Morning MEDtalks with Dr KK Aggarwal 9th July 2018

Ayushman Bharat: Will cross subsidy be the answer?

Ayushman Bharat is National Health Protection Scheme by the government for 40 crore people who are from BPL or EWS category. These otherwise either are non-insured or were covered in the previous RSBY scheme.

The rates provided for LSCS (caesarean section) are 9000/-.

The medical profession says our cost is 57000/-

Then what is the answer. Will cross subsidy be the answer?

Cross subsidization is the practice of charging higher prices to one group of consumers to subsidize lower prices for another group.

Suppose Mr X goes to dinner with two of his friends Y and Z. X’s meal costs 100/-, Y’s meal costs 200/- and z’s meal costs 300/-. The total bill is then 600/- and everyone decides to split the bill evenly, for 200/- each. X’s meal is under costed. Z’s cross-subsidizes Alex for 100/-. Y is neither cross-subsidized nor cross-subsidizes anyone else.

TN-IMA has shown that the real cost of a caesarean in private sector is 57515/- (say 57000 for calculations) for 50 bedded hospital with 50% occupancy. The rates will be lower if the occupancy is 90%.

In Ayushman Bharat the government proposes to pay 9000/- for basic hospital (10% extra can be given by states, 10% extra for entry level NABH, 15% extra for NABH accredited and 10% extra for DNB- MD teaching hospitals, setups in rural areas 10% extra).

Even if it comes to 12000, the establishment will have to provide a subsidy of 45000/- Rs.

How will the establishment cover the cost?

Ayushman Bharat covers 40% of the population

1. The government should give 40% concession in taxes to such establishments (property tax, income tax, service tax, land at concessional rates where applicable etc)
2. All hospitals who are given concessional lands instead of free services can be asked to register under the Ayushman Bharat
3. Or the rich must provide the cross-subsidy to the poor. The package rates of the rest 60% should be higher than the derived prise. CGHS, PSU and insurance rates needs to be revised accordingly.

Typically, a hospital run in three tier system: single room (fully private), three bedded shared (semi private) and general economy ward. Cost of a procedure is 100 Rs for private, 60 Rs for semi private and 30% for the general ward. 10-20% of the beds are reserved for the general ward.

CGHS rates are applicable to the single room also. Even the ministers will be charged the same rates. The charges for BPL or ESW thus has to be lower than that.

Note: The above is just one example and a concept. The actual prises will vary with the average cost derived when all procedures are included.

For example, The Centre has included 1,354 packages in which treatment for coronary bypass, knee replacements and stenting, among others, would be provided at 15-20% cheaper rates than the Central Government Health Scheme. Stenting at Rs 40,000, coronary artery bypass grafting at Rs 1.10 lakh, vertebral angioplasty with single stent at Rs 50,000.

Some of the other rates are Knee and hip replacements Rs 9,000 each, caesarean delivery at Rs 9,000 and hysterectomy for cancer at 50,000.

There is no rationalisation of the rates. Cardiology reimbursement and caesarean reimbursement are not rational.

Dengue epidemic in SHIMLA and CUTTAK

With the onset of monsoon season, the hill state of Himachal Pradesh is witnessing the rise in a number of dengue cases (96 confirmed cases) with most of the cases being reported from Bilaspur district.

Cuttak: Dengue 46 confirmed patients are coming to SCB from Jajpur, Kendrapara, Bhadrak, Balasore, Keonjhar, Nayagarh, Khurda, Cuttack and Puri districts.

Salt reduction

Dietary sodium reduction can lower BP in both hypertensive and normotensive individuals, prevent hypertension, and enhance the BP response to most antihypertensive therapies. The

extent of BP reduction because of reduced sodium intake is greater in blacks, middle- and older-aged persons, individuals with hypertension, and, likely, patients with diabetes or kidney disease.

In hypertensive individuals reduce dietary sodium intake to <2.3 g of sodium or 6 g of salt /day (lower the better). In persons without hypertension also reduce dietary sodium intake to the same level with the goal of preventing hypertension and decreasing the risk of stroke and other cardiovascular events

Disease to know

Kyasanur forest disease is characterized by fever, headache, GI symptoms and bleeding. It is transmitted by ticks or contact with infected animals (incubation period 3-8 days). Infection is endemic in India.

The disease is caused by a virus belonging to the family Flaviviridae, which also includes yellow fever and dengue fever. The disease was first reported from Kyasanur Forest of Karnataka in March 1957. The disease first manifested as an epizootic outbreak among monkeys killing several of them in the year 1957. Hence the disease is also locally known as monkey disease or monkey fever. The disease has shown its presence in the adjacent states of Karnataka including Kerala, Maharashtra, Goa, Tamil Nadu and Gujarat

Latent TB: CHOOSING BETWEEN TST AND IGRA

There are two major tests for identification of latent tuberculosis infection (LTBI): the tuberculin skin test (TST) and the interferon-gamma release assay (IGRA) blood test. Both evaluate cell-mediated immunity.

For patients with low-to-intermediate risk of progression to active disease or patients with a history of BCG vaccine in childhood, the IGRA is preferred over TST.

TST is acceptable in individuals with high risk of progression to active disease.

A dual testing strategy (perform one test and, if negative, perform the other) may be used, in which a positive result from either test would be considered positive.

Use of IGRA as a confirmatory test for TST has been shown to be effective in contact tracing.

TB index case (GTN- GeneExpert for all, trace and treat early, and notify all)

WHO estimates that, worldwide, highly infectious, smear-positive pulmonary TB develops in over 4 million people annually (2.8 million in India).

If we assume that each of these patients has at least three close contacts, such as in their household, and that the prevalence of active TB among the close contacts is 2.5%, the number of early TB cases that could be identified among close contacts is at least 300 000 per year (210000 per year in India).

How to handle Index MDR and XDR TB cases

Atlanta attorney Andrew Speakers case has started the debate on the role of compulsory isolation and quarantine in TB control.

In May, after being diagnosed with a drug-resistant TB he flew to Europe for his wedding. While he was there, lab test at CDC indicated that he was suffering from XDR- TB.

CDC contacted and asked him to stay in Italy. Fearing isolation in an Italian hospital, he flew to Prague and then Montreal, bypassing his inclusion on the federal no-fly list, which doesnt apply to flights outside the United States. In Montreal he rented a car; then he drove into the United States.

Weeks later, while he was being treated at the National Jewish Medical and Research Center in Denver, laboratory tests revealed that he did not have XDR tuberculosis but instead had multidrug-resistant (MDR) tuberculosis. MDR tuberculosis is resistant to the first-line drugs isoniazid and rifampin. XDR tuberculosis is also resistant to a quinolone and to an injectable second-line drug.

Speakers case provoked a flurry of media attention and public outrage.

1. MDR and XDR TB are a threaten the nation.
2. These patients must be put on isolation and quarantine.
3. Isolation applies to someone who is known to be contagious, and quarantine applies to not-yet-ill people who or goods that may have been exposed to a disease.
4. Isolation and quarantine may be voluntary or compelled by law.
5. TB is more commonly addressed by isolation than by quarantine
6. Both the states and the central government have the authority, in appropriate cases, to compel isolation and quarantine.
7. TB and influenza with pandemic potential are among the listed diseases.
8. Patients who are isolated by law have right to counsel and a hearing before an independent decision maker.
9. In TB courts have upheld detention when a patient has failed to follow medical advice.
10. During the 1990s TB epidemic, New York City did not rely only on isolation orders; it increased funding for TB control and directly observed therapy. Courts have pointed to the failure of particular patient to comply with directly observed therapy as a justification for detention.

Suggestions

1. MDR and XDR should be isolated (voluntary) till they are non-infective on directly observed drugs.
2. MDR and XDR should be isolated (legally) if they deny treatment.
3. Rs 500 per month is given to all TB patients for nutrition. All XDR and MDR patients should be paid extra to cover the loss of wages during the period they become non-infective.
4. Rs 1000 is given to doctors for completing a TB treatment case and Rs 10,000 should be given after fully treating an XDR or MDR case.
5. Each XDR and MDR patient should be treated as an index case and mandatory testing of contacts should be done
6. Open MDR and XDR patients should not be allowed to travel by public transport or visit public places till they are negative.
7. MDR and XDR TB cases should be given job immunity. Like HIV AIDS such cases should not be discriminated in the jobs
8. Newer MDR/ XDR drugs should be introduced in the country at the earliest.
9. There should be designated centres in the country to treat MDR and XDR TB cases
10. Admissions, all investigations and all related treatments costs should be borne by the government

Participate in the survey on inflammatory bowel disease: https://docs.google.com/forms/d/e/1FAIpQLSedaDx2iXiwU1vBpYdU6ebfCap-7PYAPSqXRJTeg8ULvNOcLg/viewform

Dr KK Aggarwal

Padma Shri Awardee

President HCFI

Vice President CMAAO