WHAT IS THE IMPACT OF AAROGYASRI ON THE FUNCTIONING OF PRIVATE HOSPITALS/NURSING HOMES IN AP?

The Aarogyasri programme has a varied impact on different hospitals depending on their size (number of beds), location (urban, semi-urban or rural) and technology level.

Consider 200 bedded hospitals (most of them are empanelled under Aarogyasri) – some of them would have closed without Aarogyasri. They are able to sustain their business because of Aarogyasri patients. Even 50 bedded hospitals which are enrolled with Aarogyasri have been able to survive and grow. In semi-urban areas the sustenance has become difficult for 50 bedded hospitals and smaller hospitals which have not been able to enroll into the scheme. Many un-empanelled hospitals had to either shutdown or scale down once Aarogyasri began. Surgical practices have reduced.

I have a 50 bedded hospital with basic specialties services (Medicine, surgery—neuro and urology included, orthopedics, obstetrics and gynecology, pediatrics and anesthesia). The mainstay of my practice pre-Aarogyasri was surgical procedures including laparoscopic (keyhole) surgeries.Now our surgical practice has come down by 50%.

How easy is it for private hospitals/nursing homes to get empanelled under Aarogyasri?

The high technology requirement is a definite barrier. Most of the new hospitals which are established to take advantage of Aarogyasri find it difficult to enroll due to the technology intensive empanelment criteria. These are focused on high end technology for diagnosis and treatment, higher end specialists and super-specialists to conduct procedures. This requires a high initial investment.

In my own experience, I tried to get my 50 bedded hospital empanelled under Aarogyasri. I submitted all the requirements and queries as per their specifications; their team instead of visiting my facility, came up with a totally new set of queries unrelated to the previous set. Most of these questions were about technology.

I had sought empanelment for pediatric care procedures. I met all the scheme’s criteria for pediatric care. The Aarogyasri team after sometime insisted on neonatal (new-born) care requirements (which are different from those of pediatric care) like phototherapy units, etc. The same unpredictable demands come up in relation to operation theatre and diagnostic equipments. When I applied for empanelment for surgical procedures they also insisted on orthopedic procedures. This has not just happened to me but also to many other doctors who run 50 bedded hospitals.

We are not empanelled .We have adapted by strengthening and shifting to treatment of those conditions which require medical management (as opposed to surgical treatment), especially for conditions not covered under Aarogyasri. That programme only covers 953 procedures and luckily for us the list leaves many medical needs uncovered.

It is not just high-end technologies that cause difficulties to hospitals, but also the pre-requisite of higher specialties in surgical skills that are being specified by Aarogyasri. The Medical Council of India does not prohibit surgery by an MBBS doctor. Initially, under Aarogyasri, the only criteria for doing laparoscopic surgery was some internationally recognized certification of the doctor’s competence. Even a general surgeon needed this certification. Now they have specified that only general surgeons with a certification of having done at least 100 laparoscopic surgeries would be eligible to perform laparoscopic surgeries under the scheme. Now, in a rural setting you don’t find many general surgeons, it has always been MBBS doctors (without an MS degree but with surgical training and experience) who have been doing the basic surgeries and serving people.

Take my case—I have been trained by Dr. Mitra (of Apollo Hospitals, Chennai and Hyderabad) in laparoscopic surgery. At that time, there were only 3-4 laparoscopic surgeons in AP of which I was one. I have trained many surgeons in laparoscopic surgery. I have certified for Aarogyasri that they have conducted 100/200 laparoscopic surgeries under my guidance. This certificate issued by me is valid for eligibility under laparoscopic surgery, but I am not eligible to do laparoscopic surgeries myself even though I have been trained by the country’s leading laparoscopic surgeon, because I am only an MBBS doctor. So yes, there are many aspects of Aarogyasri that are biased against small hospitals in semi-urban/rural areas and towards large corporate hospitals in the cities.

How does Aarogyasri get operationalized and what is its effect on patient care?

Aarogyasri has had a series of deleterious effects on patient care as a whole. These may be due to technology effects, reimbursement limits, eligibility for funding, specialization criteria and due to diseases not being in the Aarogyasri list.

To look at the technology effect, take the example of laparoscopic gallbladder surgeries. Laparoscopic surgery provides a great advantage over traditional open surgeries in gallbladder removal. Hospital stay is 2-3 days and the patient can go to work in 5-7 days. Healing is better for many reasons. But sometimes the operating doctor decides to convert laparoscopic surgery to an open surgery with a wide incision to ensure safety of the patient after assessing the patient’s gallbladder through the laparoscope. However, an open surgery is paid only Rs. 10,000 as against Rs. 30,000 in laparoscopic surgery even though the hospital stay and other expenses are more in the open surgery.

For an example of the difficulties caused by partial inclusion of a category in Aarogyasri, let us look at poisoning. There are many cases of poisoning in rural areas especially among women, but all poisoning is not covered under Aarogyasri. Only organophosphorous (OP, or pesticide) poisoning which requires putting the patient on a ventilator (breathing apparatus) is covered. This too is covered only initially for 7 days, after which the patient needs to re-apply for further eligibility. In my hospital about 25% of OP poisoning cases require ventilator support. But any poisoning (both OP and non OP) case, even if ventilator support is not needed, requires prolonged hospitalization of 10-15 days, gastric lavage (flushing out the poison through water or saline pumped into the stomach), ICU stay for 3-5 days, medicines, medico-legal coverage, etc. In some cases of corrosive (Super-Vasmol hair dye) poisoning tracheostomy (making a cut in the breathing pipe) is required, but it is not covered under Aarogyasri. People do not prefer to take poisoning cases to government facilities, as they fear a police case; so most of them end up in a private hospital, incurring huge treatment costs. Scorpion stings are not covered but snakebites are.

Dengue fever is an example of non-coverage under Aarogyasri. The sale of (blood) cell counters has increased in the private hospitals. Every fever is now treated as a probable dengue case and a cell count is done. Platelet counts can fluctuate due to multiple reasons, dehydration, excess of dilution factor, or sampling error; platelet fluctuation because of dengue is rare. Even in cases where an abnormal count is shown by automatic cell counters, a manual verification is mandated before the results can be interpreted. But the patient is at the receiving end of arbitrary decision making. Any fever case can be made into a dengue case. The system can play on the psyche of the patient and expose him to unnecessary treatment, hospitalization and expenses. The worst thing is hemorrhagic dengue fever or dengues with serious complications are also not covered under Aarogyasri.

Finally, there is a learning curve for both the doctor and the medical system each time a new technology is introduced ( e.g., laparoscopic surgeries). A lot of experimentation is done, and many inexperienced people try their hand at these technologies. Normally 1% injury to common bile duct is accepted in laparoscopic cholecystectomy (removal of the gallbladder through keyhole surgery), but the injury rates were higher under Aarogyasri. The treatment of these complications was not covered under Aarogyasri. Hospitals were supposed to bear the cost, but they shifted it on to the patients. So it would seem as if the Aarogyasri programme is also functioning as a paid skill development programme for surgeons at the risk of patients who need medical care!

To sum up, high end technology does provide value in some methods of treatment, but it also acts as barrier for entry of smaller hospitals into the scheme in semi-urban areas. It also lends itself to overuse/misuse because a basic volume of procedures needs to be done to sustain the technology, irrespective of whether it is needed or not in the best interest of the patient. The high cost of investment has to be recovered and technology has to be sustained.

(Adapted in good faith from www.funnytimes.com)

In response to protests over such procedures, recently the Aarogyasri trust has restricted surgeries like hysterectomy (removal of uterus), cholecystectomy (removal of gallbladder), appendicectomy (removal of appendix) and thyroidectomy (removal of thyroid glands) to government hospitals in order to restrict overuse/misuse of these procedures by private hospitals.

Is there any difference in care between general patients and Aarogyasri patients in government and private hospitals?

In government hospitals, the government surgeons and specialists can earn Rs. 1 lakh over and above their salary per month from Aarogyasri payments. The team (doctor, nurses, ward boys) treating the patient shares 30% of the Aarogyasri payments, of which a major portion goes to the doctor. This is an incentive for them to focus more attention on Aarogyasri patients. In addition the Aarogyasri patient can afford drugs and investigations not available in the hospital. So the Aarogyasri patient is rated higher than the general patient in government hospitals.

It is exactly opposite in a private hospital. The Aarogyasri patient is operated/treated upon by the assistant surgeons/junior doctors (trainees) in most of these hospitals. Low end technology and inferior quality material are used. These patients are kept in separate general wards, which are less equipped and more crowded than the normal wards. They are under-served compared to normal private patients. The effort here is towards maximizing profits of the hospitals and doctors.

I think there is a provision under Aarogyasri for stay in the private wards (both in the government and private hospitals) at additional cost over and above that covered by Aarogyasri for patients who can afford it.

Initial expenses on tests required to arrive at a diagnosis acts as a barrier for the real poor in accessing services at private hospitals. Another issue is that patients referred to government hospitals are channeled to private hospitals. I have referred many patients to Osmania Medical College cardiology and surgery departments, but only one in ten referred patients finally reach there. Others are siphoned off by touts to private hospitals for a commission. Even in referral there is a system of cuts and kickbacks.

Aarogyamitras in general have been of immense help to a poor patient trying to negotiate the complex system of a hospital and in receiving treatment.

What is the nature of external/ political influence of private sector in policy and empanelment or other matters of Aarogyasri?

Doctors have strong influence on politicians, but during YSR government there was very little political influence in empanelment and payment processing. Influential doctors who approached YSR were clearly told that he does not interfere with Aarogyasri operations. This sent out a strong message, “political influence is not useful in Aarogyasri”. But this was true only of smaller individual/group-owned hospitals. The corporate sector would threaten Aarogyasri of withdrawal from the scheme if the trust did not comply with their collective request. Now things have changed, there is more access through third party lobbies (both politicians and otherwise).

How would you want the AP health system and Aarogyasri to evolve?

The public in AP has appreciated Aarogyasri. For a person in need of health care, coverage under the scheme has a big impact. But many conditions are not covered; only tertiary care is. It can be an excellent platform to offer universal health care. It has strong political appeal. What the health activists could not do over so many years, YSR did in a short time. Health is now on the political agenda of AP. Efforts should be directed to make Aarogyasri available to everybody.

Our (Jana Vignana Vedika’s) slogan is: Aarogyasri for all diseases, for everyone and only in the government hospitals. Not at the cost of public health

Referrals to private hospitals should be allowed only for those cases for which government hospitals certify that treatment facility is not available with them. Different mechanism of financing can be established. Those who can afford it should pay a premium or tax.

The public health care system has been systematically brought down. The strategy has been to first squeeze funds, not appoint the requisite workforce leading to a lowering of performance of government health sector. This result has raised anger in public towards government facilities, and increasing frustration among public sector employees. Once this atmosphere is created, services can be shifted to private sector (through incentives, land grants, exemption from import duties, etc.). I think this strategy needs to be reversed, we have to strengthen public sector and use it to provide treatment through public financing. In my opinion, health and transport should not be run by private sector. Even CGHS (Central Government Health Scheme), ESI (Employees State Insurance) and Indian Railways are referring patients to private health facilities—we need to reverse this trend.

Increased emphasis should be laid on preventive measures. For example during British rule, there was a practice called Dry Friday. Everybody acted on Friday to keep the surrounding and drainage dry. This had virtually eliminated dengue as public health menace. But now government is not interested and health activists have failed to mobilize people.

How do you now ask a poor beneficiary not to go to a private sector hospital? Isn’t this a political question?

Political will is required. Some amount of consent and coercion is also required. If we provide treatment for all ailments at government health facilities and invest in public health care, the reversal will happen. A poor person should feel that he is able to get treatment for all ailments at government hospitals.

Will people realize that they are being taken for a ride through populist measures, not really benefiting them?

Yes, there are many examples of such realization. Smoking has reduced in railway premises. Awareness, law, stigma, implementation, all have played a role. Sale of useless tonics has come down by 50%. Sales of cool drinks has reduced. Use of safe drinking water has increased even in rural areas. Village people are purchasing water cans. But it should be the duty of government to provide safe drinking water.

A last comment on Aarogyasri?

Aarogyasri should not be scrapped. It is a knife that was used to stab the public health sector, now the same knife should be used to stab back at privatization. There is no rationale for the focus on only high-end medical care cases under Aarogyasri. Many a time high end care is unnecessarily provided so that patient can be covered under Aarogyasri at an early stage. All this depends on the attitude of the hospital management – how profit driven they are!

Dr. Vijay Kumar is a well-known health practitioner and health care activist. He is a founder member of Jana Vignana Vedika, an organization that is committed to socialize principles of health care and public health. He is part of National Association of People’s Movements. He heads a nursing home called Nellore Hospitals at Nellore. He was earlier working for seventeen years at Dr. Ramachandra Reddy Hospital, also at Nellore. This interview is the record of a conversation between him and Rajan Shukla, Veena Shatrugna, Sheela Prasad and R. Srivatsan.