Will Modicare improve India’s 145th rank in access to healthcare


Game Changing health care scheme announced in this year budget promises cashless inpatient healthcare to 50 crore plus population. Benefeciaries of the current schemes like CGHS etc will be included in this NHPS or Ayushman Bharat Scheme. If implemented with sincerity this could indeed change many of the poor health care indices India is burdened with like the maternal mortality rate of 174. The devil of course is in the details primacy of which is the way this scheme will fund the healthcare to be provided.

The larger corporate hospitals in Tier I and Teir 2 cities are primarily the ones who have been consulted while formulating this scheme. Academic institutions have also given their inputs sitting in their ivory towers. Unfortunately the ground reality of the Small and medium healthcare establishments has been totally ignored and since those included in Modicare will primarily be those with monthly income of less than 7000 Rs the expectation that care to them will be provided by the Fortises and Appolos is fallacious. Those who are claimed will benefit from Modicare will find it difficult to come to the cities for inpatient care under the cashless facility. If at all they need access to quality healthcare in small towns and villages. It is the small and medium healthcare establishments in every small town which need to be encouraged to accept Modicare for the scheme to succeed.

The various rules and laws being passed so generously by the Government formulated from “ivory towers” are ensuring closure of the existent SMHCE in these areas what to talk of opening new ones. Honourable Suprme Court says that doing hysterectomy in a nursing home which does not have an ICU is negligence per se. Courts also want NICU to be there in every nursing home conducting delivery. AIIMS issued guidelines for minimum standards of a 10 Bed ICU costs 21000 per bed per day to maintain without the patient and consequent use of drugs disposables, investigations etc. At rates prescribed tentatively in modicare a hospital following the AIIMS guidelines would incur a loss of nearly 20000 per day per bed with 100 % occupancy. The Economies of scale work only in hospitals of more than 500 beds which will not include the SMHCEs

Unlimited compensation claims also is a sword that will take many casualities in healthcare sector struggling to survive. If 1 caesarean patient in 100 goes to court for compensation it will increase cost of the remaining 99 caesareans manifold and this is not factored in the generous 9000 allowed under Modicare. Doctors will have to become Robinhoods and steal from patients who can afford to subsidize the poor under Modicare. Non viable rates by insurers is the biggest cause of corruption in healthcare. Hospitals cannot afford to lose bulk clients like ECHS, CGHS and now Modicare. But irrational rates force these hospitals to do billing which may not be genuine to cover for the rates which are irrational to start with. Question is frequently asked why these hospitals accept poor rates in first place. The answer lies in differential procedure charges for superspeciality hospitals under CGHS rates as well as some rates for some procedures being viable while some procedures being non remunerative. In Medical cases drugs and disposables being payable, fraudulent billing of these is rampant whereas routine surgeries have package rates at which no surgeon would operate what to talk of total Bill of procedure including drugs and disposables.

Having invested heavily on infrastructure, equipment and human resources the hospitals join the rat race to be empanelled in Government schemes for a regular source of revenue. Ultimately then the doctor as a professional has to cede ground to the owner / management of hospitals to “run” the hospitals and then bottom line becomes the buzz word not the mortality rate. The rate at which Government is forcing Insurance companies to bid for Modicare will break the back of the biggest of them and they in turn will squeeze the service provider hospitals who will not pay their surgeons and physicians all the while providing the Government convenient scapegoats for non implementation of its game changing Scheme.

Dr Neeraj Nagpal 
Convenor,Medicos Legal Action Group, Managing Director MLAG Indemnity,
Ex President IMA Chandigarh
Director Hope Gastrointestinal Diagnostic Clinic,
1184, Sector 21 B Chandigarh 
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