Can the Govt. force hospitals & doctors to comply with the price capping under the Ayushman Bharat National Health Protection Scheme?


Dr KK Aggarwal    28 June 2018

When we talk of affordable health care, we need to have value for money for both masses as well as classes. The economically weaker section of the society or BPL with more than 40 categories are today deprived of secondary and tertiary health care.


Without insurance, it is not possible for a citizen to afford secondary and/or tertiary health care. Workers drawing a salary of up to Rs 21,000/- a month are mandatorily covered under ESI. Those who have a salary of more than Rs 21,000/- should pay the private insurance premium on their own. Then there is a subgroup of people in this income bracket, the EWS and BPL, who cannot even afford any insurance premium.


The responsibility falls on the state to provide health care to all under Article 21, “No person shall be deprived of his life or personal liberty except according to procedure established by law”.


The Ayushman Bharat National Health Protection Scheme, therefore, can be a way to bridge this gap. The scheme principally targets the poorest and the vulnerable sections of the society. It will cover more than 10 crore poor and vulnerable families (approximately 50 crore beneficiaries) providing coverage upto 5 lakh rupees per family per year for secondary and tertiary care hospitalization with no restriction of family size. This coverage of Rs 5 lakh for the whole family for the economically backward patient may be sufficient in 80-90% cases.


The experience of the National insurance companies has been that reimbursement has been more than the total premium collected, so they were forced to bring in TPA to cap the prices of reimbursement which has been practically accepted by the medical establishment.


The Govt has fixed the pricing for 1,354 treatment packages under the Ayushman Bharat National Health Protection Scheme. More than 20 specialties like cardiology, cancer care, neurosurgery and neonatal care have been covered under the scheme depending on the type of therapeutic category and procedure. These package rates include all the costs associated with treatment i.e. the govt. has capped the total money required for the treatment.


Without invoking the Essential Commodities Act, the govt. cannot cap the prices but they can cap the prices for enrolling the medical establishment under their loop or at the most, the govt. can provide the list of hospitals as preferred hospitals as is the prevailing practice in third party reimbursements.


Participating in the scheme is voluntary; the hospital may or may not choose to join. Success of the scheme will depend on how many will enroll in the scheme. If the participation is poor, the govt. will be forced to revise the reimbursement charges. But, if the scheme gets off successfully, then the govt. may continue with the present reimbursement rates.


But everybody needs to work with the govt. and not compare the rates of the Ayushman Bharat National Health Protection Scheme with those of CGHS, PSUs, TPAs as they are not meant for the EWS/BPL patients but for rich patients.


Charity has to be at the cost of the rich. Therefore, the govt. may consider subsidizing the cost of poor by way of subsidizing package in Ayushman Bharat National Health Protection Scheme by revisiting the rates of package for non Ayushman Bharat subsidized people who are not in the income bracket of this scheme.



Dr KK Aggarwal

Padma Shri Awardee

Vice President CMAAO

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

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