Indu Bhushan is at the helm of what is pegged as the world'smost massive government-funded health schemeAyushman Bharat , which provides health coverage to well over ten crore families in India.

Until a few months ago, Bhushan, a former bureaucrat and East Asia head of Asian Development Bank, was a fit man. Only recently, his blood pressure shot up all of a sudden and he wonders why, as he straps on the testing apparatus to his arm to take a daily reading.

Bhushan and his team had been working late into the evening, even 12 hours at a stretch, to make the scheme a reality. "I would not have had it any other way," says the CEO of the National Health Agency . Yet, there are a volley of concerns about the cashless health insurance scheme that remains to be addressed.

A growing line of worried private doctors has been knocking on government doors, seeking joint meetings with government think-tank NITI Aayog's member, (health), VK Paul and Indu Bhushan to complain about the rates at which they are being asked to perform surgeries and other medical procedures .

Girdhar Gyani, CEO, Association of Healthcare Providers (AHPI), India, leads the pack. Barely 10 days back, Gyani met Paul and Bhushan to illustrate how different States, which already run State-level government insurance schemes , have radically divergent rates for performing the same surgery that Ayushman Bharat demands be carried out at a lower rate.

Center's rates vs the rest

Gyani explains with an example. For a hysterectomy, Telangana allows for a charge of ?62,000 while Karnataka has pegged it at ?50,000. Tamil Nadu charges 34,000 and Maharashtra 35,000, for the same procedure. Ayushman Bharat package rates put the amount at ?20,000, which is not agreeable to the States already running their schemes. The package rates drawn up by the Central government then remain a mere ‘guideline.’

Prices were drawn up unrealistically, says VK Monga, Finance Secretary of Indian Medical Association. “A surgery requires an anaesthetist, a surgeon, specialists like paediatricians if we are dealing with child issues. A hospital has to pay their fees, supply medicines to patients for, say, five days in the hospital, supply another set of drugs on discharge. How is all this possible with a low package rate?” questions Monga. 

Towards appropriate pricing

While private doctors criticise the scheme saying the pricing is not scientific, Bhushan reacts, “How are we to devise appropriate pricing? The scheme is being criticised that pricing does not have a scientific base and does not represent cost structures across geographies. So we need meaningful participation of private stakeholders as we do not want to replace one unscientific pricing methodology with another, neither do we want to keep revising rates every few months.”

The crux of the issue, as was seen in the case of stents, is whether hospitals recover their targeted amount from other billing categories. Hence, even if a procedure is slated to cost ?20,000 under Ayushman Bharat, the actual bill for the patient could be more.