Aayushman Bharat
I recently had the privilege to attend an interactive session with Dr Vinod K Paul Member Niti Ayog entrusted with key responsibilities in the roll out of the prestigious “Aayushman Bharat” the National Health Protection Scheme. This was organized through kind offices of the CII at Chandigarh as first of the many sessions being planned across the country. It was indeed a surprise that a person of cabinet rank on behalf of Govt and Niti Ayog came personally to interact with stakeholders regarding this ambitious project. I applaud the effort however
1) Deliberately or otherwise in this ambitious plan the primary unit of healthcare of modern scientific medicine that is the MBBS doctor has been totally ignored. The number of PHCs remaining around 30000 which are as per existent number there appears to be no plan to recruit more MBBS doctors to provide primary healthcare.
2) The wellness centers appear to be nothing more than rechristened Subsidary Health Centres which then is only a cosmetic change only. This scheme would have been a phenomenal game changer if all wellness centers were to be having an MBBS doctor as the team leader. The propaganda that MBBS doctors do not work in villages is a myth which is broken by the fact that we have only 1750 vacant posts for MBBS doctors to work in villages (in PHCs) whereas 60000 MBBS doctors are produced in India every year.
Our suggestion; Use Those Foreign Medical Graduates who have not cleared the licentiate exam as team leaders instead of AYUSH Bridge Course doctors in case of vacancies which are not filled by MBBS doctors in all the 150000 wellness centers.
3) The effort in the NHPS is aimed at empowering the “mid level health care professional” who is not an MBBS but either a nurse practitioner or an AYUSH doctor who has undergone a bridge course. Obviously then funds have been kept aside for this recruitment but not to increase the number of MBBS doctors involved in primary healthcare. Also if this move is because the AYUSH will need to be paid less , let me shatter the myth because once appointed as team leaders / Medical Officers they will be soon demanding party with MBBS doctors and courts will be extremely obliging. Since the primary health and wellness structure comprises of PHCs also which will continue to be headed by the MBBS doctors I expect this to happen soon.
Our suggestion; Increase number of posts for MBBS doctors as well as the number of Primary Health centres to atleast double the current number.
4) Despite the good intention the majority of the participants at this particular meeting were hospital administrators marketing professionals and the discussion was centred on operational details of the scheme vis a vis larger more than 100 bed hospitals. The Small and Medium Healthcare establishments which are usually a husband wife team with some qualified and trained unqualified staff members who find it difficult to deal with empanelments, pre authorizations, pursuing payments with insurance companies etc will have to really work hard to get their voice heard otherwise if yesterdays meeting was an example they are going to be trampled in the mad rush of corporate hospitals seeking empanelments under what they consider is a new opportunity to make money.
Our Suggestions;
a) Remove SMHCEs of less than 50 Bed from ambit of Clinical Establishment Act, Biomedical Waste Management Rules, Air & Water Act etc which is now a major hurdle in establishing new clinical establishments of the kind needed to be promoted in tier 2 & tier 3 cities. The 27 licences a 10 bed nursing home needs under CEA has lead me to offer my nursing home for sale / lease along with many others in similar situation that I am aware of.
b) Release 60 % billed amount for SMHCE within one month of billing irrespective of any dispute. Either remove the hospital from the list of empanelled hospitals or make them viable by releasing substantial payment in time.
c) Incentive of exemption in income tax was given earlier to 100 bed and above hospitals being established in smaller cities. This plus removal of commercial charges for utilities being levied on small clinical establishments of less than 50 beds which also double as home for the doctor couple would help.
d) Change of Land use which becomes a major issue while setting up a hospital project in smaller towns should not be needed if a small hospital is being built along with residence of doctor.
e) Exemption from bureaucratic hassles and red tapism for Small and Medium healthcare sector of less than 50 beds will go a long way in making this scheme a success. The License Permit Raj which has been unleashed on medical professionals favors the corporate Giants who have deep pockets and can deal with 30 odd authorities and Departments through their administrators and Liason teams. The Solo doctor nursing home if has the doctor running around the various departments for the licences and permits then the hospital cannot run.
f) Rates offered to SMHCE which may or may not be NABH approved may be lesser than those offered to corporate hospitals but not by a margin of more than 25%. The example of exorbitantly differential rates can be found on page 506 of Nabhis Compendium of May 2011 which shows rates of enteral stenting Sr no 1206 as Rs 3200 for non NABH, 3680 for NABH and Rs 40000 for a superspeciality Hospital. How can such gross difference in rate of one procedure be explained within the same city done probably by the same person but in different establishments.
g) There are number of specialists (MD/MS) who are trained in various superspecialities like cardiology , gastroenterology , neurology, urology, plastic surgery etc but have not done a superspeciality qualification. Such specialists may be permitted to practice as specialists of their field. The current embargo placed by MCI and consequently by various courts needs to be abolished to encourage MBBS doctors with training and experience to work as specialists in these areas and similarily for MD doctors to work as Nephrologists , Gastroenterologists and cardiologists. They may find it difficult to establish themselves in metropolitan cities due to presence of many others more qualified but then they would shift focus to teir 2 & Teir 3 cities which is what is the aim under the NHPS.
h) Designate doctors as public servants In view of peculiar nature of their work involving public health and safety amendment in IPC Section 189, 332, 333 ,353 to include even private doctors within the definition of public servants so that violence against them can be dealt with strictly. Another amendment in criminal law is needed prescribing punishment to public official who does not take action in case of complaint of violence against a doctor or vandalism in a clinical establishments.
5) One major flaw I see in this plan is is non engagement of various MBBS doctors and specialists, who practice in various clinics without inpatient facility. They can be used as independent referal authorities to triage the need for hospitalization in the empanelled hospitals. This will avoid unnecessary hospitalization and consequent expenditure. Given the limit of 5 lacs a patient directly approaching an empanelled facility would be likely admitted due to financial interest. An independent clinician may offer an alternate less expensive line of management.
Our suggestion; Such independent clinicians not affiliated with any hospital be identified and hired on a retainership basis. They may be paid a reasonable figure for 100 patients every month from whom they would not charge their consultation fee but provide their consultancy services within the lump sum figure paid monthly.
6) The biggest flaw in the ambitious project is non engagement of the major stakeholders. We are talking of providing modern scientific medical services to about 40-50% population through this scheme but we have not provisioned for hiring MBBS / MD /MS / MCh / DM doctors at any level. 70-80% of the inpatient and outpatient healthcare is currently being provided by independent entrepreneur - doctors who are mostly MBBS, and above. This large chunk of current providers is ignored in this scheme. Ignoring them to focus on primary care by (public sector non MBBS) Mid level healthcare provider , or straight , the corporate hospitals to be empanelled for inpatient care is risky and fraught with danger.
There is excitement about the scheme amongst corporate hospitals who see this as a business opportunity, in the politicians who see this as a vote gathering exercise, among the poor who see this as a safety net, but majority of the true healthcare providers feel ambivalent having past experience of not being able to deal with insurers and social schemes unless you play the game by the “Indian rules”. As doctors we are in our comfort zone dealing with medical challenges. The logistics, human resource, management , red tape and bureaucratic hurdles foreseen make us feel as bystanders in this Great Indian Medicare Show being unfolded.
The idea of posting this on facebook is so that others with positive intent can improve on this rough draft so that it can be sent as feedback to the GOI
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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