Even as most big hospital groups seem to have sorted out their differences with public sector health insurance players to resume cashless mediclaim policies for patients, it is thousands of smaller nursing homes which are now threatening to stall the seamless resumption of cashless services.
Differences over the ceiling prices for procedures offered by the insurance players have led thousands of nursing homes to boycott resumption of cashless policies to their patients.
?The boycott movement started with the eight thousand odd nursing homes in Maharashtra which are members of the Association of medical consultants. It is fast gaining momentum across the country as many nursing homes are offering heavy discounts to patients who are not opting for the cashless services. It may snowball into a national crisis very soon,? an industry member from the Nursing Home Association told FE.
The four government-run insurers who control over half of the market, had last July unilaterally withdrawn cashless facility in most corporate hospitals in big cities alleging that hospitals overcharge them placing their business under strain and distorting the market.
The insurance companies, which decided to scrap the cashless treatment facility are New India Assurance, United India Insurance, National Insurance and Oriental Insurance. Subsequently, insurance companies and hospitals agreed to classify hospitals according to the infrastructure and services offered and fix graded rates for procedures accordingly.
Accepting that nursing homes and insurance firms have not yet ironed out differences, Johnson & Johnson medical India managing director, A Vaidheesh, also chairperson, CII sub-committee on accessibility, health insurance and the medical industry, which is mediating the settlement of the dispute said ?More open minded dialogue from both sides is needed to arrive at consensual rates of procedures. Nursing homes do play an important role in the overall healthcare ecosystem as of today and it is important to resolve this crisis.?
Apart from the nursing homes, many big hospitals in the Mumbai region are still to resume the cashless facilities. ?A very small component of the overall revenues of these standalone hospitals comes from insured clientele, so they have not bothered to resume the cashless facilities,? the industry member told FE.
He added, ?The insurance firms are even insisting on capping doctors? fee which is not feasible. The entire focus of insurers has been on output rather than outcome. While output considers how much a single patient pays up during an hospital admission episode, outcome would take into account whether the same patient would have to undergo several admissions because his procedure was hurried up to keep the cost under the cap?.
The nursing homes are challenging the calculation of caps on procedures alleging that it is not based on actuarial data and hence is not scientific. The insurance firms however maintain that inflated and fraudulent claims are commonplace.
?It doesn?t augur well for insurance industry and healthcare sector. Offering cashless facility through nursing homes would have widened the network of insured people over time. Also, it is not easy for common man to shell out R50,000 to R1 lakh immediately in times of urgent need,? a healthcare expert said.
