What is the issue?
- The union government in its budget had announced the massive “National Health Protection Scheme” (NHPS).
- Brainstorming with state governments that already have comprehensive Health Insurance Schemes has highlighted the many challenges.
What are the challenges?
- NHPS was touted as the “world’s largest health protection plan”, but concerns of expenditure and infrastructural support sprouted almost immediately.
- States like Kerala, Tamil Nadu and Andra Pradesh already have some form of mass health insurance program and their experience is now being analysed.
- Niti Aayog and the Union Health Ministry organised a consultation with these states, where several serious challenges were flagged by them.
- Moral hazard - refers to the tendency of insured people to buy or be sold additional healthcare interventions irrespective of their actual needs.
- This leading to expenses that do not necessarily add to the health and well-being of the insured but necessarily bleeds the insurer (the government here).
- Typical moral hazard procedures include Caesarean sections, hysterectomies, and procedures for inserting orthopaedic implants.
- National Family Health Survey had in fact noted a disproportionately higher number of C-sections for childbirths if government insurance was available.
- While the ideal rate for C-sections is 10%-15%, India’s private sector record a whopping 40%, which is in stark contrast with the public hospitals (11.5%).
- To plug this loophole, Kerala has made it mandatory to get all non-emergency surgical and medical packages pre-authorised.
- In Tamil Nadu’s case, 138 of the 686 eligible procedures under the insurance scheme are covered only if they are carried out in government hospitals.
- Eligibility criteria - It has been said that eligibility for NHPS scheme will be determined based on data from the socio-economic caste census (SECC).
- The number of poor and vulnerable beneficiary families eligible for the scheme is proposed to be based on deprivation and occupational criteria.
- The scheme will be open to all States/UTs and the proposed target population would comprise of:
(a) Families that belong to any of the 7 deprivation criteria
(b) Automatically included families as per SECC database for rural areas (c) defined occupational criteria for urban areas
- Several states argued that depending on the SECC would limit the reach of the scheme as the SECC data covers only a smaller target group.
- Some have vouched that the “National Food Security Act” entitlement list be used as the basis of NHPS, which might substantially increase NPHS coverage.
- Costs - During initial meetings with general insurers, NITI Aayog had calculated the annual premium per family to be Rs 1,082.
- However, insurers have pegged the actuarial premium at Rs 2,500, citing the sustainability of the scheme.
- If the government agrees to the premium amount put forth by the insurers, the cost will more than double from the present estimate of Rs 10,000 crore.
- Procedures - The Directorate General of Health Services (DGHS) has been asked to prepare a list of procedures/diseases to be covered under NHPS.
- Once finalised, the list will be circulated to states that opt for the scheme, with a provision to make marginal changes in the package rates.
- Packages are important because the coverage amount is limited, and no ceiling has been proposed on family size.
- In addition, a balance will have to be struck between prevalent need (by analysing the disease burden) and procedures that are value for money.
- For example, whether organ transplant will be covered is a tricky question, as the money paid as premium is meagre and only a few government hospitals have the capability of carrying out such procedures.
- Identification - The document for identification has also been a contentious issue as many states have opposed the usage of Aadhaar for the same.
What are the aspects under consideration?
- Parliament enacted the Clinical Establishments (Registration and Regulation) Act in 2010, and a regulatory framework for private hospitals is in the pipeline.
- The executive action for laying down standard treatment guidelines as specified in the law is hence awaited along with 3rd party audit.
- The option for pre-authorisation for non-emergency procedures like the kerala’s model is also being considered.
Source: The Indian Express
