Sehat Sahulat Programme: Misuse of facility in private sector curtails services

LAHORE : The Punjab government’s deadline for empanelled hospitals to acquire regular licences is set to expire on December 31, 2023, as well after it was forced to curtail services under Sehat Sahulat Programme / Universal Health Insurance in Punjab allegedly due to misuse of the facility in private sector.

Punjab Healthcare Commission (PHC), on the other hand, noted a considerable drop in number of empaneled hospitals applying for upgrade of provisional licences to regular ones after Health Card is stripped of a number of treatment services in private sector as well as introduction of co-payment as bulwark against any conflict of interest.

Out of the 318 empanelled hospitals in Punjab before new laid out criteria for hospitals to provide services under Sehat Sahulat Programme, PHC’s record till 20.12.2023 shows only 191 hospitals obtained regular licence for provision of treatment services under Health Card under the changed criteria.

It is learnt that, amid complaints of unnecessarily diverting of patients to private hospitals and labs, Punjab health authorities found conflict of interest in anomalies such as excessive caesarian section cases, implant of up to three stents instead of one, and use of substandard stents, unregistered ophthalmological lenses, low quality medicines. The untrained and junior doctors were engaged to perform complex procedures such as bypass surgeries.

The private hospitals recommended unnecessary tests and allegedly made counterfeit invoices by conducting small procedures and charging for bigger procedures. A private hospital performed 48 surgeries in a single day, while another private hospital submitted a bill of Rs900 million for the treatment provided to the patients.

Earlier, Punjab Health Initiative Management Company (PHIMC) had granted one month’s extension to empanelled hospitals only in cases of renal dialysis and life-threatening conditions till 31.12.2023 in line with the instructions pertaining to the de-empanelment of hospitals failing to obtain regular licences or qualify for regular licence. The previous cut-off date for de-empanelment of hospitals was set to 30.11.2023.

This exemption from regular licence/qualify for regular licence has also been given to empanelled hospitals, under the administrative control of Pakistan Atomic Energy Commission (PAEC), for the treatments related to oncology only.

In view of the long-term financial sustainability of Sehat Sahulat Programme Phase-III, the Standing Committee of the Cabinet on Universal Health Insurance (SCCUHI) implemented a 40% co-payment for all procedures being performed at private empanelled hospitals with effect from 15.09.2023, except oncology, dialysis, ICU / CCU / NlCU / HDU / Ventilator medical cases, thalassemia, orthopedics/neuro trauma cases only.

The exemption from co-payment will also be provided for all emergency and life-threatening cases as well as to the beneficiaries aged 65 years and above except for cardiology-related treatments.

The State Life Insurance Corporation (SLIC) is advised to take appropriate actions to ensure the smooth implementation of these interventions.

‘The practice of preferring patients’ treatment on Health Card has almost finished after reduction in share due to interventions like co-payment,’ a doctor at Punjab Institute of Cardiology (PIC), Lahore, where institutional private practice is implemented, informed.

PHIMC CEO Dr Ali Razzaque told The News that, under instructions from SHC&MED, PHIMC suspended Gynae/delivery cases and cataract surgeries in private empanelled hospitals after deluge of complaints regarding unnecessary C-section surgeries and usage of substandard lenses upon the patients.

He informed that those hospitals failing to obtain regular licences would de-empaneled beyond the cut-off date of December 31, 2023. ‘Thereafter, any claim made by the de-empanelled hospitals will not be a valid charge against funding provided by PHIMC for UHI,’ he said.

He informed that PHIMC imposed 40 percent co-payment by the patients to discourage the misuse of the free treatment facility. ‘This co-payment will be made on PHIMC’s negotiated rates with the private hospitals,’ he said.

The SHC&MED had also formed of a six-member committee, headed by Prof Dr Asad Aslam (retd), Professor of Ophthalmology, KEMU, Lahore, on 28.08.2023 to examine the matter of reported usage of low quality lenses in cataract procedures at selected empanelled private sector hospitals.

The committee, supposed to furnish its recommendations within 10 days, failed to make any headway. ‘The committee sought specific details from all relevant stakeholders but haven’t yet provided those details,’ Prof Asad Aslam told The News.

Caretaker Punjab Minister for SHC&ME Prof Dr Javed Akram had claimed that a ‘mafia’ had taken advantage of the situation in the absence of any specific criteria for deserving patients. ‘As a result, each enlisted private hospital submitted bills amounting to hundreds of millions of rupees,’ he claimed.

While caretaker minister claimed a ‘mafia’ has made billions through misuse of Health Card facility, the Punjab government failed to nab any gang or exposed the and doctors involved in such unethical practices. The minister, however, said that the Computerised National Identity Cards (CNICs), replacing Health Card, would help ward off malpractices in discharge of services under health insurance scheme.

‘The government must apprehend the ‘mafia’ involved in the misuse of public welfare scheme such as Sehat Sahulat Programme instead of curtailing its services,’ said Dr Shahid Malik, General Secretary, PMA, Lahore.

He demanded the govt expose conflict of interest of doctors involved in such malpractices.

The Punjab government has also started collecting premium contribution from all government employees, who are permanent residents of Punjab, by at source deduction of family-based premium, of Rs4,350 per family per year or Rs362.5 per family per month in order to ensure long-term financial sustainability of the Sehat Sahulat Programme/Universal Health Insurance in Punjab.

It is learnt that, due to these corrective measures, the monthly earning of Punjab’s teaching hospitals from Health Cards considerably dropped despite payment of premium for scheduled procedures. The SHC&MED statistics revealed that the Health Card claims in teaching hospitals could not exceed Rs1.5 billion per month, thus showing a monthly loss of Rs1 billion.

The medical claims on Health Card for the month of November 2023 stood at Rs1.5 billion increasing from Rs1.33 billion insurance claims for the month of June 2023. However, this increase in revenue has more to do with inflationary trends than increase in number of procedures.

A total of 246,000 patients were admitted in indoor wards in November 2023 in comparison to 286,000 patients admitted in July 2023.

Out of the 40,000 surgeries performed in November 2023, only 12,000 were performed on the health card. Out of 10,000 maternity cases, 2,700 C-section and 2,000 normal deliveries were performed on health cards. Similarly, out of 4,800 angiography procedures done in government hospitals, around 3,300 were done on health cards.

The hospitals under the administrative control of P&SHD have shown three times increase in claims from Rs250 million to Rs1 billion in five months as compared to Rs200 million increase registered by hospitals under SHC&MED’s administrative control during the same period. ‘As public sector hospitals at primary, secondary and tertiary care levels failed to achieve collective annual target of Rs40 billion revenue generation despite premium payment, the government has to pump in more funds to meet the hospitals’ deficit,’ confided an SHC&MED official to The News.

While Khyber-Pakhtunkhwa government has conducted performance audit of Sehat Card Plus for eight-month period from November 2020 to June 2021, neither PML-N and PTI governments conducted audit of Sehat Sahulat Programme nor the incumbent caretaker government took this initiative despite pointing out so many blunders in the programme.