Nashik Universal Coverage M F C 2011f
Shyam Ashtekar;s Background paper on how to plan Universal Health Care for a specific area- Nashik
Published on: Mar 3, 2016
Transcripts - Nashik Universal Coverage M F C 2011f
December 7, 2010 Contemplating UHC for Nashik -Dr Shyam Ashtekar, With the help of Dr Ratna Ashtekar and Dr Suhas Joshi11. BackgroundWe have been working in Nashik district for the last 25 years and have closely seen the plight of peoplewhen they seek medical care at government or private hospitals. Nashik is a better off and growingdistrict and city in the so called Golden Triangle of Mumbai-Pune-Nashik. But it is also a story ofcontradictions.Based on European health plans (meaning social security systems in European countries like Germany, etc.), Ipresume that UHC (Universal Health Cover or Coverage) becomes universal due to three features orbasic principles:a) Enrollment of all providers public or privateb) Cover to all users and communities andc) Covering most or as many health problems as possible.I presume that UHC (or UHAC, with the added A for Access) will amalgamate ‘public’, NGO and‘private’ health care providers under a broad plan of accreditation and claim processing/ reimbursement.The differences between various sectors will gradually melt into a seamless UHC.I believe that a centrally designed UHC has to be somewhat customized to states and districts. Thereforefacility map, provider profiles, costs, leverages, local politics and administration, etc., offer varying terrains for anumbrella national UHC plan. This necessitates generation of data on providers, user community, currentcosts of care, health problems’ profile and felt needs, etc.The idea in presenting details of Nashik district (or rather the city) is to stimulate thinking on possible‘models’ for a UHC or inject the idea of terrain-customized or calibrated approach. UHC is a majorpolitical program; hence local details also become important. While contemplating how UHC can beimplemented in this district, I have used my current understanding of the district and city and I am opento suggestions.2. Nashik District and City2.1 District ProfileThis is a district of contradictions, with rich agro-zones and wineries, along with tribal people in westernhalf of the district migrating for farm and construction labor, drought-prone talukas, industry (thoughnot big as Pune, Thane or Mumbai) and migrant workers from other states. This is area-wise the biggestdistrict in the state of Maharashtra. Two major cities - Nashik (18 lakhs) and Malegaon (8 lakhs) - 1 Page1 Email: <email@example.com>
together have a population of about 26 lakhs. The entire district had a population of 49.9 lakhs in 2001.The rural part has 15 blocks and is divided in three parts: a) a Western Ghat area having tribalcommunities (Koli and Kokna for instance) and having most of the river-based dams; b) irrigatedtalukas of Nashik-Niphad-Dindori surrounding the city of Nashik, and c) drought-prone talukas in theeastern zone, including Malegaon. The city of Nashik is the divisional headquarters for NorthMaharashtra and a place of pilgrimage and Kumbha. The main crops are grape and other fruits, onion,vegetables and sugarcane, with seven sugar mills to harness the latter. The district has a good networkof roads and is a major station of Central railway, but there is no major airway service. Being close toMumbai, the incomes are increasing in all sectors. The Mumbai-Agra highway is being developed as afour lane expressway from Mumbai to Indore on BOT principle. Land and property prices have grownnearly ten times in the last decade. It is a boom time for Nashik only next to Pune and may be Nagpur.The weather and water are great assets of Nashik. 2 Page
2.2 Health Sector in Nashik CityThe health sector information regarding the entire district is incomplete - especially because privatesector data from rural area is not available and is a subject of research by itself. Health relatedinformation about Nashik city per se is available. We have focused on Nashik city only in this paper -however one must add that the clientele in these facilities comes from entire district and not just the city.The NMC (Nashik Municipal Corporation) has a registry for hospitals and clinics that is updated everyyear. The information is not very systematic and is difficult to use. We have banked heavily oninformation from medical associations. It seems NMC has only a fraction of information regardingdoctors.Here is an attempted summary:• The Shirdi Saibaba 200-bed hospital is 100 km away from Nashik, but attracts lot of clientele from Nashik district as its services are good and tariffs low. In fact it has influenced and brought down tariffs of heart procedures in Nashik. It offers a heart bypass surgery for as low as Rs 50,000 to poor patients, even this can be waived off if need be. The same surgery costs around Rs 2 lakhs in private hospitals. Probably other rates are not affected in Nashik.• The MVP General Hospital attached to a private medical college is another success story with a posh hospital offering economy rates. This has a big potential for UHC in near future. Subject Number Unit/10000 Head Of Units Popln./Unit Popln. Beds 4000 450 2.2 GPs 1700 1059 0.9 PGs 1106 1627 0.6 Dentists 350 5143 0.2 Pharma Shop 1500 1200 0.8 Table 1: Medical Facilities in Nashik at a glance 3 Page
Psychiatry 50 Anesthesia 65Dermatology/Venereology 25 Ayurveda 100 Radiology 83 Pathology 65 ENT 26 Super-speciality 25 Internal Medicine 75 General Surgery 85 Pediatrics 140 Ophthalmology 80 Orthopedics 87 Gynecology 200 Dentistry 350 Unani 7 Homeopathy 153 Ayurveda 1250 Allopathy 121 Degree not available 91 Table 2: Doctors in Nashik Source: Data from NMC and medical associations. The last five categories are in the GP sector. Table 3: Hospital beds in Nasik city (2010), pooled data 1100, 27% All public 2000, 49% hospitals All trust 1000, 24% hospital All Pvt hospital 4 beds Page
2.3 Health Care Expenditure in Nashik District: An EstimateHere in Table 4 is a ‘reasonable’ guesstimate on health expenditure in Nashik district, assuming 55 lakhspopulation and number of providers and beds, etc., available from the study. Table 4: Private Sector Revenue Estimate (income and estimates in Rs) Category Number Income per Day EstimateNashik City Consultants 1,041 6,000 2,279,790,000 Dentists 350 4,000 511,000,000 GPs 1,600 1,000 584,000,000Rural+Malegaon City Consultants 300 5,000 547,500,000 GPs 2,000 800 584,000,000Add for Bed Income in the District at 50% Occupancy 4,500 500 410,625,000Total 4,916,915,000Add Pharma Sector Expenses at 33% of Doctor Incomes 3,428,986,970 Total Pvt Sector 8,345,901,970Public Sector (Exp Est) N Annual BillPHCs 102 9,600,000 979,200,000CHCs of 30 Beds 24 7,500,000 2,160,000,000District & Sub Dt Hospitals 4 10,000,000 384,000,000 85 Doc+500NMC Med. Expenses Paramed+Medicines 130,000,000Malegaon & Other Municipal areas. 26,000,000ESIS Hospital/Disp Nashik 30,000,000 Total Public Sector 3,709,200,000Trust Hospitals (ExpenseEstimate)Major Trust Hosp (Guesstimate) Total 1000 Beds in 4 Units 4 120,000,000 480,000,000 Grand Total 12,535,101,970Rounded To 1,250 CroresPer Capita Annual Exp on Medical for 55 Lakh Popln. 2,279Rounded Per Capita Annual Exp 2,300 5 PageNote – The above guesstimates is based on following assumptions inter alia:Consultant incomes are taken to be just about lower values, equivalent to about Rs 1.5 lakhs per month.
Actual incomes may be much higher since this includes, consulting, visit fees, procedure fees etc. Medicine costs are also taken at lowest. Public and Municipal health expenses are based on monthly bills for full staff, noton actual expenditure. Army medical services are not included in this table.2.4 Health Care Facilities: Rural ProfileI have no up to date information on private providers in Nashik, nor of Malegaon. A detailed report onHealth Human Resources (HHR) of the district, with breakup by cities, towns, villages, etc., is necessaryto understand how UHC can manage provision and access. Some general points can be said here: • Rural HHR is likely to be a reverse picture of the Nashik city: fewer consultants, more GPs, unqualified doctors, etc. Malegaon city HHR can be a small replica of Nashik city. • Hospital beds will be more in public sector (taking together PHCs and CHCs) than private sector. Trust hospitals are scant or absent in rural areas. • MBBS doctors will be mainly in government centers, while non-allopaths will dominate the private sector. • Rural services are clustered in some villages: our study in five blocks of Nashik showed that all doctors are clustered in 16% of villages. This distribution would not be better today. • Barring some work in basic specialties, most of specialty work flows to the city. Hence rural communities have to travel to Nashik or Malegaon for all higher medical needs.2.5 Fees and Rates Table 5: Fees and Rates of Various Sectors in Nashik (in Rs) Private sector charges MVP Hospital Rates Item (without medicine) RSBY Maximum Cover GP Fees (Usually Includes 30-50 None -an Injection) PG-Consulting-Specialist’s 200 NoneConsulting Fees Specialist’s Super 500-1,000 NoneConsulting Fees Normal Delivery$ 10,000-30,000 2,500 1,500LSCS (Caesarian Section)$ 25,000-50,000 4,500 1,500MTP (Medical Abortion)* 2,000-4,000 500Appendix Surgery 15,000-40,000 8,000 1,000Hernia 10,000-25,000 8,000 1,500Hip Fracture: Surgery with 25,000-70,000 10,000 1000-1500ProsthesisCataract (Indian Lens) 5,000-12,000 5,000 500 Angiography 6,000-10,000 10,000 ? Heart-Bypass Surgery 150,000-200,000 NA(CABG) Charge ICU Daily 2,000-5,000 300 200Ventilator 750Bed Charges 500 150Sonography# 600 100-250X-Ray Chest Adult Size 250-500 110 6Hysterectomy Vaginal 25,000-50,000 10,000 2,000 PageMedicine Costs As per details 15,000 ?
$ In MVP hospital 1st &2nd delivery and LSCS are free and there is no separate charge for LSCS.Hernia in pediatric age group is free.*MTP with TL is free in MVP, #Obstetric sonography in MVP hospital costs Rs 1002.6 Learning from Doctor and Hospital Data for UHC1. Good public hospitals are scant and crowded, while others are dysfunctional because of politics, corruption and malpractices. People use public hospitals as last resort or because there is no money to shell.2. In Nashik, the hospital and consulting rates are high, but RSBY or low cost policies hardly meet the costs. Even co-payments cannot meet the gap.3. The rates in the private health sector look high, especially for BPL and just APL people. Even Mediclaim finds it tough to pay these rates and the recent cashless row is mainly because of these high rates. RSBY rates are far too low for this sector, which is why RSBY does not find takers in the private sector even in poor districts like Sholapur (Source: My conversation with previous Director of Health Services of the state).4. The MVP hospital rates are impressively low; the hospital has 500 beds and has occupancy of 50- 60% at anytime. Being a medical college hospital, it is indeed a win-win arrangement for the institute and patients.5. Primary Care Sector: While computing population ratios, we assumed that GPs serve only the city population which makes it almost one formally trained GP for 1250 population. Do we need more GPs in the city’s health care pyramid? We also need primary health workers in the urban health system. Only 7 % of the GPs are MBBS. So we need ways to train others and ‘mainstream’ them.6. Public and trust hospitals together command 50% beds, and can be a major leverage for UHC.7. The public hospitals need to be made fully functional and trust hospitals utilized more fully.8. Most public and trust/institute doctors are in some kind of private practice and hence the public hospitals are starved of dedicated doctors. This is also a major challenge to UHC.9. NMC itself needs to work out a system of accreditation of nursing homes. The NMC data is quite deficient.3.0 Mediclaim and RSBY (Rashtriya Swasthya Bima Yojna) in Nashik3.1 Health InsuranceApart from the four public sector companies offering mediclaim policies, 18 private companies are inthe fray. When I googled for information about my age, 1 lakh cover and city of Nashik, websitesoffered me 16 products from 15 companies including four from public sector companies. About 18-20TPAs (third-party agents) operate in the city. The total number of insured people is not available but issurely far more than the 3% figure that is quoted. One reasonable guess is that 20% people of the cityhave some kind of cover-either from company, government or insurance. We also have companymedical cover for employees, which can be with private insurance firms. According to Mr Kini, aMumbai-based chartered accountant studying this problem, the current mediclaim business is a viciouscircle where providers, TPAs, insurance companies and consumers are cheating each other. Consumers 7want to make maximum claims, providers want higher tariffs and make false claims, insurance Pagecompanies are in claim denial mode, and TPAs ask for ‘cash’ to process higher claims. The costs of care
are jacked up because of this vicious circle. RSBY tariffs can’t be fulfilled in this adverse environment..Tariffs may be declared soon for all procedures. These are important lessons from UHC.3.2 RSBY (Rashtriya Swasthya Bima Yojna)RSBY premium is borne by government, hence cards are issued free of cost to BPL families. However,the RSBY implementation in Nashik district is almost zero since the public sector company (the NationalInsurance Co Ltd) branch in Nashik is not active on this front, unlike Jalgaon district. This could be dueto some factors including the issue of non-availability of providers at the RSBY rates. Secondly BPL(Below Poverty Line) survey in the NMC area is not completed -- this is what we learnt, so RSBY cardshave not been issued to families, thus the funds are just not spent. In effect we have no RSBY till now inthe district. The agency for each district is decided by Ministry of Labour (MOL), Government of Indiafor 2010-11. The MOL offers Rs 70 per policy to the agency for all work up to issuing RSBY cards,which is a good incentive. (Arogyam had requested Government of India for getting this work. RSBYmust be kick started in Nashik, without which BPL families cannot get cover.)4. Making a UHC plan for NashikAdmittedly, making and implementing a full UHC plan for Nashik is a long journey. UHC needs fourcomponents: supply of health care, users, insurance and control bodies. Let us see about how these fourcomponents look in the context of a possible UHC.4.1 Supply of Health CareWe have a heavily clustered health sector in Nashik district, as is expected. Rural scene is dominated byGPs, many of whom are not qualified. Consultants dominate the cities.The district data on rural doctors’ lists only about 25% of doctors for various reasons, including thefactor of bogus doctors. Consultants are mainly in the cities, so are the beds.The GP - primary sector - is dominated by non-MBBS doctors, the later being only7% in the city ofNashik. But the gross ratio of population per GP seems close to good (assuming 1000 per GP is good forIndia).We have no norms on population per consultant. This is very difficult factor to decide or guess, becauseit involves epidemiology, expectations of people, paying capacity, population density and transportaccess, supporting hospitals, the mix of public-private-trust sector and so on.The hospital beds are divided neatly between public and trust (semi-public) on one side and privatehospitals on the other. One would like to think of using the public-semi public sector as leverage, but thesame doctors run these institutes in different time slots! They will try to protect the private domainsrather than public-semi public sector.Accreditation and regulation of facilities is nearly absent although Nashik MNC has taken to registrationlong back. The ZP (Zilla Parishad) also started registration of doctors/nursing homes some 5 years ago. 8 PageEven the data is incomplete.
4.2 Community and UsersObviously the rural-urban divide, socio-economic and organized versus unorganized sector disparitiesare all going to matter for UHC. The acceptance of UHC will be vastly different across disparities. UHCneeds to be designed with focus on BPL and APL, but the better off may not want it in that form. HenceUHC may be sectoral and partial to begin with.4.3 Pool and InsuranceAlthough RSBY, mediclaim and low cost insurance get nowhere near a UHC plan, these are the buildingblocks for future UHC. A reformed and revised RSBY can be a major leverage, along with low costpolicies that are described in later sections of this article. Group insurance schemes can make a swiftmove to pre-UHC formations.Even by modest estimation, the total annual cost of care in Nashik district is above Rs 1200 crores (percapita about Rs 2400). Theoretically, UHC has to reach a pool size of Rs 1200 crores just to meet all theclaims, nearly half of it - the salary part included - coming from Government and urban local bodies.(For the state of Maharashtra with 11 crore population, this 50% provision means a support of nearly Rs12000 crores through state, center and local bodies. The pool has to also provide for some capital costsfor facilitating health facilities in unserved areas, but we are not taking this issue now. Currently thetotal public provision is not more than Rs 4000 crores including state Government health services,medical education department, local bodies including Mumbai Corporation and ESIS).4.4 Control AgenciesAny new UHC apparatus has to have a district body to manage and monitor. Since UHC will be a legalarrangement, the control body has to combine local bodies (Municipal Councils and Zilla Parishads), insurancebodies, associations like NIMA (National Integrated Medical Association), IMA-FOGSI, trust representatives,clients and client groups, etc.Single agency to pay for claims may be a risky idea, because of corruption and caste politics. Theground rules for claim settlement will be uniform, but agencies for claim settlement/servicing should bemore than one with some element of competition and preference.It involves right actions from many corners and fronts -- government, labour ministry, NMC, ZillaParishad, trusts, medical associations, industries and employers, political parties and leaders, consumergroups, etc. In my opinion the most essential parts of UHC project are: a) Get enough good hospitals in secondary and tertiary level in the city that offer low cost care with scientific and rational parameters. This can be done by helping trusts/groups start hospital facilities in NMC or government-funded premises and equipment grants. b) Improve and include public hospitals of NMC and government of Maharashtra to service UHC (now mainly RSBY) at same tariffs, earn income from UHC and give incentives to doctors and staff. Gradually public hospitals should earn salaries from UHC services rather than treasury. 9 . Page c) Make available low cost insurance cover in the context of tariffs in the ‘good hospitals’.
d) Start good pre- and post-hospital care network through NMC-State Government-Trust-PPPs to reduce costs and exploitation, improve access and efficiency.We can begin with these small steps and work towards UHC.5. Efforts and Experiences of RCT for Low Cost Health Care through InsuranceRCT-Arogyam (RCT is Rukmini Charitable Trust, Thane. Arogyam is a local firm working with RCT forspreading low cost care. Therefore RCT-Arogyam is a combine of the two - this arrangement helps in a trust tobe in the business of health insurance.) has a small unit working from its Nashik office. The insurancerevenue at this point is Rs 88 lakhs, which is small but able to barely meet its expenses. So RCT-Arogyam itself has about 0.1 % share of private plus trust portion of Nashik’s health sector. RSBY isexpected to cover some 1 lakh plus families, which costs the government about Rs 5 crores annually. Noother company is offering low-cost insurance; and RSBY is inoperative. If we presume BPL and justAPL sector together to be around 50% of population, which is 27 lakh population and hence about 5lakh families, the RSBY business is about Rs 25 crores. Therefore it is a long journey on a narrow path.The goal is to ensure providers supplying low cost care in each ward, and to get APL families to buyinsurance and seek care and RSBY made available at the earliest. This will enable the BPL+APLpopulace to get medical care and cover with dignity minus today’s hassles.RCT-Arogyam offers policies with the backing of Oriental Insurance. They have four individualpolicies, offering various plans much like mediclaim. The principal instrument for general category isthe universal health cover (UHC) available at Rs 500 annual premium. This offers Rs 30,000 cover,within Rs 10,000 at one time, and includes pre-existing illnesses, excludes pregnancy and abortion. Thisis for a family of five.5.1 RCT’s Group Medical Cover (GMC)Arogyam-RCT combine launched their group insurance scheme last year with very attractive terms.When I was in the YC Maharashtra Open University last year, we got about 300 plus families ofemployees covered for all problems (including pre-existing illnesses) up to Rs 1 lakh cover, exceptmaternity, dentistry, plastic surgery and AIDS, for all family members from a 3-month old baby to 79-year old adults. The total payment was Rs 12.5 lakhs, which included a small accident insurance fromLIC. As the year closes, the claims have crossed the premium amount and will almost double thepremium by end of the term. I may point out here below the experiences.There was very stiff opposition to this by unions as some elements were interested in reimbursementschemes which were lucrative to middlemen as well as doctors in the league. The scheme was roundlyattacked for 2-3 months. Even the new Vice-Chancellor asked me to close the scheme and shift toWockhardt hospital. He did not know that Wockhardt hospital did not provide general services but onlyservices for heart, joints, cancer, etc. Some influential private doctors harassed employees and got themto complain against the GMC. But at the end, it seems the university is giving them a renewal this year. 10It has saved the university about Rs 20 lakh this year, and the general employee is happy and thankful.But the premium costs will go up this year due to higher claim ratio. The GMC was purchased by some Pageother institutes. At this stage of medical insurance, the national pool is able to absorb such losses at
places. UHC will have to draw from state, city or district pool and account for losses. The ‘free meals’will stop once the business gets serious. Somebody will have to foot the subsidy.Theoretically, GMC is much better than individual insurance. It saves many administrative hassles andcreates a bargaining power from the organized sector and disbands the reimbursement rackets. We feelthat even the state government and its bodies should go for GMC rather than reimbursement, the latterhas created huge corruption rackets. Incidentally, the civil surgeon of Nashik was arrested in this periodfor amassing wealth from such a racket (cash Rs 12 lakhs was found in his office). GMC can pave theway to UHC in steps. But one problem is the huge number of workers who are in the unorganizedsector.6. Some Expected Hurdles in UHC and SuggestionsUniversal health access cover is far different from the sum total of individual policies available today,but the path to UHC has to cross this jungle. The Canadian health reforms started off from a county. Tounderstand the major effort on UHC, we need to understand and plan for a district of good size andaverage resources and assets. Nashik can be a case study. If UHC is the long term goal for making goodcare available to all, some problems need to be understood. Suggestions are given in italics.6.1 Unions and EmployersUnions do not support group insurance because of vested interests and mistaken ideas of good medicalcare at any cost and with company support (third party payment). We need educate trade unions tounderstand the health economics and the benefits of GMC. Women’s micro-credit groups, associationsof domestic workers, self-employed or lone workers, farmers, contract labour and staff etc need to buycover, perhaps with some help of employers. It is necessary reach out, propose good policies andproducts.6.1 Unions and EmployersUnions do not support group insurance because of vested interests and mistaken ideas of good medical care at anycost and with company support (third party payment). We need to educate trade unions to understand the healtheconomics and the benefits of GMC. Women’s micro-credit groups, associations of domestic workers, self-employed or lone workers, farmers, contract labour and staff, etc. need to buy cover, perhaps with some help ofemployers. It is necessary reach out, propose good policies and products.6.2 Consumers Unaware of RSBYThe target consumers are unaware of both RSBY and APL policies. We need to tell them about theschemes, their rights, benefits and enrolment procedures. However the organizers themselves are waryof promoting any insurance, they see it as a liability. We can start from some organized and needygroups.6.3 RSBY inoperative in NashikWhatever the tariffs of RSBY, it can still be a major leverage for getting hospital care. The central 11government’s Ministry of Labour must monitor the situation in each selected district. The distribution of PageRSBY, implementation must be monitored by state Government health department.
6.4 Cashless!The consumer does not have to pay cash to the hospital; the insurance agency/TPA settles it by chequeat the time of discharge. Unless these cashless transactions cease; medical insurance will bleed thecompanies. Rates must be prefixed and declared by medical insurance companies, district associationsand/or RSBY. Extra claims should not be entertained.6.5 The Unwilling ProviderThis is a major hurdle; we cannot get enough private providers at economy tariffs. But they will beavailable as we go ahead with Trust providers. A long term alternative/addition is to get NMC ownedpublic hospitals to serve the UHC and earn incomes and incentives for staff. The effort is on to negotiatewith major Trust hospitals that are looking for stable clientele. This will optimize other private sectorrates. Some corporate hospitals may also be willing to serve the sector, with copayments. But co-payment needs to be capped.6.6 The All Pervasive Private ConsultantPublic hospital doctors run their own clinics and hospitals. The same is true about trust hospitals. At theend of the day it is the private consultant calling the shots in all three areas. Can we address thisproblem under the umbrella of UHC? In the long run, yes! But immediate implications are scary, asprivate consultants will resist amalgamation and protect the private establishments.6.7 Cross PracticeSince GP sector is full of Ayurveda and Homeopathy practitioners, and that they have no systemic (andsystematic) formal training in modern medicine; referral criteria are very flexible and there is noaccountability to modern science or any apex body. The patients suffer and so do the good doctors whowould like to stick to science. A bridge course is necessary for GPs for better diagnostic protocols andstandard treatment guidelines.6.8 The Quack ProblemQuacks are ubiquitous and in various forms, the main form is a medical practitioner without any validformal degree diploma. They are aplenty in many cities and rural parts. They influence many decisionsof patients and doctors regarding interventions for purely business reasons. The good doctor suffersfrom them in several ways. Quacks cannot be wished away at least in rural areas. We should makeavailable graded certificate courses for these village practitioners and let village panchayats give themplace and clientele. This will restrict the problem to PRI framework.6.9 Dysfunctional Government Super-Specialty HospitalThe high cost MS hospital in Nashik is a non-starter for last 12 years. This is expected to take care of all majorproblems regarding brain, heart, kidneys and joints etc that require high cover and cannot be done through RSBY.he HHR is the key, which is a general problem with Maharashtra. There are no signs of this hospital starting innear future. I suggest that this hospital be handed over to the Medical University at Nashik, or Medical EducationDepartment with full establishment costs. The state’s Directorate of Health Services has no capacity to run thishospital at all. This can be a PPP model and there is need to rope in successful hospitals like Shirdi SaibabaHospital for its management for five years. 12 Page
6.10 MalpracticesMedical malpractices are quite common, and take many shapes and formats; some of them are nowsystemic like cuts and commissions. Here are some salient examples.• A reputed private company pays Rs 1 crore as premium for health cover, but the claim ratio reaches 4-5 times within the year. Every year they are ‘refused’ by the insurance company. This happens because of false claims, overbilling by hospitals and collusion of hospitals with worker unions. Many top companies have similar experience. My suggestion: switch to GMC or declare cap on medical expenses. This holds good also for state government establishments: give GMC and not reimbursement.• Some city hospitals have been blacklisted by insurance companies and TPAs, for serious malpractices.• Many hospitals charge double for insured patients. Fixing service costs is the answer. Clients will start choosing economy hospitals. Unless claim scrutiny is genuine and tariffs settled and accepted, no insurance company can profit from medical insurance.• Rampart cuts and commission practice (to the tune of 50%) has already made life vicious for patients and consumers and also for the ethical, good doctors. This causes false claims, overbilling and mistrust and a feeling of helplessness among good doctors and honest consumers. UHC will take care of this problem in the long run. A good primary care network that supports pre- and post- hospital care will reduce some of the problem.• Reimbursement is lucrative: Government itself has got this great addiction. Everybody profits in reimbursements, except the helpless taxpayer. Just to give an idea of the chronic scam: a Class 1government servant claimed Rs 9 lakhs for the two cerebral strokes of his 75-year old father (who eventually died in one year). He could not have made this money had he just some RSBY-UHC cover and no reimbursement scheme. My advice is: Wean away government establishments from reimbursements.6.11 Ensuring Outpatient ServicesPrevalent insurance covers only inpatient costs and some procedures. Many costs are incurred asoutpatients, especially most routine investigations. These are costly and so are medicines.Hospitalization is required less often, but outpatient consultation is required often. Unless the latter getscover in the scheme, people are not interested in cover; they would rather prefer to decide if and whenhospitalization is imminent. It may be a good idea to declare consultation rates for each city and districton some criteria. But free outpatient is unlikely to succeed.6.12 Covering Obstetric EventsChildbirth, caesarians, abortions are not covered in most policies as these are ‘predictable’ events. ButUHC must cover these events.6.13 Corruption and Caste-PoliticsA real hurdle can be corruption mainly while settling claims, which is happening with cashless claimsand some TPAs. This will balloon as the UHC grows. The users, providers, TPAs may align on caste-corrupt lines. This menace, along with caste affiliations will make UHC unattractive for many honestand leading providers. This needs careful consideration. This rock alone can shipwreck the UHC.6.14 Short-Term Recommendations 13We need many action points from different agencies: Page
1. The NMC should take an active political role, but if this is not forthcoming, a trust like RCT – Arogyam has to engage in advocacy and promotion, negotiate with IMA and consultant bodies.2. Conduct and publish studies of costs of care, expenditure patterns, utilization of public-private facilities.3. Systematic registry of all care providers, with details and updates, start an accreditation mechanism with help of administration and IMA-Nashik IMA, etc. (the related nursing establishments regulations and laws must be active by this time).4. Reform the hospital regulation mechanism or accreditation system to guide clients and consumers to hospitals with better practices.5. Start and spread of RSBY, and low cost policies, GMC, and educate people about their importance. Work with small communities and associations like micro-credit groups, cooperative bank account holders. Get private providers and Trust hospitals to support RSBY and UHC. We need a scheme for promoting trusts and groups to start hospitals by supporting capital costs, offering place and space in each ward, with service guarantee. This will cut down hospital rates and make them UHC-friendly. This will also thwart growth of private hospitals that we see today.6. Buttress RSBY with some co-payment, but declare official co-payments.7. Establish a network for good primary care: pre- and post-hospital care with help of Family Physician association, NMC dispensaries and urban health centers.8. Activate Nashik super specialty hospital, if necessary by PPP with likes of Shirdi Hospital.9. IRDA has to look into ‘regulation’ of the insurance sector and tariffs. Put information on website.10. Set up a district fund pooling Government resources, NMC funds, donations, RSBY, etc., under a joint local body (which needs a State Act for support) which will manage UHC.There is no way India can revive its public service to commanding heights in competition with thecurrent private sector. Building a UHC is a chakravyuha; but probably there is no other way for us. Wehave to start doing many seemingly imperfect things with a vision of UHC for low cost, rational andhumane care for all people. It has to be a multi-systemic effort, and many players need to team up. It isalso an ideological battle. It is nobody’s case that UHC is easy or a panacea. UHC will not be free ofcorruption and malpractice. But even then, we must all walk towards a UHC system.AddendumDr Suhas Joshi, Medical Director of RCT wrote the following response to this paper -Dear Dr Ashtekar,The scheme which we launched last year in Nashik was an effort to reduce cost of treatment at all levels.First we launched a policy named platinum plan. The plan had pre existing diseases covered from 4thmonth onwards after taking the policy. For OPD we had empanelled about 10 GPs in the plan thepolicyholder will get free consultation for the year from the GPs. The idea was if consultation is madefree people will go to the doctor early and with early treatment the number of hospitalization will comedown. The trust had agreed to pay the GP Rs 50/- per family registered with them irrespective ofwhether the facility was availed or not. The scheme was a failure. The reasons for failure were asfollows 14 • Renowned GPs were not interested .They felt the amount too meager to attract them • Those who joined were all BAMS and homeopaths, and the policyholders were not ready to Page consult them even free as the trend is to consult directly a consultant.
• As we could not provide the numbers the registered GPs lost interest in the scheme. So from next year we omitted this facility. • We had empanelled few consultants who had agreed to give across the table discount to the policyholders in the OPD treatment. Very few people availed this facility. Those consultants who had some patients were cooperative but others started complaining that we are not getting clients from you. It was expected that the panel doctors understand the benefits of the scheme and promote this to their patients, which was in their interest also. • We had taken a few dentists on panel who offered one free dental check up and concessional treatment. This benefit was taken by many. • We had tied up with Thyrocare, Ranbaxy and Piramal Diagnostics who would give discount to policy holders at investigation level. The beneficiaries were small in number. As the treating doctor had his preferences about reports from a particular laboratory, this was conveyed to us by our policyholders. • Pre-existing cover mediclaim was the only benefit for which people are coming to us. • We had appealed to a number of agents working in insurance field to promote our scheme. A number of them have joined us, but they are selectively selling our products to those who have planned treatment or severe disease resulting in high claim ratio. Unless we get all people to join this scheme the company may cancel the special policy sanctioned due to loss. • We had meetings with a number of senior citizens groups as we can provide cover for them, but the overall response is they want everything free of cost. • We met some politicians who are reportedly working for masses and are leading groups of workers, drivers, autorickshaw drivers, etc. The politicians are not interested in long-term projects like this. • This all boils down to numbers. If we can provide numbers many service providers will join. And doctors must promote health insurance as it is in their interest also. These experiences will surely help creating a roadmap for UHIS. Regards, Suhas Joshi A Note on Group Medical Cover (GMC) from Dr Suhas JoshiGroup medical cover for health insurance is a tailor-made health insurance policy specially designed fora particular group taking in to consideration their needs.The routine health insurance readily available on individual basis has got many problems. The individual medical insurance is available to all up to the age of 45 years. But in this policy preexisting diseases are not covered. Usually people avoid confirming their pre existing disease at time ofinsurance for fear that the policy may not be issued. Subsequently when it comes to settling of claimthey suffer as doctor makes mention of pre existing disease. 15 After the age of 45 pre medical checkup are necessary, involving cost, inconvenience and time. Anydisease detected during the check up is labeled as pre existing and excluded from claim making the Pagepolicy useless as that is the condition for which he will require treatment. The latest age of entry is 65.
The GMC policy is designed to suit the needs of the group. You can take cover for pre existingdiseases right from day 1 of the policy, maternity and newborn child can be covered, a cover usually notavailable with routine policies. The policy is issued to a defined group, for example employees of an organization, members of club,members of professional organization, members of a charitable trust etc. The condition is all from thegroup should be insured. Factories, employees of business establishment take the benefit of this policy. There is flexibility of terms as per requirement. We have issued a group mediclaim to YashwantraoChavan Open University covering all pre existing diseases from day one but without maternity cover.We have issued a GMC to a group of colleges from Dhule with routine terms, but the average premiumcomes less than normal rate of individual policy. We have covered a group of drivers with accidental cover, the cost per lack comes just RS 145,in itthere is a death benefit of Rs.80000/- and hospitalization expenses reimbursement of RS.20000/-. Yashwantrao Chavan University has paid a premium of Rs 1139675 plus 10.3 % service tax, the claimsso far settled are to the tune of Rs.1279343, which exceeds premium paid but still some time to go tillDecember end the claim ratio will cross 100%.But as compared to reimbursement procedure here is abenefit of cashless treatment all over India. Of course the tendency of exploitation is seen here also.Well-known manufacturing units from Nashikare known for their false claims resulting in very high claim ratio and cancellation of the policy midway. That also caused a few hospitals to be blacklisted for being hand in glove with workers in issuingfalse receipts. This is one way to insure as this gives a comprehensive cover and should be opted for by groups. Moreand more groups should be encouraged to take GMC. If given option as in individual policy many people do not take insurance cover for he/she feels he/sheis healthy and nothing will happen. In GMC she/he gets automatically covered with the group. 16 Page