The Cost Of Insurance Based Funding
Context:
- The Tamil Nadu public health model is well-known. When compared to the average for all of India, it has ensured equity in healthcare delivery, significantly lowered maternal and infant mortality, increased immunisation rates, and produced a low total fertility rate.
- The way that healthcare is funded has changed during the last ten years. The funding mix varies, ranging from cash from the National Health Mission to the Chief Minister’s Comprehensive Health Insurance Plan (CMCHIS). The advantages and disadvantages of funding from insurance firms are discussed in this essay.
The following benefits of decentralisation:
- The key advantage is the decentralisation of medical and healthcare administration. The department heads now have a considerable amount of purchasing power. Red tape has been removed. As a result of scientifically sound medical advancements, individual departments now have the authority to prioritise their needs and make decisions about patient care more quickly.
- On the other side, the medical college currently runs each department separately. To raise earnings and cut losses, each of these divisions competes with the others. As a result, in secondary and tertiary healthcare systems, patients and their ailments are viewed through the prism of indemnification.
- In public sector hospitals, bargaining with insurance providers has grown to be a time-consuming process for the already overworked patient care teams. As a result of insurance companies’ administrative delays, hospitals are now more concerned with collecting money from businesses than they are with providing care for patients, conducting research, or teaching.
Not having compassion:
- Instead of being a precise science or a commodity, medicine is an art that calls for passion and compassion. Not just because of administrators, but also because we ensured that doctors came from a variety of socioeconomic backgrounds, paid them fairly, and gave them options for post-graduation and super specialisation, we were able to achieve positive health indicators over the past 50 years.
- In turn, they introduced rural Tamil Nadu citizens to the concept of modern medicine and contributed to its long-lasting success. Medical professionals’ compassion will decrease if public health is viewed as a company with a profit-loss analysis.
- Insurance companies in Tamil Nadu got payments from the CMCHIS totaling 7,783 crore between 2012 and 2021. Government hospitals have only claimed 2,895 crore of this amount. The remaining money have been given to private hospitals. Less money will be allotted to public hospitals as a result of this disproportionate “diversion” of funds.
Getting near a UHC:
- As a key component of the development agenda, the idea of universal health coverage (UHC) is a subject of intense debate. During the Covid-19 outbreak, the international health systems badly failed, making universal health care necessary. In order to recognise the importance of UHC, the UN declared December 12 as World Universal Health Coverage Day (UHC Day) in 2017.
- According to the United Nations’ definition of UHC, everyone should have access to the medical care they need without worrying about having to suffer financial hardship. The Sustainable Development Goal 3.8’s main component is to achieve universal health coverage (“Achieve universal health coverage, including financial risk protection, access to quality essential healthcare services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all”).
Ayushman Bharat and PMJAY:
- The government provides all financial support for PM-JAY, the largest health insurance/assurance initiative in the world. It was first established in February 2018 and offers an insured amount of 5 lakh rupees per family for secondary care (which does not require a super specialist) and tertiary care (which involves a super specialist).
- The PMJAY programme provides participants with cashless and paperless access to services at the point of service, which are hospitals having empanelled status. Health benefit plans pay for surgery, medical care, daycare, and diagnostic tests as well as pharmaceuticals.
- The users of this entitlement-based initiative are those who were identified by the most recent Socio-Economic Caste Census (SECC-2011) data.
- The Northeastern states, Jammu and Kashmir, Himachal Pradesh, and Uttarakhand receive 90:10 of the cash for the centrally funded programme, which is distributed 60:40 among other states and UTs with their own assembly.
- Unconstrained UTs receive total central funding.
- The National Health Authority (NHA) was founded as a stand-alone organisation under the Society Registration Act of 1860 to carry out PM-JAY in cooperation with state governments. The implementation of AB PM-JAY across the State is the responsibility of the State Health Agency (SHA), which is the State’s highest administrative agency.
Conclusion:
- Tamil Nadu has a distinctive and robust policy structure that can work well with PMJAY and other government healthcare programmes in order to provide universal health coverage. The Tamil Nadu model ought to be used by states who are lagging behind in providing public healthcare.
