Health insurance for all can be a reality

In Budget 2018, the government had made a few announcements. (a) On a National Health Protection Scheme (NHPS) providing insurance cover of Rs5 lakh per family; (b) Having an initiative to establish new government medical colleges and hospitals, and upgrading existing district hospitals under the programme; and (c) Setting up of over 1,50,000 health and wellness centres throughout the country.

In March, the Cabinet cleared the Ayushman Bharat National Health Protection Mission, dubbed Modicare.

An integrated approach in implementation of all the three initiatives can steer the country towards having universal healthcare. The success of the flagship NHPS, aimed at making available secondary and tertiary care to the needy could largely depend upon how successfully the other two initiatives are implemented.

The two major concern areas identifiable in the existing government health insurance schemes are enrolment and abuse or overtreatment or unnecessary hospitalizations. We have situations of fictitious enrolments, unnecessary hospitalizations or unnecessary hysterectomies, and other such instances.

Steps to implementation

Studies indicate that 65% of the healthcare expenditure in the country is for outpatient care, which are primarily out of pocket expenses. If comprehensive healthcare is the goal, effective financing and delivery of primary healthcare is vital. Setting up of 1,50,000 health and wellness centres is a big initiative and it has to be primarily implemented effectively. There is a strong case for public private partnership in establishing and running these health centres with specific measurable goals. Private participation could be further encouraged by means of tax benefits or subsidies.

Every NHPS beneficiary should mandatorily register with one of the wellness and health centres, which can function on capitation basis. To avoid unnecessary usage, a nominal co-payment can be collected from beneficiaries when such facilities are used. Medicines and diagnostics can be provided at subsidized prices or free to those who cannot afford it. These centres—manned by Primary Care Physicians (PCPs)—will provide outpatient care, including diagnostic facilities and medicines, and also act as gatekeepers for NHPS. Polyclinics with specialists and higher level of diagnostic facilities should also be established for referrals from the primary centres.

Every beneficiary of NHPS should consult a PCP in the health and wellness centre, and treatment in polyclinic by a specialist would be only on referral from the primary centre.

Existing as well as the new district hospitals should be equipped to be on par with corporate tertiary care hospitals. Existing as well as new medical college hospitals should be equipped to be on par with corporate super specialty hospitals.

Admissions of any NHPS member to a hospital should be only on referral from the PCP or the specialist, except in emergencies such as accidents. The PCPs and the specialists will act as gatekeepers for hospitalizations and would be responsible for preventing unnecessary hospitalizations and surgeries. Suitable mechanisms have to be built to prevent collusion of PCPs and specialists with hospitals.

Hospitals that are empaneled under the health protection scheme should be graded according to their infrastructure available and quality of care provided, and then continuously monitored also. The government must set up a National Health Regulatory Authority and insist on all state governments to set up similar authorities. All the heads of such regulatory authorities should become members of the National Health Regulatory Authority. This would bring in uniformity in the healthcare sector in the country.

An integrated approach to implementing all the three initiatives would have far-reaching effects on the country’s healthcare scenario, and we could see a healthier India. Rationalizing treatment or surgical procedures, and use of medicines and diagnostics will bring in reduction in healthcare costs. This would also lead to stabilizing the premiums of NHPS and ensuring continuous improvements in terms of coverage.

India has the problem of big numbers. Just launching NHPS without integrating the wellness centres as well as the government infrastructure may not yield the desired result in the long run. We must realize that implementation of such schemes requires strong planning, strong regulations, simple and efficient processes, and continuous monitoring through the use of advanced technological platforms. Implementation failures can not only result in an exponential rise in costs of such schemes, but also put a strain on future allocations as well towards the healthcare sector.livemint


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