Lack of awareness around the Ayushman Bharat Arogya Karnataka (ABArK) scheme blocks eligible claims.
In the waiting room of Vydehi Hospital, Basavaraj, a farmer from Raichur is waiting for the receptionist to call him for a follow up checkup. The ABArk scheme has put a smile on his face as it helped him cover for his kidney treatment. He was able to save Rs. 45,000 through it. However, he was not aware of his eligibility for the scheme until the doctors informed him.
“I have a Below Poverty Line (BPL) card, which makes me eligible for ABArK. I initially came to Vydehi Hospital for treatment and the doctor asked me if I was eligible for the scheme.Then he suggested that I should go to a government hospital for the approval letter to claim the benefits of the Arogya Karnataka scheme,” he said.
Various studies show that awareness is low and there is a poor response to government health insurance policies stated Srinivas P.K., advisor, Ayushman Bharat Arogya Karnataka. He said, “The uptake of membership drive is very poor, and people are not coming forward. In the Arogya Karnataka scheme, even Above Poverty Line (APL) families were included, which is not the case in other states.”
He added that the new health programme is a step in the right direction and Karnataka is ahead of other states.
“An Accredited Social Health Activist (ASHA) worker told me about the scheme,” said Serigappa another patient from Raichur. He also received financial help and medical care under this scheme for his son’s chemotherapy.
Minakshi Kamath, an APL citizen, Karnataka said that her family has private health insurance and didn’t know that they were eligible for the ABArK scheme.
The scheme is available in 3,547 empanelled hospitals. Srinivas PK said that the patients go to government hospitals and get themselves checked. Now, if this procedure is unavailable in a government facility then they can take a recommendation letter and go to the empanelled hospitals for the required procedure.
Empanelled hospitals fulfill the minimum prescribed medical standards and are thereby tied up as network hospitals by the insurer. There are certain requirements to apply for the scheme – the patient should be a resident of Karnataka, an Aadhar card holder with a BPL card. This makes them 100 per cent eligible for the medical procedure.
A study by Clinical Epidemiology and Global Health on the Ayushman Bharat-Arogya Karnataka Health Scheme (ABArK) states that the utilization of this scheme requires further improvement by creating more awareness among the public. This would help in reducing the out-of-pocket expenditures and burden of accessing healthcare facilities states the study.
Srinivas further added that the older health insurance scheme, the Yeshaswini scheme, had an upper limit of Rs. 2 lakhs for a family, but with the new scheme, the upper limit is now Rs. 5 lakh for a family. If the claim crosses Rs. 5 lakh, then the patients need to pay the remaining amount out of their pockets. The government extends the credit line for APL members to an extra Rs.50, 000, which makes it up to Rs.2 lakh, if needed.
Scheme drawbacks
Ratheesh Adukkadukkath, administrative officer at the Santosh hospital, Bengaluru said that the private hospitals only accept BPL patients and have an upper limit of upto Rs. 1.5 lakh for the ABArK scheme. Of the cases that they get under emergency, the upper limit of Rs. 5 lakh is only acceptable for Intensive Care Unit (ICU) patients.
Ratheesh added that the hospital follows all the treatment procedures given by the government. However, the number of people turning up under the scheme is low. If some patients don’t know about the procedure, they are guided to the government institutions to get a referral by the hospital staff.
Nitin Manjunath, facility director, Narayana Hrudayalaya Hospital, said that they see 50-100 patients each day, usually for heart surgery. The operations had a waiting list, and BPL patients are given priority.
He added that APL patients do not use Arogya Karnataka because of the basic amenities they get under the scheme—general rooms are not to their satisfaction while private rooms are not covered by Arogya Karnataka. As a result, most APL patients choose a private health insurer over a government one. The government will pay a specific amount for each medical operation.
Nitin said that the scheme is loss-making for private hospitals. Therefore, they have asked the government to increase the amount granted for various medical procedures.
He added that during the first and second waves of COVID, the government set the rates for various services, such as the ICU at Rs. 10,000 and ventilator at Rs. 15,000 per day. They had roughly 600 patients in the hospital at its peak, which was a significant loss for the hospitals as they earned less for the services that they performed.
“Many patients come to the hospital without BPL or ABArK cards, and there is a dedicated counter to assist them in enrolling in the system. I believe that the lack of knowledge is a key issue with the Arogya Karnataka plan. But it is a new scheme and I expect more people to enrol in the future,” Nitin said.
According to Vamsi Krishna, co-lead of health Financing and UHC cluster at IPH (Institute of Public Health), a health non-governmental organisation (NGO), the hospitals which are under Arogya Karnataka are not aware that they are empanelled hospitals in the first place to guide the patients through the process of Memorandum of Understanding (MoU) with executive level. They also found that seven out of ten people don’t know they are empanelled with Arogya Karnataka.
“The main drawback is that patients must first visit a government hospital to acquire a referral to a private empanelled hospital. Secondly, the patients at the APL level must be aware of the programme. Hospitals might be up to 100 kilometres away from the patient’s home. Some of the services provided by hospitals are also denied. Patients may go to the nearest hospital while they are at home, and that hospital will not state it is non-empanelled since they do not want to lose consumers, and patients must pay for it out of their wallets,” he said.
Kutumba ID
An APL member who doesn’t possess an APL card should be a member of the Kutumba– and Entitlement Management System. Kutumba is an Integrated Social Information System which consists of a social registry, integrated beneficiary management systems, beneficiary registry, payment platform and a grievance redressal system.
After being referred to the Kutumba services portal, residents can log into the Kutumba website and apply online for a Kutumba ID. When applying for the Kutumba ID, citizens must complete a few processes. They must log in using their Aadhar OTP and submit their information, including the details of all family members. They must also choose a member as a Single Point of Contact (SPOC), and upon final submission, they will get a temporary Kutumba ID. Srinivas said that there are around 1.6 crore families already enrolled in Kutumba.
In Karnataka, Kutumba ID is the sole identity for resident families. This database acts as a centralised repository used by departments to evaluate applicants’ eligibility and grant benefits. Citizens communicate with the government via online and offline means on regular basis. They are required to fill out forms and upload documents, which are then manually screened by government officials. Furthermore, residents must repeatedly submit the same paperwork to different offices to receive other services.
Scheme Popularisation
Krishna further said that the solutions to these problems are primarily hospitals retaining boards outside, even though they are not affiliated with the Arogya Karnataka scheme. He also stated that hospitals must promote the health insurance programme for citizens to find it beneficial.
“Illiterate people who can’t afford the health care are the primary beneficiaries of the scheme who are not able to get the benefits as they don’t know how to avail the scheme. In terms of health insurance, it is a step in the right direction,” he said.
Dr Ravi Babu, Chief Administration Officer (CAO), at Vydehi Hospital, Bangalore, said that the problem of the ABArk particularly persists in rural areas because the claims are much lesser in those areas.
“People are still using all the old insurance schemes, particularly the Yeshashwini scheme, which is popular in the rural areas of Karnataka. As of now, we are guiding people to change their health insurance scheme from the old one to ABArk before doing any procedure. This is because the government still has not figured out how to convert most of the population to ABArk, and getting an ABArk card is not difficult. One can apply online for the scheme but the targeted citizens are not educated so they need guidance,” he added.
The government entities like Primary Healthcare Centres (PHCs) and ASHA are also working towards popularizing this scheme and making people aware of the benefits. Ramakrishna a representative of HakkiPikki, a local tribe of Karnataka said that the health department went to their area and asked them to enrol into the Arogya Karnataka scheme. He added that some of them have faced difficulty enrolling into the scheme but ASHA workers helped them get enrolled.
Vasudev Reddy, insurance coordinator, Vydehi hospital said that they get 700-1000 patients annually in their hospital under the Arogya Karnataka scheme.
He added that in Arogya Karnataka, non-emergency procedures called 2p and 3a require a recommendation from a government hospital. According to the procedural code (Ayushman Bharat benefit package) for private hospitals, patients must submit reports after the treatment. The average transaction for a patient is Rs. 50,000, and the money is issued based on the medical treatment. If a patient had an accident, he can be directly admitted to the ICU without government referral.
“We treat the patients and upload their reports on the website of the Suvarna Arogya Suraksha Trust (SAST). Following the release of patients, the approval procedure takes time. The funds are released in bulk all at once. Family members will have different cards, but they will be able to claim the insurance on the same card. The government will cover 30 per cent of APL patients’ expenditures, with the remaining costs handled by the patients,” he added.
However, a study shows that a total of 1367 COVID-19 cases were admitted during the last two years in Karnataka and 714 patients utilised the scheme. Moreover, the majority of the patients who were eligible for the scheme were from Karnataka, accounting for 93.92 per cent of the total patients.
Under the Arogya Karnataka Yojana, the state government is already providing health care to 1.15 crore BPL families and 19 lakh APL families bringing the total to 1.34 crore families.
Ayushman Bharat Pradhan Mantri Jan Arogya Yojana is a universal health coverage scheme and was implemented as the Arogya Karnataka Scheme in 2018. The number of PM-JAY eligible families as per SECC/RSBY data is 62, 09,073.
Under the scheme, out of the eligible families under the Ayushman Bharat–Arogya Karnataka Health Scheme, the central government will bear 60 per cent of the cost for 62 lakh RSBY (RashtriyaSwasthyaBima Yojana) families and 40 per cent will be borne by the state government. For the remaining 72 lakh families, the state government will bear 100 per cent of the total expenditure incurred.
