Published in Economic Times | By Sajjan Singh Yadav| On February 28, 2018
With the National Health Protection Scheme (NHPS), GoI has developed a focused approach, aimed at getting the healthcare scheme on the ground with a timeline. This flagship health scheme is different from its earlier version announced in 2016, as well as the one before that, the Rashtriya Swasthya Bima Yojana (RSBY).
The increase in annual insurance cover per family from Rs 1 lakh to Rs 5 lakh denotes a steep growth in its depth. The amount was a paltry Rs 30,000 under the RSBY. The breadth of NHPS has also expanded with a target population of 100 million now, up from 65 million under RSBY.
And it is precisely this multi-fold increase in the scheme’s scale that makes it more vulnerable to charlatans. Apart from siphoning funds, such a situation may also engender unethical medical practices for quick monetary gains causing more harm than good to the beneficiaries.
Evaluations of the RSBY and other states-run health insurance schemes point to the fact that such unethical practices are already rampant. These include unnecessary hospitalisation, extension of hospital stay beyond requirement, needless investigations — especially high-end ones like CT (computed tomography) scan, and magnetic resonance imaging (MRI) — unrequired surgeries, and billing for superfluous and unrelated treatment packages.
Reports of unnecessary hysterectomies in Chhattisgarh and Bihar are understandably shocking. An alarmingly high rate of 47% caesarean sections in empanelled hospitals has also been reported in Chhattisgarh. Various other states have also reported such malpractices, although of a lower magnitude.
Admission of patients in excess of declared bed strength, use of substandard implants and consumables, and facilities without the required number of doctors are some other malpractices that have come to light.
Reported instances of frauds in RSBY and other state-sponsored insurance schemes include fabrication of medical records, charging for procedures for which the specialties are not available, and charging extra for registration, diagnostics and treatment. Over time, the number of such frauds have gone up and this has emboldened fraudsters.
The labour ministry, which was implementing the scheme till recently, also uncovered false insurance claims filed by 60 hospitals in different states. A prominent insurance company was reportedly involved in floating ghost beneficiaries under government insurance schemes.
Which is why effective prevention, detection and control of such frauds and unethical practices will be crucial to NHPS’ success. The zeal for quick implementation shouldn’t take attention away from this critical aspect of a scheme of such a scale.
The building blocks of such an effective mechanism would be an adequate IT infrastructure and sound systems. Before the NHPS rollout begins, an integrated, pan-India IT platform with strong data analytics is crucial for generating alerts, identifying triggers and flagging abuses. Logic systems built on ratios and percentages can easily help in detecting suspicious cases. Some of the relevant parameters to watch out for are high bed occupancy, admission-enrolment, intensive care unit (ICU)-general ward admission, and caesarean section-normal delivery ratios.
Similarly, high percentages of surgeries compared to the prevalence rate of a medical condition, and of day-care procedures and single-day hospitalisations could also be some of the points to watch out for.
Other indicators of a possible fraud could be a higher number of manual claims, treatment of patients from other districts in large numbers, an increased number of complaints of a single hospital, and repeated admission of the same individuals.
Simultaneous admission of multiple members of a family, late night admission, early-morning discharge, extended stay in the ICU, high average claim size, uniform length of stay in the hospital, and sudden increase in admissions are other easy giveaways to fraud.
Early detection of such instances would require a strong data analytics team at the state level. A team should be constituted to investigate those cases and take effective action.
A strong system should comprise standard treatment protocols, defining minimum standards of implants and devices, mandatory pre-authorisation of packages prone to abuse, and earmarking certain packages only for public health facilities.
This would also require equipping public health facilities to work as an effective gatekeeper. An effective and efficient grievance redressal system and telephonic feedback of discharged patients is also critical.
Hopes and expectations of millions of people are riding on the success of NHPS. The scheme should not turn into an example of good intentions, bad implementation.
The writer is an Indian Administrative Service officer currently pursuing a doctorate from the London School of Hygiene and Tropical Medicine
DISCLAIMER: Views expressed above are the author’s own.