Can the Govt. force price capping under the Ayushman Bharat National Health Protection Scheme?

Can the Govt. force hospitals & doctors to comply with the price capping under the Ayushman Bharat National Health Protection Scheme?...

Can the Govt. force hospitals & doctors to comply with the price capping under the Ayushman Bharat National Health Protection Scheme?

MED talks with Dr KK Aggarwal

When we talk of affordable health care, we need to have value for money for both masses as well as classes. The economically weaker section of the society or BPL with more than 40 categories is today deprived of secondary and tertiary health care.

Health insurance

Without insurance, it is not possible for a citizen to afford secondary and/or tertiary health care. Workers drawing a salary of up to Rs 21,000/- a month are mandatorily covered under ESI. Those who have a salary of more than Rs 21,000/- should pay the private insurance premium on their own. Then there is a subgroup of people in this income bracket, the EWS and BPL, who cannot even afford any insurance premium.

Article 21 - state to provide health care

The responsibility falls on the state to provide health care to all under Article 21,

“No person shall be deprived of his life or personal liberty except according to procedure established by law”.

Ayushman Bharat National Health Protection Scheme targets the poorest

The Ayushman Bharat National Health Protection Scheme, therefore, can be a way to bridge this gap. The scheme principally targets the poorest and the vulnerable sections of the society. It will cover more than 10 crore poor and vulnerable families (approximately 50 crore beneficiaries) providing coverage up to 5 lakh rupees per family per year for secondary and tertiary care hospitalization with no restriction of family size. This coverage of Rs 5 lakh for the whole family for the economically backward patient may be sufficient in 80-90% cases.

National insurance companies

The experience of the National insurance companies has been that reimbursement has been more than the total premium collected, so they were forced to bring in TPA to cap the prices of reimbursement which has been practically accepted by the medical establishment.

Ayushman Bharat National Health Protection Scheme fixed the pricing for treatment

The Govt has fixed the pricing for 1,354 treatment packages under the Ayushman Bharat National Health Protection Scheme. More than 20 specialties like cardiology, cancer care, neurosurgery and neonatal care have been covered under the scheme depending on the type of therapeutic category and procedure. These package rates include all the costs associated with treatment i.e. the govt. has capped the total money required for the treatment.

Essential Commodities Act : Govt. cannot cap the prices

Without invoking the Essential Commodities Act, the govt. cannot cap the prices but they can cap the prices for enrolling the medical establishment under their loop or at the most, the govt. can provide the list of hospitals as preferred hospitals as is the prevailing practice in third party reimbursements.

Participating in the scheme is voluntary; the hospital may or may not choose to join. Success of the scheme will depend on how many will enrol in the scheme. If the participation is poor, the govt. will be forced to revise the reimbursement charges. But, if the scheme gets off successfully, then the govt. may continue with the present reimbursement rates.

But everybody needs to work with the govt. and not compare the rates of the Ayushman Bharat National Health Protection Scheme with those of CGHS, PSUs, and TPAs as they are not meant for the EWS/BPL patients but for rich patients.

Rates of package for non Ayushman Bharat

Charity has to be at the cost of the rich. Therefore, the govt. may consider subsidizing the cost of poor by way of subsidizing package in Ayushman Bharat National Health Protection Scheme by revisiting the rates of package for non Ayushman Bharat subsidized people who are not in the income bracket of this scheme.

Dr KK Aggarwal

Padma Shri Awardee

Vice President CMAAO

President HCFI

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