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New Delhi, Oct. 11: False claims, unnecessary surgical procedures and “ghost patients” appear to be dogging government-sponsored health insurance schemes for the poor, a study released today by the World Bank has cautioned.
The study, described by its authors as a comprehensive analysis of several health insurance schemes launched over the past decade, said there was emerging evidence of unnecessary care and called for “tough control measures” to curb the observed trends.
The number of people covered by Union or state-funded health insurance in India increased from 37 million in 2004 to 243 million by 2010. The independent central and state schemes typically involve small premium payments — Rs 500 to Rs 600 per family per year — and offer hospitalisation insurance cover from Rs 30,000 up to Rs 2,00,000.
The study has said certain hospitals empanelled under a scheme called the Rashtriya Swasthya Bima Yojna (RSBY) perform many more hysterectomies than would be expected, or combine hysterectomies with simultaneous surgical removal of ovaries to increase charges that can be claimed.
The RSBY launched in 2008 covered 23 million families in 2010. In some patients who sought treatment under the scheme, hernia and appendectomy procedures were similarly combined to maximise revenues from the scheme.
Internal reviews of another scheme in Andhra Pradesh that covered about 20 million families also suggest that health care providers were inducing demand for hysterectomy, appendectomy and renal stone lithotripsy.
In another government scheme, the study said without naming it, officials discovered that hospitals were converting outpatient care into inpatient care only to seek reimbursement as all the schemes cover only services that involve hospitalisation.
“These are among many challenges facing these schemes,” said Somil Nagpal, a medical doctor and health specialist with the World Bank, New Delhi, a co-author of the study. “There is not enough institutional architecture to conduct major governance functions, most schemes have severe human resource shortages, and there is no systematic attempt to cost services or collect market prices to improve package rates,” Nagpal said.
The study seems to corroborate suggestions by sections of public health experts that the new wave of insurance schemes for the poor are contributing to “provider-induced demand” — the term for health care practitioners coaxing patients to undergo surgical procedures or other hospitalisation procedures that they do not really require.
A senior Union health ministry official said one way to curb such observed irregularities would be to rely on district-based disease information. “We may need to look at district-wise disease data to know where this is happening, and this also requires intensive regulation at the state level,” said Keshav Desiraju, additional secretary in the health ministry.
Many schemes have disempanelled hospitals after investigations. The RSBY has disempanelled 54 hospitals, while a scheme in Karnataka has struck off 58 hospitals.
The study said that the population covered by such schemes was likely to rise to about 630 million by 2015. It has recommended increasing health insurance coverage for both outpatient and inpatient care to include all poor and near-poor patients.
The other co-author of the study was Gerard La Forgia, the World Bank’s lead health specialist.
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