Hyderabad: What has been simmering for years together has now erupted as a volcano with Telangana Specialty Hospitals Association (TSHA) announcing withdrawal of all cashless healthcare services to Employees’ State Insurance (ESI) beneficiaries from November 1, 2017.
The drastic decision has been attributed by TSHA to ESI’s inordinate delay in reimbursement to hospitals with dues of several patients dating back to the year 2012 remaining unpaid, the TSHA said in a statement on Saturday.
In their statement, over TSHA hospitals empanelled with ESI in Telangana have requested ESI beneficiaries to make a note of the same and get ready to pay in cash.
For the record, 44.70 lakh ESI beneficiaries availed cashless insurance facility from these empanelled hospitals in Telangana in 2015 alone. (Check the state wise list of ESI beneficiaries)
The agitated private empanelled ESI hospitals claimed that their attempts to resolve their issues with the central governmental authorities were futile, leaving them with no other option than to withdraw cashless services.
Delay and delay:
They claimed that their dues have been mounting since 2012 but the ESI authorities failed to honour their own guidelines. Hospitals have signed agreement based on the terms and conditions defined by the CGHS, which has provision to make 70% payment within 5-working days of submission of bills by hospitals but in none of the cases, payments have been made within such a stipulated time, they claimed.
Worse, these empanelled hospitals have to wait for months and years to get the dues.
What’s more the ESI’s arrangement with UTI Infrastructure Technology And Services Limited (UTIITSL) to process their reimbursements have been a complete failure. This pushed the empanelled hospitals to a state of un-sustainability, forcing them to refuse beneficiaries.
It is not clear what the former labour minister (independent) Bandaru Dattetreya did to resolve their issues.
Improper costing:
ESI is a government health insurance scheme, under which beneficiaries receive cashless health care from empanelled private hospitals and which are reimbursed by the government as per documented agreement.
They blamed improper empanelment and costing procedures adopted by ESI for the mess. The current ESI costing is based as per Central Government Health Scheme (CGHS) but it is completely an unscientific model.
In fact, none of us in the country, including the government have authentic data on costing of medical procedures. The rates for medical procedures by ESI are fixed by calling tenders from hospitals & nursing homes having 50-beds and above.
The tender conditions are same, irrespective of category of hospitals with no prior verification done, whether the hospitals, submitting tenders comply with minimum patient safety protocols or whether they have the facilities competence to carry out the quoted procedures.
The lowest quoted rates are fixed as industry standard and applied for all including the tertiary care super-specialist hospitals. In the process, many rates come out to be highly illogical and unviable. It amounts to compromising with the safety of patients more so when studies have shown that millions of patients were losing life globally as well as in India, due to absence of safety protocols in hospitals.
Patient safety goes for a toss:
World over, quality and patient safety in healthcare is driven either through regulation. ESI being government run scheme, it should be imperative that patient safety must be key consideration while empanelling of hospitals. ESI as a rule should not empanel any hospital unless it has been verified based on established minimum criteria on patient safety.
ESI should make it as mandatory criteria before empanelment of hospitals. Even IRDA has made it mandatory for hospitals to have NABH Entry Level certification before these could be empanelled by insurance companies but they are not followed.
Unauthorised deductions:
Over the years, ESI has been unilaterally deducting bills of empanelled hospitals without rhyme or reason.
Worse, they have the most unworkable rates and heavy deductions that resulted in revenue losses. Now, a situation has arisen that empanelled hospitals have no other option than to stop taking ESI patients on cashless services, lest hospitals would have to close down permanently.
It is time that the union ministry of health and family welfare (MOHFW) takes cognizance of the problems in consultation with stake holders i.e. providers and beneficiaries and come out with long lasting solution.
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List of ESI Hospitals
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