Is Ayushman Bharat what doctors prescribed?

Chennai: On 23 September, the brainchild of the Prime Minister Narendra Modi, Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), which is termed as the world’s biggest government-sponsored insurance scheme, was launched.

In yet another development, Chief Minister Edappadi K Palaniswami has increased the insurance cap of the Chief Minister’s Comprehensive Health Insurance Scheme of the State from Rs 2 lakh to Rs 5 lakh, which was to ensure everyone benefits equally, regardless of whether they get covered under the Central health insurance scheme or not.

The feature of the Central scheme includes covering the charges for almost 1,300 ailments including heart diseases, kidney and liver disorders and diabetes and reimburses the expenses up to Rs 5 lakh per family, every year.

Setting the target audience as the poor and deprived families, the Ministry plans to reach out to 8.03 crore people in the rural and 2.33 crore in urban areas.

Though the scheme has been widely lauded by several political leaders, it has received severe flak from doctors and other experts in the country.

The Jan Swasthya Abhiyan, in a press release, stated that the AB-PMJAY is based on the discredited ‘insurance model’ despite massive evidence against the effectiveness of such insurance-based schemes involving major participation of the private sector in service delivery.

PREMIUM COST

Dr Ravindranath, general secretary, Doctor’s Association for Social Equality, assessed that the Central government would be liable to pay more than Rs 25,000 crore to private hospitals and private insurance firms every year and the premium cost per family would shoot up to Rs 25,000.

Experts opined that with so much funds, several new government hospitals can be constructed.
However, Tamilnadu Health Systems Project Director, Uma Maheswari, said, “The premium amounts to Rs 699 for up to Rs 2 lakh and would remain the same. The remainder that was not in the earlier tender, the insurance provider has decided to rule out as an addendum to the original tender. It will not be under premium or insurance mode, but assurance or reimbursement mode.”

She further stated that the number of procedures availed of in private hospitals that get covered under CMCHIS scheme are consciously restricted to maintain the same premium amount. Failing to do which would result in increased cost.

“The State has paid Rs 500 crore from inception until now to the private hospitals for treatment,” she added. Speaking about the success factor in CMCHIS, she added, “35 per cent of the premium amount we pay comes back to the government. In all, 260 institutions are empanelled in the scheme, and they are able to generate 35 per cent of the money that I’m paying as claims to the insurance firm and which is paid back to the government with which needs like infrastructure, recurring cost and incentives to employees are met.”

MIDDLE CLASS TO BEAR THE BRUNT?

The middle-class strata, which is ineligible to apply for health insurance, will bear the brunt as a fallout of the new scheme. They will be forced to opt for insurance policy in private firms, added Ravindranath.

However, Uma Maheswari stated that there would be increase in the flow of patients but that will not impact the cost factor.

“The State is the medical hub in the entire world and Chennai is regarded as the lighthouse in medical industry. In such a case, people would visit our State for getting treated and we can witness several people coming to Tamilnadu. In such a case, the cost will be balanced and will not escalate,” justified Uma Maheswari.

Bhavani Prabhakar