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Delhi healthcare providers seek stay order on implementation of package charges
Falaknaaz Syed - Mumbai
Healthcare providers in the Capital, namely, Delhi Medical Association, The
Delhi Nursing Forum (a body of 600 nursing homes), Indian Medical Association
(IMA) have filed a writ petition against Insurance Regulatory Development Authority
of India (IRDA), The National Insurance Company Ltd and three TPAs namely Paramount
Health Services Pvt Ltd, Alankit Healthcare Ltd and Park Mediclaim Consultants
Pvt Ltd in Delhi High Court.
The writ petition filed last month by the healthcare providers seeks a stay
order on the implementation of the fixed package charges under the cashless
scheme for various medical treatments, procedures and services rendered by the
healthcare providers.
Recently, Insurers and TPAs under the aegis of the General Insurance Council
and the IRDA have launched ‘The Package Deal Pricing’. As per the
move, healthcare institutes are graded and package charges for various medical
services and procedures have been decided as per the grade of the healthcare
institute. The move aims to control the abnormal claims ratio in health insurance.
Since package charges are pre-determined, they will act as a ceiling and prevent
healthcare providers and hospitals to charge above a certain limit.
Delhi healthcare providers have found the charges abysmally low and allege that
the TPAs have threatened to withdraw cashless service from those hospitals that
do not agree to the package charges. According to them, the scheme will force
them to provide sub-standard treatment and they fear that incase they don’t
sign the agreement, TPAs will divert their clientele to those hospitals which
agree to carry out treatment at the package charges fixed by the TPAs.
TPAs had given healthcare providers a deadline of 31st August to sign the agreement
and announced that the package charges will be effective from 1st September.
However with the healthcare providers seeking judicial intervention, mere 280
nursing homes and small hospitals have signed the agreement according to sources.
The first hearing on 29th August was inconclusive and the Delhi High Court has
directed both the parties to reappear after two weeks.
Also according to sources, an out of Court negotiation attempt between the healthcare
providers, National Insurance Co Ltd and TPAs has failed.
Dr V K Monga, Chairman, Delhi Nursing Forum, said, “As soon as we received
reports of package charges being enforced on Delhi nursing homes and hospitals,
we wrote our objections to IRDA, National Insurance Co and various TPAs at the
beginning of the month. IRDA wrote back to us that they are looking into the
matter. But they have not sent us any more information till date. The TPAs are
forcing some and luring others into signing the agreement. That is why DMA had
to approach the Honble High Court of Delhi. DMA, IMA and many corporate and
small hospitals of Delhi have formed a common platform to tackle this issue.”
“The scheme is anti-patient. If a person has an insurance cover of one
lakh and another person has a cover of Rs 5 lakh, how can both of them be send
to ‘B’ category hospital?” questions Dr Monga.
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Other arguments of the medical providers taken
from the petition
- Package charges fixed for the room rent
includes nursing care, boarding, lodging, television, infusion charges,
injections, and administration charges and even the charges towards
oxygen.
- Package rates for practically all procedures/
treatments are unrealistically low. For instance, Room charges (in one
category) is Rs 225. In an air-conditioned room, on an average, air-conditioning
is utilised for 18 to 20 hours and the cost of electricity alone per
day comes to about Rs 225 at the rates applicable to nursing homes.
- Ventilator charges have been fixed only
at Rs 500. While the same costs the hospital/ nursing homes Rs 1500-2500
per day. Pertinently, even the CGHS rates are Rs. 1500 per day.
- The charges of visits by consultants in
ICU have been fixed at Rs. 500/- per day, irrespective of the number
of visits per day.
- Senior Consultants will be reluctant to
come for visits in the night and spend hours to get paid Rs. 250/- with
all deductions.
- If the ventilator charges are reduced
to Rs 500, it is more likely that patients would not be put on ventilator
with automatic gadgets, rather they would be treated with small ventilators
only.
- The rates have been fixed by the TPAs
without reference to the enormous capital cost and running maintenance
costs of the sophisticated medical equipment, a large part of which
is imported, as also the cost of skilled manpower required to operate
such equipment.
- Various ill reputed, ill-equipped hospitals/
nursing homes that do not offer quality services and treatment are making
a beeline to accept the packages proposed by the TPAs.
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Says Dr Vinay Aggarwal, hon secretary general of IMA, “TPAs do not have
the expertise to accreditate healthcare institutes. It’s the job of the
government and rating agencies. But here, the TPAs are acting as accrediting
agencies. Besides they are determining rates for hospitals.”
“The TPAs have a listed price taken from service providers.
They can check if the service providers are on those charges. Insured patients
want to avail treatment at good hospitals and so have bought the policy. Why
should the TPA determine which hospital a patient should go to and not in the
other? We want the IRDA to decide about the charges and the accreditation, ”
he adds.
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The move is anti-patient. If a person has an insurance
cover of one lakh and another person has a cover of Rs 5 lakh, how can
both of them be send to 'B' category hospital?
Dr V K Monga,
chairman, Delhi Nursing Forum
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There has to be some kind of regulation in the healthcare
industry. If arbitrary charging by healthcare providers is allowed, then
consumers will end up paying higher premium.
Dr Nayan Shah,
managing director, Paramount Health Services
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It is imperative at this stage for the
government to step in to regulate the health insurance sector, to prevent
the adverse effects of such cost containment
techniques that have been blindly
adopted from the west.
Deepak Mendiratta,
chief (Health Plan & Health Insurance Administration),
Max Healthcare
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Healthcare providers argue that the treatment for two patients
suffering from the same disease can be different. For instance, if the patient
is diabetic and has to undergo an appendicitis operation, a lot of care goes
in management of diabetes before the surgery. Also the stay in such a case will
be extended for more than two days, and so it won’t be possible for a hospital
to provide treatment in the pre-determined package charge of Rs 10,000 in X
hospital and the treatment will be out of pocket for the patient.
Meanwhile, Consumer Co-ordination Council, a registered national coalition of
55 leading consumer groups across the country is deciding to file a similar
writ petition against the implementation of the package charges by the insurance
companies on behalf of the consumers.
Informs Bejon Misra, chairman, Consumer Co-ordination Council, “The two
sides are fighting for their respective interests. But no one is thinking of
the end consumer. We are planning to file a petition against the insurance company’s
move to protect the interests of the consumer. Patients should have a right
to choose a hospital or a doctor of their choice. The insurance cover should
not deprive the consumer of this choice. Such a move if implemented by the insurance
company will force the patient to seek sub-standard treatment. ”
Says Deepak Mendiratta, Chief (Health Plan and Health Insurance Administration),
Max Healthcare, “The emphasis of this move is on cost. So the doctor will
make a conscious effort to see that the treatment does not go beyond the package
amount. As a result, he may be forced to resort to cost cutting thereby reducing
both the quality as well as appropriateness of medication, detailed examination
and investigation etc, which will impact patient safety. Such a move will not
only have implications on a doctor’s autonomy to treat but also impact
doctor-patient relationship.”
The TPAs on other hand feel that the cashless system has been abused to the
hilt and so it is imperative to bring in standardisation and regulation in the
healthcare industry. An insured patient admitted to the hospital is made to
undergo an array of unnecessary tests by the hospitals thereby increasing the
bill.
Says Dr Nayan Shah, managing director, Paramount Health Services, “There
has to be some kind of regulation in the healthcare industry. If arbitrary charging
by healthcare providers is allowed, then consumers will end up paying higher
premium. Can an airline charge 10 times higher because the client is wealthy?
Then how can a healthcare provider/hospital charge more from the insured patient?
We have decided customary and reasonable charges,”
On the allegation of giving a discount to some medical providers, Dr Shah said
that IRDA and insurance companies check the accounts of the TPAs and so there
is no room for underhand dealings.
Argues an expert from the TPA side, “In various countries including the
USA, the providers are paid fix charges as per drug or diagnosis. There is different
payment for say an appendix surgery with or without complications. How many
nursing homes display the fee schedule?”
Avers Mendiratta, “It is imperative at this stage for the government to
step in to regulate the health insurance sector, to prevent the adverse effects
of such cost containment techniques that have been blindly adopted from the
west and which will result in shifting towards unregulated models of healthcare
delivery. This will also promote limited access to new technology and medicines
for insured patients resulting in unnecessary suffering, prolonged illness and
side effects from forced drug substitution.”
falak@expresshealthcaremgmt.com
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