Ayushman Bharat: hospitals no longer obliged to treat 10 pc of poor patients for free

As the Narendra Modi government celebrates the success of Ayushman Bharat, medical professionals working with poor patients say that the poor are being short-charged at the expense of private hospitals. At the start of new year, the Modi government declared that nearly 6,85,000 patients had availed free treatment within the first 100 days of the rolling out of the scheme.

The claim, however, is full of flaws and likely to backfire politically, say doctors and former officials.

Private hospitals empanelled under Ayushman Bharat-Pradhan Mantri Jan Aarogya Yojna (AB-PMJAY) no longer have to treat a mandatory ten per cent of their patients for free, as used to be a requirement previously.

“Ten per cent of all the work that hospitals did was supposed to be free-of-cost. Under the Ayushman Bharat model, they will now get some amount, so hospital beds will be full,” says former Indian Medical Association (IMA) President Dr KK Agarwal.

The noted cardiologist and Padma Shri awardee laments the lackadaisical outreach of Ayushman Bharat, billed as the “biggest healthcare scheme” in the world, saying government’s own flawed planning process is keeping the PMJAY from reaching its potential.

“The biggest problem is a lack of transparency around the scheme. Many important things about the scheme haven’t been looked at properly,” he says.

“It hasn’t caught up the way it should have been, if it were devised keeping just the 2019 elections in mind,” says Dr Aggarwal confidently, noting that his experience is based on the poor patients he works with. “We sponsor heart surgeries for many patients who don’t have an Ayushman Bharat card. It is not reaching the people the way it should have,” says Dr Aggarwal.

The criteria for identifying persons under PMJAY-AB is what he believes is squarely flawed. “Why should only those covered under the Socio-Economic Caste Census (SECC) be eligible to avail the Ayushman Bharat. The very fact has left millions of poor without cover,” he says.

The IMA has been arguing that there isn’t a need for a different slab under Ayushman Bharat, and the rate slabs followed must be that of Employees’ State Insurance (ESI) and the Central Health Government Scheme (CGHS).

Over 50 per cent of the poor will be covered if we expand the ESI to include employees working in the group of less than 10 workers, as per Dr Aggarwal, who adds that the government could contribute for workers who couldn’t afford insurance premium.

As per ESI rules, for all workers making below Rs 21,000 per month, the employer contributes 4.75 percent and employee contributes 1.75 percent.

In fact, the finances of Ayushman Bharat, which has superseded other healthcare schemes in the states, don’t also seem to quite stack up.

“The biggest misnomer is that it is a Rs 5 lakh scheme per family per year,” says the ex-IMA boss.

According to the Ayushman Bharat rate slab, the caesarean delivery costs Rs 9,000. So, the hospital is not allowed to charge more than, with the patient enrolled under PMJAY having to pay nothing.

Similarly, the hip replacement surgery (cemented) in the Ayushman Bharat scheme costs Rs 75,000, lower than what any private hospital would charge for those without an insurance.

“The government isn’t contributing more than Rs 1,500 for every person enrolled under Ayushman Bharat. The government contribution was apparently higher under different schemes that Ayushman Bharat superseded,” says Dr Aggarwal.

While presenting some crucial data on Ayushman Bharat, Dr Vinod Paul from the NITI Aayog, the architect of Ayushman Bharat, had declared that “some medical procedures were reserved only for public hospitals.”

The lower Ayushman Bharat rates that the empanelled hospitals would get once they are on board has been flagged as a major concern, as per government officials.

At the time of its launch on September 25, Prime Minister Narendra Modi had announced that nearly 13,000 hospitals had been empanelled under the Ayushman Bharat. It is learnt that the majority of these were government hospitals, as the private ones remain sceptical about it.

Another fact remains that healthcare remains a state subject under the current rules. The opposition to rolling out a centralised healthcare scheme, including by certain government officials and members of the medical fraternity, have been conveniently ignored.

“The government must pass an ordinance to bring health under the concurrent list. At present, it is a state subject. All the problems will be taken care of,” says Aggarwal.

Politically, the perception about the success of Ayushman Bharat that the government has been propagating in the lead-up to national elections is likely to boomerang, he says

“Even if the voters buy into their claims about the success of Ayushman Bharat and bring them back to power, the BJP for sure would start losing in the states,” says another prominent Delhi-based doctor.

(A translated version of this article has already appeared in the print edition of Navjivan).