Ayushman Bharat-Arogya Karnataka does not fully deliver on promised assurance of health coverage  

Four years after it was implemented, the scheme continues to face problems. There are issues like reluctance of private hospitals to empanel, non-revision of rates, and many ailments not being covered

Updated - October 21, 2022 12:31 pm IST

Published - October 20, 2022 11:00 pm IST

Although the total coverage is up to ₹5 lakh per family under the scheme, many complex life-saving procedures or implants that cost above ₹2 lakh are not covered.

Although the total coverage is up to ₹5 lakh per family under the scheme, many complex life-saving procedures or implants that cost above ₹2 lakh are not covered. | Photo Credit: Getty Images/iStockphoto

Four years after the Ayushman Bharat Arogya Karnataka (AB-ArK), the State’s flagship health assurance scheme, was launched, easy access and free treatment during emergencies still eludes people.

With most emergencies usually falling in the cardiac and trauma-related speciality, getting treatment within the golden hour is crucial for patients. Although patients are free to walk into any empanelled hospital (public or private) without the mandatory referral (required under the scheme) during emergencies, patients tend to rush to the nearest available private hospital and end up paying out of their pockets many times. With not more than 51 private hospitals in Bengaluru empanelled under the scheme, it is hard for patients to find the right one during emergencies.

Proximity issue

The scheme covering 5.09 crore beneficiaries was launched to provide cashless primary, secondary and tertiary health care to the poor and vulnerable population. It is being implemented in an “Assurance Mode” by Suvarna Arogya Suraksha Trust (SAST), the State’s nodal health agency.

In Bengaluru, with only 51 empanelled hospitals, that too not evenly spread out in the city, families of patients have to either pay and get treatment or commute through the city’s horrendous traffic looking for an empanelled hospital. Sometimes, they end up paying even at an empanelled hospital as some facilities have empanelled themselves for selective specialities due to low package rates and late payment issues.

Procedures not covered

Besides, although the total coverage is up to ₹5 lakh per family under the scheme, many complex life-saving procedures or implants that cost above ₹2 lakh are not covered. This makes it inevitable even for BPL patients to pay out of their pockets for such procedures.

Doctors said many patients are not aware that the ₹5 lakh coverage is for a family of five. Even if the family has a single patient, individual coverage can be only upto ₹1.75 lakh.

Moreover, there are some diseases that require staged procedures. A second procedure may be required within six months of the first procedure. But the cost of the second procedure is not covered under the scheme.

Low package rates

In all, there are more than 26,000 private healthcare providers in Karnataka. Of these, 8,000 are registered under the Karnataka Private Medical Establishments (KPME) Act. Only 572 of these private hospitals are empanelled under the scheme. And only 51 of them are in Bengaluru.

Most private hospitals are not keen on empanelment citing “low-package rates”, fixed by the government for the 1,650 procedures covered under the scheme.

Also read: Ayushman Digital Mission: Karnataka tops in registration of health facilities

Arogya Karnataka that was rolled out in March 2018 in the State was co-branded with Ayushman Bharat on October 30 in the same year after the State signed a Memorandum of Understanding (MoU) with the Centre. The scheme is now called Ayushman Bharat Pradhan Mantri Jan Arogya Yojana Arogya Karnataka (AB-PMJAY-ArK).

The 1,650 procedures comprise 294 simple secondary, 251 complex secondary, 934 tertiary care procedures, 171 emergency procedures. While the simple secondary procedures are completely handled at the government hospital level, for all other procedures patients need to be referred by a government hospital to a private facility.

Prasanna H.M. president of Private Hospitals and Nursing Homes Association (PHANA) said most private hospitals are not keen on getting empanelled as the current package rates hardly cover the actual procedure costs.

“The referral process is a hassle for both healthcare providers and beneficiaries, especially for tertiary services. How can you expect a patient to go to a government hospital first and then get referred to a private hospital during an emergency? The patient should have the discretion to choose the nearest hospital,” he argued.

Rates not revised

Pointing out that the package rates under the scheme have not been revised after October 2018, Dr. Prasanna said the government should take up a scientific costing of procedures and hold deliberations with the private hospitals. “We can discuss among our member hospitals and arrive at consensus. When the actual cost is more than the procedure package rates, how can hospitals manage?” he asked.

Dr. Prasanna said a representation seeking revision of rates was submitted to the government again six months ago. “The rate revision should happen at the national level. We are forming a federation of private hospitals and nursing homes to take up the issue,” he said.

A senior doctor from a tertiary care government hospital said, “Many consumables and implants are imported, and with soaring dollar prices it all adds to the procedure costs. Moreover, when the actual cost is more than the procedure package rate, the scheme does not allow the empanelled hospital to collect the difference amount from patients.”

C.N. Manjunath, director of Sri Jayadeva Institute of Cardiovascular Sciences, underlined the need for revision of package rates and also inclusion of complex procedures and implants that cost above ₹ 2 lakh. There is also an urgent need for focused and targeted empanelment of healthcare facilities in all districts, he said.

Under consideration

Admitting these issues as major drawbacks in the scheme, State Health Commissioner Randeep D said the referral system is in place with an intent to encourage maximum service seeking at public healthcare institutions.

The commissioner, who acknowledged that empanelment of private hospitals has been a challenge, said increasing package rates is under the consideration of the State Government.

“The National Health Authority (the national agency implementing the health scheme) has been insisting on adoption of a new Health Benefits Packages (HBP) 2022. If this happens, more than 2,000 procedures including oncology, cardiac, cochlear implant and bone marrow transplantation surgeries and implants will be covered at enhanced rates. We are also working on decreasing the turnaround time of claim processing by enhancing human resources. A proposal has been submitted to the government,” he said.

Attributing the delay in package rate revision to the pandemic, he said, “It is worth pointing out that during COVID-19 there were several hospitals which got empanelled. A total of 2,39,736 patients were treated free of cost under the scheme during the three COVID-19 waves. Private hospitals should also extend cooperation beyond COVID-19, as stated in the KPME Act.”

BPL beneficiaries

The commissioner said over 90% of the beneficiaries under the scheme are from the BPL category, and since inception, 75% of cash outflow is benefitting the BPL population. “Of the total 38.91 lakh beneficiaries treated under the scheme (from inception till September 2022), 35.38 lakh are BPL beneficiaries who have been treated at an overall cost of ₹3,936 crore,” he said.

The State has recorded the highest ever pre-authorisations this financial year, thereby already recording 82% of last year’s achievement in the first six months. “While 12,94,027 pre-authorisations were approved last year at a total cost of ₹1,765 crore, this year (till September) we have approved 10,72,684 pre-authorisations at a cost of ₹838 crore. We are poised for a record 20 lakh pre-authorisations in this financial year,” said the commissioner, who was the in charge executive director of SAST till September.

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