The state government’s ambitious ‘cashless’ health scheme, the Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY) to develop a healthcare system along the lines of United States, (as the Andhra Pradesh Chief Minister late YSR Reddy also did) is struggling to survive, and so are thousands of patients who otherwise cannot afford complicated life-saving surgeries, discovers Vishnudas Sheshrao
List of patients is growing
According to the Health Department’s reports, an estimated 6,791 patients who were identified as authentic beneficiaries of the RGJAY scheme could not get their surgeries done due to multiple reasons, including reluctance on the part of private and government hospitals. Many patients have therefore been waiting for months for their turn for medical surgery at the few empaneled hospitals designated by the state government and incorporated under this scheme.
However, the waiting list figures provided by the state health department is just the tip of iceberg as many tens of thousand of patients across the state have been making the rounds of district civil hospitals to enroll their names or to the tehsil offices to make corrections in ration cards and arranging of other documents. These patients are struggling at various levels of the scrutiny process and the state has no data on it.
Problems right from the start
Within six months of this scheme being kick-started, several private hospitals which were enlisted as participants lost interest and are reluctant to conduct health camps and surgeries, as the insurance companies did not pay their bills for as long as four months after submission, which otherwise should have been done within 14 working days.
Even further, the state government-owned district civil hospital and rural hospital authorities are not interested in this scheme. The original scheme, named Arogya Shri and initiated in Andhra Pradesh, gave incentives to doctors of civic hospitals for carrying out surgeries under the scheme. However, the Maharashtra government made no provision of any incentives for government doctors carrying out extra duties under RGJAY apart from their routine work.
Consequently, organizing health camps, which is first step of this scheme, is doing well only on paper.
On July 12, 2012, the state government initiated this scheme on a pilot basis in eight districts – Amravati, Dhule, Nanded, Gadchiroli, Mumbai and Mumbai suburbs, Raigad and Solapur. But it actually started only by November 2013, strategically just six months before the general parliamentary elections and exactly one year before the state assembly elections, with an aim to gain political mileage from the lower class whose income is below Rs.1 lakh per year.
However, it did not take off as intended due to multiple reasons, including no incentive at government hospitals for doing the extra work and carrying out long and complicated surgeries, unattractive payment packages for surgery, unreasonable delays in payments from insurance companies, too many documents to be produced from the hospitals and the impractical attitude of senior state government officers sitting in their air-conditioned offices in the state capital, Mumbai.
Good scheme if correctly implemented
This scheme is being popularised and promoted as ‘cashless medication’ in the slogans, announcing that the insurance company will pay for bed charges, nursing and boarding, surgeons, anesthetists, medicals practitioners, consultants fees, blood, oxygen, OT charges, cost of surgical appliance, medical and drugs, X-ray, food and one time transport fare from home to hospitals as per tariff of State Transport (ST) Corporation. However, several diagnostic tests have not been included in the package and that is creating confusion between the hospitals and the patients, with complaints and counter complaints being filed.
In about 45 days, this scheme will celebrate its second anniversary. However, the state could not issue the much-touted Health Card to more than 35 to 40 per cent of the people who qualify for the scheme. Even these were issued in Mumbai and have still to cover the rest of Maharashtra. Even though the Ration card is declared as an option to the Health Card, the problems arise when the Ration card is not updated to include every family member's name, or not renewed at all. On several occasions, insurance and consequently, medical treatment is denied to authentic beneficiaries only because the name of the patient was not visible enough or there was no date visible on the ration card, there was a difference in name or the spelling or ration card is not stamped and signed by issuing authority.
Flawed eligibility criteria
Those who are issued with ration card after April 2013 are not eligible for RGJAY, despite falling within the specified income group, as the state government had paid insurance premium to the insurance company on the data of ration card available as on April 1, 2013.
According to officials, the state paid the premium for 29 million families of the state at Rs.333 per family per year. Every family would get cover of Rs.1.50 lakh and the facility will be applicable only with empanelled hospitals. There are total 475 empanelled hospitals (400 private and 75 government hospitals) across the state.
Not viable for some
Some of the surgeries like hernia, vaginal or abdominal hysterectomy, appendectomy, cholecystectomy, and discectomy are conducted only at government hospitals. Consequently, patients in remote area of Gadchiroli or Dhule have to travel all the way to either Nagpur or to Mumbai which is not feasible for them. Some of these surgeries which are life-saving and need to be carried out on an emergency basis become even more complicated due to long waiting list at the hospitals and the travel to big cities where food and accommodation become unaffordable.
Overambitious and impractical scheme?
The National Insurance Company, which is entrusted with the insurance of this scheme, ambitiously quoted a premium Rs.333 per family per year against an insurance cover of Rs.1.50 lakh to bag this tender, not realizing that it was under quoted and meant huge outgoing expense. Now this company has hired foreign returned post-graduate doctors as executive doctors to cross check the insurance claims.Every application that does not qualify on some technical ground or the other, saves National Insurance Company up to Rs.1.50 lakh.
Scope for discrimination
These executive doctors, as third party auditors on behalf of the insurance company, have been denying claims on smallest of the small grounds like – concerned doctor did not hang stethoscope around his neck in the photograph, no video clip of the operation, no post surgery X-ray with visible stitches, or photograph of the doctor or hospital authorities giving bus fare to home destination in cash to the patient not attached in the file.
Private and government hospitals, where the core competency is to be in surgeries and medicine have had to open computer room and photo studios in hospitals to make documents for the insurance files.
In one case, the claim file was simply returned to the hospital as it did not have a photo of the medicine which was injected into the patient before the heart-related operation. After four days, hospital managed to send the file back along with photo of the wrapper of relevant injected medicine. Again, the file was returned by the insurance company with the remark that the bar code on the wrapper of the medicine was not visible. In the meanwhile, the cleaning staff at the hospital had thrown away the wrapper with the garbage. The file is still making its rounds.
Large unpaid bills
Deputy Chief Executive Officer of RGJAY, Ajay Gulhane, admitted to delays in the payment of bills by the insurance company. He said, “As per the rule, the payment of medical treatment should be done within 14 working days. However, this is not being followed, so naturally some hospitals are not happy with it.”
In Solapur district, Zilla Parishad officials said that bills from two hospital amounting to Rs.90 lakh each are pending and bills totalling Rs.1 crore from the Barshi Cancer Hospital’s are pending with insurance company. He said, “Even hospitals need to pay the bills of medical experts, mediacl and administrative staff, monthly outgoings.”
Hospitals too feeling discriminated against
Besides payment issues, hospitals are complaining of inequality in payment slabs. For the same type of surgery, different hospital are paid different packages. The state has classified hospitals into five categories, A, B, C, D, and E (not applicable or empanelled). This classification is done on the basis of infrastructure available at hospitals. For a particular surgery, an A category hospital gets Rs.100 whereas a B category gets Rs.90, a C category gets Rs.80 and a D category hospital gets Rs.70. Therefore hospitals which fall under the B, C and D categories, and their number is large, are not willing to work under the RGJAY scheme.
Consequently, many hospitals have stopped conducting health camps and are reluctant to carry surgeries due to payment delays and discrimination. However, because of this, it is the patients who continue to suffer and are forced to take rounds of various hospitals in the hope that the RGJAY will give them a new lease of life.
Sumit (6 years and three months old) a cardiac patient, son of Nilesh Kadam, resident of Wada in Satara district. His diagnostic tests had been done four months ago and he needs cardiac surgery. For the last five months, his father has been making the rounds of the local tehsil office and the RGJAY office to make the correct documentation. His application was not accepted because the local tehsildar wrote the date under his signature. RGJAY officials rejected the application stating that the date in the ration card should have been written at the top right hand corner of the page.
THE LONG RISKY WAIT
6,791 total patients who were identified as authenticate beneficiary of this scheme are waiting for their turn for operation, among them are:
654 patients awaiting urgent cardiac and cardiothoracic surgery
345 patients of cardiology are waiting for tests and evaluation
408 patients for treatment of genitourinary system
151 patients for general surgery
123 patients for neurology complaints
126 patients for neurosurgery