Policy & Issues

Indemnity in peril

Smart card: Hospitalisation expenses are only being partially met by the scheme. Photo: V. Sreenivasa Murthy  

The Rashtriya Swasthya Bima Yojana (RSBY) — a health insurance scheme that provides free hospitalisation to the poor — would become a major fiasco if insurance companies continue to throw a spanner, reveals a World Health Organisation-supported study. The RSBY is a flagship programme of the United Progressive Alliance (UPA) government.

“Since its launch in 2008, RSBY has covered nearly 33 million Below Poverty Line (BPL) families and provided succour to 4.2 million patients who needed hospitalisation. This is a remarkable achievement in a country like India with its myriad problems and obstacles to implementation,” says the study, conducted in Gujarat’s Patan district by Bangalore-based Institute of Public Health.

However, the main objective of RSBY, which is to protect the poor from hospitalisation expenses, is only being partially met, said Dr. N. Devadasan, principal investigator of the study. “It is unacceptable that even after four years of the scheme more than 50 per cent of enrolled patients had to incur out of pocket (OOP) expenditure at the time of admission.”

The study, carried out with the help of WHO’s Alliance for Health Policy and System Research, Geneva and the Indian Institute of Public Health, Gandhinagar, surveyed a total of 2,920 families across more than 500 villages of Patan district, which had enrolled in the RSBY during 2010-2011. The report was presented at the 2 Global Symposium on Health Systems Research at Beijing, China recently.

The survey found that the scheme had targeted the ‘real’ poor — 65 per cent of the enrolled families were landless, 87 per cent did not have any toilet facility and 71 per cent were casual labourers. Also, 97 per cent of the enrolled families had received the card and none of them had to pay any extra money over and above the statutory Rs. 30,” the investigators said.

However, a disconcerting finding was that of the 526 admissions, only 227 patients (43 per cent) did not have to spend any money at the time of the admission. The rest of the patients incurred OOP expenditure ranging from Rs. 10 to Rs. 1,50,000. The average OOP expenditure was Rs. 10,692 per patient. Further, 188 patients (36 per cent of all patients) had a RSBY card but still had to pay at the time of admission. This was because most of them (122) were asked by the hospitals to purchase medicines from outside.

“This is against the contract that the hospital has signed with the insurance company and thereby with the scheme,” said Dr. Devadasan. “In other words, the patients with RSBY cards incurred nearly 55 per cent of the expenses incurred by non-insured patients. They thus may get disillusioned by the ‘free hospitalisation scheme’. There will be a tendency to drop out of the RSBY scheme. This, in turn, will also trigger a vicious circle of high claims and higher premiums, thereby making the scheme unsustainable.”

Detailing the report, he said 66 patients either did not receive the card or received a card that did not work. Another 16 patients belonged to families enrolled in the RSBY but discovered that their names were not included in the card due to problems in the BPL list or computer list. Also, 93 patients did not use the card because of lack of knowledge. Only two patients had diseases that may have led to crossing the upper limit of the Rs. 30,000.

“All the above figures are for expenses during the hospitalisation period. If one were to include the pre and post-hospitalisation expenses, the amount of OOP expenditure would be much higher. While a few patients stated that the money was collected as an advance, none of the patients had received a refund of this advance at the time of discharge,” the study revealed.

One of the main reasons cited for the malfunctioning of the scheme is the lack of governance by the insurance companies. “It is their duty to monitor whether patients are getting appropriate free care or not. It is time for the State nodal agencies to take notice of this problem and immediately take corrective action against the insurance companies and the private providers,” said the investigators.

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Printable version | Jan 20, 2022 8:47:03 PM | https://www.thehindu.com/sci-tech/health/policy-and-issues/indemnity-in-peril/article4217948.ece

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