Explained: Why Mamata Banerjee’s Health Insurance Scheme Does Little To Help Bengal’s Ailing Millions

by Jaideep Mazumdar - Sep 17, 2021 07:12 PM +05:30 IST
Explained: Why Mamata Banerjee’s Health Insurance Scheme Does Little To Help Bengal’s Ailing Millions
CM Mamata Banerjee’s Swasthya Sathi health insurance scheme does little to help ailing millions.
  • The reason: abnormally low rates fixed by the state government for treatment of beneficiaries at private hospitals.

The deep flaws in Bengal Chief Minister Mamata Banerjee’s flagship Swasthya Sathi health insurance scheme are coming to the surface and rendering the scheme a useless one for most beneficiaries.

The reason: abnormally low rates fixed by the state government for treatment of beneficiaries at private hospitals. The rates fixed by the government are a fraction of that charged by private hospitals, thus forcing the private healthcare facilities in the state to keep only a small number of beds reserved for 'Swasthya Sathi' patients.

As a result, most 'Swasthya Sathi' patients are being turned away from the top private hospitals since the beds reserved for such patients are always full. Also, most doctors and surgeons refuse to treat or operate on 'Swasthya Sathi' patients because of the very low consultation fees and other charges fixed by the state government for such patients.

According to this report in The Times Of India, there were no beds available in most of the top private hospitals in Kolkata on Thursday (September 16). These much-sought-after private hospitals have stopped admitting 'Swasthya Sathi' patients.

Also, the beds that the private hospitals had reserved for these patients are being squeezed because of the huge rush of non-Covid patients who are flocking to the private hospitals for the non-emergency treatments, especially elective surgeries, that they had kept on hold due to the pandemic.

Given the very low rates for treatment and surgeries of patients under the 'Swasthya Sathi' scheme, the top private hospitals of the state were reluctant to empanel themselves with the state government and treat 'Swasthya Sathi' patients.

For instance, a private hospital can charge only Rs 80,000 for an open-heart surgery on a 'Swasthya Sathi' patient whereas the usual charges are about Rs three lakh. The charges for a hip-replacement surgery have been fixed at Rs 85,000 whereas private hospitals usually charge about 2.5 times that amount. Private hospitals can charge only Rs 19,500 for a gall-bladder operation on a 'Swasthya Sathi' patient, an amount that is less than half that charged from other patients.

The treatment of patients under the 'Swasthya Sathi' public insurance scheme is cashless, which means that the private hospitals raise the bills and send them to the state government for reimbursement. Another sore point with the private hospitals is the long time--45 to 60 days at present; it was 21 days till before the Assembly elections--taken by the state government to reimburse the bills.

This, say private hospitals, add to their substantial losses in treating 'Swasthya Sathi' patients. "We have to now deploy our executives to pursue this matter of reimbursement. This is an added hassle and a big irritant," said a senior executive of a private hospital chain.

Earlier this year, the Bengal government cracked the whip on reluctant private hospitals and forced them to empanel themselves under the scheme. They were warned that they would lose their clinical establishment licences (issued by the state government) if they failed to do so. Chief minister Mamata Banerjee had also lashed out at private hospitals which were reluctant to empanel themselves, warning them that they would lose their licences if they did not do so.

Mamata Banerjee launched the health insurance scheme in February 2017. But she made it universal in January this year with an eye on the Assembly elections.

The insurance cover of Rs five lakh per annum per family was extended to all, irrespective of income. Also, all members of a family, including the parents of both the spouses, were brought under the insurance scheme.

As a result, crore of people enrolled for the scheme and the number of those seeking treatment in private hospitals also went up manifold. The private hospitals demanded that the rates be enhanced, but that plea went unheeded.

It was then that they decided to reserve only a small fraction of the total beds available in their facilities for 'Swasthya Sathi' patients. AMRI Hospitals, which runs three facilities in Kolkata, has only 60 beds for 'Swasthya Sathi' patients, Belle Vue has 22, Medica Superspeciality has 30 and Peerless Hospitals has 38.

Private hospitals argue, and rightly so, that they cannot be compared to state hospitals which can charge low amounts from patients.

“We have high overheads and don’t compromise on quality of infrastructure and services. Our facilities are much better than even the top government hospitals and we have to pay our doctors also much more than what the government does. And unlike government hospitals, we constantly upgrade our infrastructure and facilities,” said the chief executive of a major private hospital in Kolkata who did not want to be named.

Private hospitals say that over the past four years, they have been cross-subsidising the cost of treating patients under the state scheme.

But that is only possible if the number of Swasthya Sathi patients is low. “Ideally, cross-subsidisation works if the number of patients under the state scheme is limited to just five percent of the total number of patients in a hospital,” said Peerless Hospital CEO Sudipta Mitra.

That is why private hospitals have been forced to reserve only a small number of beds for Swasthya Sathi patients. If all such patients who line up for treatment or surgeries at private hospitals are to be admitted, the private hospitals will go into the red and will have to shut down.

“There is no way any private hospital or nursing home can sustain itself for even a couple of months if it has to offer treatment to more than five percent of patients at Swasthya Sathi rates,” said the head of another private hospital.

Aratrika Das, a pulmonologist at Rabindranath Tagore International Institute of Cardiac Sciences (another premier private healthcare facility that is empanelled) told Swarajya “it makes no sense to offer first-grade medical treatment at fourth-grade rates”. She said that while her consultation fee is Rs 700 for attending to patients in the general ward and Rs 1500 for attending to patients in the ICU, it is a paltry Rs 250 for patients under the ‘Swasthya Sathi’ scheme.

“Why should such rates be imposed on us? Private hospitals have to maintain certain standards and provide the best facilities and treatment. That costs money and the ridiculously low rates of treatment prescribed under the ‘Swasthya Sathi’ scheme would make private hospitals completely unviable,” said Dr Das.

The reservation of only a small number of beds by the private hospitals for treating Swasthya Sathi patients defeats the whole purpose of the state health insurance scheme. "The idea of a state health insurance scheme is to enable the poor to avail treatment at top private healthcare facilities. But if that does not happen, or only a very limited number of the poor are benefitted, what remains of the scheme?" wondered a public health activist.

Also, with everyone--even the middle-classes and the affluent--enrolling themselves under 'Swasthya Sathi', the poor are being pushed out of admissions in top private hospitals. "The middle classes and the affluent (who have enrolled under Swasthya Sathi) have contacts and pull strings to get themselves or their family members admitted in beds reserved for Swasthya Sathi patients. This means denial of this subsidized treatment to the poor who really need it. This is why income should have been a determinant for enrollment under Swasthya Sathi," said the health activist.

Bengal's poor and disadvantaged who have been enrolled under the Swasthya Sathi scheme thus have to rely on government hospitals for treatment. Which, in effect, means they have not benefited at all since they are being forced to flock to the ill-equipped, overcrowded and poorly-managed state hospitals anyway. Swasthya Sathi has brought no benefits to them.

Another major drawback of Swasthya Sathi is that beneficiaries can avail treatment only in healthcare facilities in Bengal. The only hospital outside Bengal to which Swasthya Sathi beneficiaries can go is the Christian Medical College (CMC) at Vellore. But there is a long queue of patients seeking treatment there and CMC, anyways, treats the poor at highly subsidized rates.

None of the much-sought-after private hospitals in Bangalore, Hyderabad, Chennai, Mumbai or Delhi where tens of thousands from Bengal go for treatment every year are empanelled under Swasthya Sathi. That's because of the ridiculously low rates of treatment offered for Swasthya Sathi beneficiaries.

And Mamata Banerjee has not been able to arm-twist them, as she has done with private hospitals within Bengal, into empanelling themselves under her pet health insurance scheme.

For Swasthya Sathi to have been effective equal to, or more, than the Union Government's Ayushman Bharat (Pradhan Mantri Jan Arogya Yojana or PM-JAY), it ought to have been limited only to the poor and the rates of treatment and surgeries offered to private hospitals should have been at least 2.5 times the prevailing rates.

But for Banerjee, immediate gains triumph over long-term benefits. "She made Swasthya Sathi universal a few months before the Assembly elections in order to get votes. The Swasthya Sathi rates are low because debt-ridden Bengal cannot afford to pay the hospitals more. This has defeated the whole purpose of the scheme and made it completely ineffective," said an ENT surgeon with a major private hospital in Kolkata.

In the final analysis, like many populist welfare measures rolled out by Banerjee, her Swasthya Sathi scheme is also turning out to be a useless one for the poor and disadvantaged millions in Bengal.

Also read:

-How Mamata Banerjee’s populism could deal a body blow to private healthcare in Bengal

-Why Mamata Banerjee’s health insurance scheme is much ado about nothing

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