Where insurance schemes may be injurious to health

Over the last few years there has been a virtual competition among the States to launch government-funded health insurance schemes. The “success” of Arogyasri in Andhra Pradesh has ensured that every ruling party feels that such a programme could give its image a significant boost as it did for the late YSR.

However, many of these schemes, for which huge budgets have been allocated, do not appear to have been thought through and could in fact end up doing as much harm as good.

The first logical requirement for one to avail oneself of a government-funded health insurance scheme is an illness that would have to be ascertained by a government doctor. This is to ensure that the private hospital is not deceiving the patient to claim the insurance payment from the government. The existing ESIC, CGHS and even the Arogyasri largely insist on this (with some exceptions).

Except in emergencies, the patient must go to a government hospital and the doctor there must do the initial screening and relevant tests, if required, to satisfy himself about the presence of disease that requires treatment. Referral to another government or private facility happens subsequently.

In Tamil Nadu, this vital and fundamental step does not exist. The patient can walk right into any of the accredited/empanelled private hospitals with his Insurance ID card and the private hospital can diagnose the patient’s problem and ask the insurance company for approval (based on the tests done in-house) for surgery or other treatment. Once the approval is given, the private hospital delivers the service and proffers the claim. What is there to prevent the private hospital from fudging the test reports and seeking an approval for surgery?

Well, nothing. The doctors of the insurance company will have to go by whatever the private hospitals say and the test reports they provide and even if the entire record is cooked up there is no way this can be detected. That is why it is critical for the government doctor to first verify if there is an illness that needs treatment. There is always the possibility of collusion between the government doctor and the private hospitals in the area but at least the way the scheme is meant to function would be the correct one.

Even worse, under the scheme, the empanelled private hospitals are to conduct camps to detect diseases in the population. The patients identified there can be referred to the hospitals for further care. So the government is not only verifying the diagnosis made by the private hospitals but it is also mobilising the weakest, poorest, illiterate and most vulnerable sections of society and delivering them to the mercy of the unregulated private sector.

The government’s argument would be that the panel of doctors set up by the insurance company is anyway going to scrutinise the request for approval and so the risk of approval being given without proper screening is reduced. However, this argument does not hold water. The insurance company has no independent mechanism to verify whether the medical record put up by the private hospital seeking approval is accurate and anyway it is the responsibility of the government as the provider of the service to ensure that its patients are not potentially put at risk or misled.

A few simple amendments to the scheme can correct these serious deficiencies. The initial diagnosis (for all except emergencies) and investigations should be done at a government facility or at a centre that does not involve itself in further care of the patient. The government must also set up a committee of its expert doctors to carry out a daily audit of the cases to identify and track fraud before the patients are potentially harmed. If a hospital is found to have proffered fraudulent claims, then it must be liable for prosecution, not just for removal from the insurance scheme. This is a vital patient safety measure.

This committee must release in the public domain not just the absolute number of procedures done under the scheme but also how many requests for approval were turned down by the insurance company (with reasons) and the number of patients put potentially at risk. If this committee works in tandem with the doctors’ panel of the insurance company, it would be possible to take proactive steps to prevent fraud, not just audit it. Use of fraud detection software can also help in this process.

Another flaw in the scheme is in identifying which patient gets to be treated at government facilities and who gets to be referred to the private sector. If two patients turn up at a government hospital requiring a procedure that is performed at both a government hospital and a private one, which patient is to be referred to the private hospital? There are no clear answers.

A lot of effort is being made to ensure that ID cards are given to the beneficiaries and the biometric identification system is likely to be followed. While the government is taking every step to ensure that the right patient gets the treatment, it is doing little to find out if he or she needs any treatment at all in the first place.

In India, where even in areas where there are adequate safeguards and regulations there are scams aplenty, this scheme puts the most disadvantaged and medically illiterate people at risk of being exploited. Since no one is tracking the outcomes, we will not even know how many patients suffered as a result.

Government health insurance schemes in their present form give plenty of photo ops to show how lives have been saved and indeed there will be many patients who genuinely benefit from the schemes. However, the way these schemes have been devised and are being implemented in States like Tamil Nadu leaves patients exposed to serious risk of losing their lives or at least their organs (uterus being a prime example.

Under the earlier health insurance scheme, by the end of 2009 more than 16,000 women underwent hysterectomy or ovariectomy, 540 of them under 35 years of age. The insurance company itself admitted that its audit showed that many of these surgeries were suspicious).

It is very likely that the Chief Minister may not have been briefed about the minute details of the revised health insurance scheme in Tamil Nadu. With a little tweaking, the present scheme can be made a model one worthy of emulation across the country. Will the Jayalalithaa government take note?

(The writer is a consultant in internal medicine with a significant involvement in healthcare IT.)

DR. SUMANTH RAMAN

http://www.thehindu.com/opinion/open-page/article3220759.ece