Private hospitals under the Ayushman Bharat scheme charging more than their government counterparts is not a matter of concern for the government, the chief executive of the scheme has said.
“We see it as a positive development that this fact was brought to light. It should not be taken as the private sector fleecing us,” Ayushman Bharat CEO Indu Bhushan said at a conference on October 21, 2019.
“When it comes to small illnesses, people go to public hospitals. But when it comes to bigger and serious ones, they choose the private ones. It is simply because private hospitals are better equipped and offer better responses than the public ones,” he added.
This statement exposes the trust deficit at the level of the government itself for public hospitals.
It arises from the results of an investigation that the National Health Authority (NHA), the implementing agency of Ayushman Bharat, undertook on neonatal care provided under the ambitious health insurance scheme brought forward by the Modi government.
Under this scheme, five treatments are covered for neonatal care. They include critical neonatal care package (Rs 7,000 per day), advanced neonatal care package (Rs 6,000 per day), intensive neonatal care package (Rs 5,000 per day), special/chronic neonatal care (Rs 3,000 per day) and basic neonatal care package (Rs 500 per day).
Not only were private hospitals giving a significantly higher number of services across states, but also, the public-private spending was much differential, the investigation said.
Even for the preliminary package of basic neonatal care, the least costly one, the total spending in private hospitals across all states was almost double or more of the cost incurred in public hospitals.
Likewise, the total spending of the critical neonatal care package was at least three times as expensive in private hosptials as in the public ones.
What evidence of better outcome?
Bhushan had said the better infrastructure at private hospitals gave them reason enough to charge more.
Likewise, the investigation also said “the availability of specialists, better infrastructure and better quality care at private hospitals” were the factors due to which it could be ascertained that private hospitals were providing the bulk of the care.
The former head of a Union government institute, National Health Systems Resource Centre, T Sundararaman said there was not much scientific evidence to suggest specifically that treatment outcomes were better in the private sector, especially in terms of neonatal care.
“Also, in the name of infrastructure, one has to understand that most of the big private hospitals and chains had built it decades ago. They have already recovered the cost from the patients,”
“The government, through this scheme, is providing bulk customers to private hospitals and the sheer number must offset the investment made on infrastructure, which they must have already recovered by now. The government should not allow differential pricing even if it is strongly determined to increase the participation of the private sector in this scheme,” he added.
The government did check whether there was any malpractice at the end of private hospitals in the light of differential pricing, the NHA investigation noted.
To this end, the government audited two private hospitals of Jharkhand. Both had high quality of infrastructure, it said and qualified that “the neonatologist was very renowned in the area. And, he was available on the premises all the times. The Pediatric Intensive Care Unit (PICU) and the Neonatal Intensive Care Unit (NICU) wards were well-equipped with round-the clock availability of paediatrics and nursing staff.”
Another public health expert formerly associated with the Tata Institute of Social Sciences, on the condition of anonymity said the government was using Ayushman Bharat as an alibi to dump public healthcare.
“The fact that they do recognise that public healthcare facilities are not performing on par should be alarming. Instead, they seem to be suggesting that since the public sector is not doing good, they would invest all possible resources to attract private sector under the guise of this scheme,” the expert said.
Longer stay, unnecessary services
It is just not about differential pricing between the public and private sector. There are other, marked differences too highlighted in the paper.
The average length of stay in private hospitals was longer than the public hospitals. This is critical because billing depends on the number of days spent. The lengthier the stay, the higher the claims of the hospitals.
“The median length of the stay for cases booked under advanced neonatal care package (Rs 6,000 per day) was six days in public hospitals as opposed to nine days in private hospitals,” the NHA investigation noted.
“Similarly, the median length of the stay for critical neonatal care package (Rs 7,000 per day) was eight days for the public hospitals as compared to 12.5 days in case of private hospitals,” it added.
The investigation also laid bare the fact that due to lack of low-end services in the private hospitals, the patients were given no choice but to utilise high-end services, thereby leading to an increment in the total claims made by the hospital.
“The medical audit (in test-check hospitals of Jharkhand) indicated that there was a lack of Step-Down PICU and general wards, leading to grater utilisation of the PICU/NICU wards. Perhaps a step-down PICU facility would have prevented unnecessary waste of services,” the report said.
Despite these shortcomings, the NHA, as the paper suggests is convinced that private sector participation is to be increased as a bulk of services are being provided by it.
“It is just not for neonatal care but even in the case of cardiology services, people are more inclined to take services of the private sector. We take it as positive development because we have opened the door of the private sector for the poor. That is the direction in which we would want to proceed,” Bhushan said in the closing remarks at the conference.