AB-Ark (India) – Another Bigger Agenda Resisting Knelling
By Geeta Sundar
Health, in the last decade has become a sector contributing to our GDP. Health has become a major expense to those who lack insurance. Our present government had good ideas, I yonder when they started the whole Ayushman Bhava…oops, Ayushman Bharat scheme. But with all good intensions, as was theirs, the pathway to misery is laden with them.
I have no issues with the scheme, as long as it’s done for a solid, remarkable cause and the need of the hour is real. But the way the scheme is being implemented, and distributed, you’d think it was a promised lottery. Every Tom, Dell and Harry has a BPL card. What, nonsense! (Yes, I exclaim with all my might!) The BPL card, and so the designation is for those in the far too little group. Not the ones who harness gold accessories and a mansion in the prosperous area and want to avail the scheme.
The whole knockout of this scheme is that the family takes the patient to the nearest primary care, where the treatment of the patient is not available – either due to resources deficiency, or the unavailability of the necessary specialist, and then hence are referred to a tertiary care for the needful. The letter is a lifesaver. It’s the only proof that the patient had been to a primary care hospital and then got referred. The letter becomes ipso-facto the major determiner and determinant for the further care of the patient. Especially in neurosurgery, we offer such schemes to anyone who bring a letter – aneurysm, gliomas, traumatic hematoma evacuations, VP shunt – however we are restricted by the ability to provide anything ‘medically’ managed in a neurosurgery ICU setting as part of the scheme.
The major part of the transaction to acquire the ability to be included into the scheme is a ‘code’. This code is more valuable than an espionage code or meet-greet-exchange of a code for nuclear reactors! I mean it. It is ‘everything’ for so many families. Each surgery is attributed to a code. Some versions of the surgery have more than 1 code, some others are bracketed under an umbrella of a possible code, whilst some versions of the surgeries that we perform aren’t even included. Imagine that! I want to do a posterior cervical approach with implants and fusion, and the named procedure won’t exist but will be under ‘spinal decompression and fusion’. It takes a while for a newbie to maneuver the ‘list of the codes’, but doable with time. And after a while we become experts as rattling our codes. ‘3A.S8.000…’
So, as I was saying, the code – is what is given by the referral hospital to consider the procedure at a tertiary empanelling hospital, and a code that is given by us to the authority that handles these transactions. The codes can be similar or the same, or different, all depends on the ‘list’. The code then is applied to the authorities that handle these requests to grant the surgery under the insured package. But this is just the start. The scheme is meant to enhance health insurance options for the poor and those who don’t have the ability to buy insurance. On rarer instances, a bunch of codes can be given, but with increased scrutiny due to a lot of fouls and frauds, the checking system has enhanced its leverage, allowing only 1 code in a time frame.
Nevertheless, the political component of this scheme goes deeper than Banyan tree roots. Who really are deserving of this scheme? Like most things in India, the disparity is far too non-mathematical. There is no linear basis, or even geometric basis to this – it’s all an interplay of networking, of connections and of power. Those deserving are rarely able to garner this, and those with enough to support a family of over seven are somehow honored with this. Sad reality, but it’s the process. Those with minority status, ‘old-rich-money’, ‘ancestral property’, ‘fancy-rich-farmers-from-rural-towns’ have proclaimed dominance over the BPL card. You know when you see them – gold bangles, gold rings, iPhone in hand…and yet by the law they are ‘below poverty line’.
Surgery is not cheap. Neurological surgery is even more expensive especially given the perioperative mortality. You can have the best surgeon, the best patient, the best circumstances and the outcome can be a dismal situation. The scheme and code can offer respite to millions for their hospital stay and care, however, the codes only provide 1/8 to 1/10th of the overall cost of the entire hospital stay right from admission to discharge. The problem here is that the government only pays the hospital the amount mentioned in the scheme and the rest has to be borne by the empaneled hospital. A big soup! An even bigger loss. So, hospitals have started adapting in similar manners around the schemes to ensure profit – they ask for all workup, radiology, imaging to be done before admission on a cash basis, and discharge the patient for readmission (rehab, postop care) within 2-3 days of the admission. Some of the hospitals, don’t allow ‘medical management of a surgical case’ as part of the scheme; and only if surgery is the plan, the scheme can be applied for. Another rule has now gained prominence – the hospitals refuse to give the scheme to those who don’t have a referral letter. Usually, the sequence of events requires the patient to be shown to a local on-call government doctor who can they refer the patient to a higher care. But, in emergency situations, the patient is brought directly to a tertiary care and forgoes the initial referral part. There are two options now – either the family takes the patient back to the primary doctor, gets a referral letter (which is dicey because the patient is not stable and complications can ensue on the transit) or they have ‘connections’ to the local party ‘MLA’ who can vouch and get them a letter for the same. Political, as I said.
We, as doctors get stuck into this endless vortex of agendas and politics for no sensible, happy reason. Even if we tried, we couldn’t get out of it. The hospital authorities linked as representatives to the scheme can decide which patient gets the Ayushman and who doesn’t. We become messengers of their interplay. To the families it appears as though we play with ‘who gets Ayushman’ and ‘who doesn’t get Ayushman’. Not one extra penny from these schemes given or not given, enter our pocket. Its all handled by the hospital. More than that, we become bad cops and have to face a myriad of tears, sobs, poor-stories, hand-clutching-bosom or falling-at-feet gestures if we state there is no availability of the scheme. Whilst we can sympathize, and understand that surgery is expensive, there is not much we can do to influence veto. For the most part, we become counselors and steadfast supporters in the patient families’ woes. We are also restrained by the number of ‘beds’ that each hospital can provide for these patients on schemes. Not every patient gets accepted – some of the elective cases are placed on a roster and we call them as and when we have available ‘beds.
India is yet to give all its citizens a unified health insurance and maybe someday in the near future, I’m hopeful we can try for it – at least then, the disparity on a health front between ‘haves’ and ‘have-nots’ will alleviate. Let’s see…
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