Same procedure sees varying rates under government health plans

NEW DELHI: Large differences in package rates — sometimes more than Rs 10,000 — for the same procedure under different government-backed health insurance schemes could be prompting private hospitals to avoid treating ailments under less remunerative schemes, while favouring beneficiaries with better packages.
The findings are part of a report by a joint working group of the National Health Authority and IRDAI. The report shows big gaps in rates of packages under different state and centrally sponsored schemes such as CGHS, ESIS, Ayushman Bharat and other programmes, often disadvantaging patients at private hospitals which subscribe to more than one scheme. In most tertiary and secondary care packages, the difference in cost for the same procedure under different schemes is over Rs 10,000 .

For instance, for submandibular mass excision and reconstruction, Andhra Pradesh, under its state scheme, pays three times the cost fixed under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY) while Kerala pays five times lower rate in comparison to the national package rate. In general, Kerala pays lower rates for most packages.
"This situation of conflicting incentives may lead hospital managers to favour admitting beneficiaries of one scheme over another or create an inequitable situation within a hospital in which more responsive care would be provided to beneficiaries from schemes with a higher rate structure," the report said.
The group, constituted to improve the insurance ecosystem in the country, has recommended uniform package rates for all government sponsored health insurance schemes. Even if this is not possible, a reduction in the range or gap will help patients.
"Given the situation and increasing beneficiary base under government schemes as well private insurance, having uniform package rates and codes will improve the acceptance of insurance mechanism and reduce market destruction. Uniform package cost will also improve the quality of care by standardising care through treatment protocols," the report said.
Different package rates often lead to hospitals or care providers seeking beneficiaries covered under schemes with better package rates and avoiding treating those with less remunerative conditions. A hospital that is networked with two or more and also with private insurers may face multiple and significantly different rates for the same procedure.
"The recommendations in the report are a step forward in enabling quaOriginal Article