‘Modicare’: Government-Funded Health Insurance Scheme

by September 17, 2018 0 comments

‘Modicare’ Government-Funded Health Insurance SchemeAlthough the Pradhan Mantri Arogya Abhiyan who deserves praise, a number of loopholes still remain.

A Haryana girl has once again made national headlines. Karishma, born through a caesarean section on August 15, 2018, in a Government hospital in Karnal, became the first beneficiary of ‘Modicare’, the world’s largest Government-funded health insurance scheme. The Pradhan Mantri Jan Arogya Yojana programme had been hailed as the pièce de résistance of Union Finance Minister’s 2018-19 Budget speech but many expressed apprehensions if the scheme would be off the blocks anytime soon.

Besides the splendid pace, there has been a rich sprinkling of innovation in its implementation. Automatic enrolment, beneficiary verification in public meetings, IT system-based monitoring of progress, creation of silver and golden records are few of the trailblazing novelties adopted so far. Flexibility provided to States in co-branding with their existing schemes, deciding implementation model and package rates, reserving packages for public health facilities and continuous consultation with the States have helped in allaying apprehensions about the scheme. Consequently, 29 States and Union Territories are already on board and a few more are likely to join.

National Health Agency and State Health Agencies have been set up to implement the scheme. Over 12,000 hospitals have been empanelled for providing cashless treatment. About 1,350 medical packages, covering surgery, medical and day care treatments, have been defined. An integrated software has been developed for beneficiary identification, hospital empanelment, transaction management and merger with State schemes. Issuing e-registration cards after the creation of silver and golden records of the beneficiaries has started. Ayushman mitras, volunteers for verification and authentication of beneficiaries and assisting them at empanelled hospitals, are being identified and trained. Pilot launch of the scheme has been done by 19 States.

In a nutshell, the Union Health Ministry and State health departments seem to be geared up for nationwide rollout of the scheme on September 23, the birth anniversary of Pandit Deen Dayal Upadhyay.

However, the euphoria created, and the competition generated among the States to beat others in implementation of the scheme, should not blindside them by frauds and failure to reach intended beneficiaries. Fraudsters are watching this mega scheme with hawk eyes. Their nefarious designs have already started surfacing. The Maharashtra Government recently filed a police complaint against people soliciting premium from beneficiaries to get them benefits of the scheme.

Another challenge will come from hospitals empanelled to provide services. Experience tells us that hospitals adopt malpractices like conversion of an OPD patient into an IPD patient, deliberate blocking of higher priced package, treatment of diseases for which a hospital is not equipped for, doctors performing unnecessary procedures and hospitals charging fees even though it is a cashless scheme. Impersonation in connivance with card-holders and hospital too have been reported.

Many States have a preferred assurance model over insurance for implementing the scheme. In this model, States will bear the financial risk of excessive claims. This is fraught with danger given that health insurance claim percentage is increasing, and public sector companies are incurring heavy losses.

Just providing health insurance or assurance won’t bring succour to the poor, especially for those living in rural and tribal areas. Access to quality health facilities and availability of manpower will be critical. India is short of three million hospital beds and is facing over 50 per cent shortage of doctors. People in rural areas bear the brunt of this shortage. This means that nothing much is going to change for them, at least in the short run. With a wide base of over 50 crore insured people, healthcare providers are more likely to go for a skimming strategy, harvesting gains from existing facilities than investing in new ones.

Package rates for various procedures fixed under the scheme are being perceived as too low by private players. This will deter quality providers from participating in the scheme. Low rates will also impact the much-desired investment in health infrastructure in remote areas. States have reserved several packages for public health facilities only. This is intended to guard against private providers enticing beneficiaries for routine procedures. However, it would mean the same level of services for the poor people unless public facilities are quickly upgraded. Moreover, there will be a cut from their entitled five lakh rupee  bounty of health insurance even for procedure which should be available free in public facilities. The proposal to share a percentage of money earned by Government hospitals with the team performing the procedure also needs a close watch for potential malpractices.

The scheme is entitlement based, with eligibility dependent on deprivation status of a family established by Socio-Economic Caste Survey of 2011. Survey data is not just old but lacks vital information to identify households, especially the shifting and migratory population in urban and semi-urban areas. Thus, several deprived families could be left out.  Additionally, the scheme hedges against in-patient care only. Outpatient healthcare expenses, which are a cause of higher economic burden and financial catastrophe for poor families, are out of its ambit.

The health of the populace is not just treatment of ailments but also hinges on multiple determinants as well as preventive and promotive strategies. While the national and State health agencies are working on health insurance and assurance models, the department of health at the Centre and the State must work on improving public healthcare infrastructure, availability of health manpower, public health measures and lifestyle changes to reduce morbidity and mortality. The success of Pradhan Mantri Jan Arogya Yojana is critical to improve access to quality, affordable healthcare and putting a brake on a vicious cycle of impoverishment. It will also be instrumental in achieving universal health coverage, health related sustainable development goals and in building a new India by 2022.

(The writer is a senior IAS officer)

Writer: Dr Sajjan Yadav

Courtesy: The Pioneer

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