India’s poor get a raw deal from insurance companies: WHO supported study

Rashtriya Swasthya BimaYojana (RSBY), a flagship health programme to provide free hospitalisation to the poor people, can become a major fiasco if insurance companies continue to throw a spanner, according to a WHO-supported study.

Since its launch in 2008, RSBY has covered nearly 33 million Below Poverty Line (BPL) families and provided succour to 4.2 million patients who needed hospitalisation, says the study, conducted in Patan district of Gujarat by Bengaluru-based Institute of Public Health.

However, the main objective of RSBY, which is to protect the poor from hospitalisation expenses, is only being partially met, said Dr N Devadasan, principal investigator of the study. It is unacceptable that even after four years of the scheme, more than 50 per cent of enrolled patients had to incur out of pocket (OOP) expenditure at the time of admission.

The study, carried out with the help of WHO’s Alliance for Health Policy and System Research, Geneva and the Indian Institute of Public Health, Gandhinagar, surveyed a total of 2,920 families across more than 500 villages of Patan district, which had enrolled in the RSBY during 2010-2011. The report was presented at the second Global Symposium on Health Systems Research at Beijing, China recently.

We found that the scheme had targeted the real poor 65 per cent of the enrolled families were landless, 87 per cent did not have any toilet facility and 71 per cent were casual labourers. Also, 97 per cent of the enrolled families had received the card and none of them had to pay any extra money over and above the statutory Rs. 30, the investigators said.

However, a disconcerting finding was that of the 526 admissions, only 227 patients (43 per cent) did not have to spend any money at the time of the admission. The rest of the patients incurred out-of-pocket (OOP) expenditure ranging from Rs. 10 to Rs. 1,50,000. The average OOP expenditure was Rs. 10,692 per patient. Further, 188 patients (36 per cent of all patients) had a RSBY card but still had to pay at the time of admission. This was because most of them (122) were asked by the hospitals to purchase medicines from outside.

This is against the contract that the hospital has signed with the insurance company and thereby with the scheme, said Dr Devadasan. In other words, the patients with RSBY cards incurred nearly 55 per cent of the expenses incurred by non-insured patients. They thus may get disillusioned by the ‘free hospitalisation scheme’. There will be a tendency to drop out of the RSBY scheme. This, in turn, will also trigger a vicious circle of high claims and higher premiums, thereby making the scheme unsustainable.

One of the main reasons for the malfunctioning of the scheme, as per the study, is the lack of governance by the insurance companies. It is their duty to monitor whether patients are getting appropriate free care or not. It is clear from this study that the insurance company has failed to do so. While our study was in Gujarat, we see similar findings in Karnataka, where we are doing a similar study across four districts. We are sure that the situation is similar in other states as well. It is time for the state nodal agencies to take notice of this problem and immediately take corrective action against the insurance companies and the private providers, said the investigators.

Simple measures like phone calls by the district nodal agency to random patients will give an idea about whether patients are getting the free care that they are entitled to. Else, this will lead to disillusionment among communities leading to decreasing enrolment and failure of the scheme, they added.

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