the need for in-patient care and procedures. The business model of private hospitals and clinics is focused on curative care, preferably complex, secondary, and tertiary level care. The private sector is not the best carrier for preventive care, that too at the primary level.

b. A large game being played today is to somehow persuade government to route its one lakh crore expenditure in primary healthcare through the private sector. The proposal from international aid agencies promoting privatization in the primary healthcare sector is to go for a model where primary healthcare in a geographical area is outsourced to a corporate entity. The demand for inclusion of primary health care and outpatient care into PM_JAY can play into their hands, as the main providers within PM_JAY are private providers. Peoples’ movements need to insist on universal comprehensive primary healthcare being through public provisioning.

c. The other demand that we must guard against is asking for more funds for PM-JAY or reimbursement at higher rates for procedures. These will only drive more money into private hands without improving health outcomes, or access to health care, or financial protection.

8. Should our main demand be roll back of all government funded insurance schemes?

The JSA has already called for a complete rollback of insurance schemes with the alternative being strengthening public health services. There is merit in such a position. But many civil society and academic groups (and the HLEG report) also call for “complete rollback of insurance schemes” with the alternative being the outsourcing of all primary, secondary and tertiary care services in a geographical area to a corporate entity or integrated care network as they prefer to call it. Sometimes the alternative is articulated as contracting in all individual private doctors in that area- which in practical terms could amount to the same. Thus, a call for “completely roll back of insurance schemes” is a slogan that we should voice cautiously if at all. Given also the popularity of the insurance schemes within trade unions as well as many other sections of the people, it may be a wiser strategy in the current context to push for limiting the presence of insurance, with larger proportion of public providers, and call for ensuring that private providers adhere to contractual terms. Moreover, primary healthcare must remain separate and should be based on public provisioning. One would also need to call for making effective and expanding the ESI network and ensuring that the ESI as well as healthcare units of public sector undertakings are not privatized using insurance or any other route.

Health Insurance India

Modicare

Health Policy

WRITTEN BY

Sundararaman T

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From Dr. Sundararaman’s Desk