Is Tamil Nadu’s visionary health insurance scheme on track? 

Tamil Nadu’s Chief Minister’s Comprehensive Health Insurance Scheme had its origins in improving access to expensive treatments for the poor. But over the years, along with expansion, came troubles, and shifting priorities now prompt the question: Is it indeed running as per plan?

A State-funded health insurance scheme, rolled out 14 years ago, was revolutionary at the time. It was aimed at allowing people from the lower economic strata to access high-quality healthcare. Over the years, it brought more services under insurance cover, including transplants, funding immunosuppressants, artificial limbs, high-cost drugs, even investigations, making it the most comprehensive government health insurance in the country. That several thousands of patients have benefited from Tamil Nadu’s Chief Minister’s Comprehensive Health Insurance Scheme (CMCHIS) is indisputable. But its implementation, critics say, is diluted in more than one way, putting both government doctors and patients on a spot.

Driven by over-dependence on the scheme-generated funds, government hospitals and their healthcare providers are facing a plethora of issues: targets and periodic performance reviews; pressure to bring more cases under CMCHIS; patients made to run from pillar to post to get enrolled in the scheme; denial of or delays in treatment to non-cardholders; and numerous challenges in getting approval for claims. It was in July 2009 that the government introduced Kalaignar Kapitu Thittam to ensure that the poor and low-income groups get free treatment at private and government hospitals for serious ailments. Today, 1.47 crore families are covered under CMCHIS, and a little over 1.30 crore persons have benefited so far. But there are shortfalls in its implementation. Many government doctors have been questioning the way the scheme is being implemented. “CMCHIS certainly improved healthcare services at government hospitals. Consider this small example. A patient may need 10 doses of an antibiotic costing ₹700-₹800 each. Spending ₹7,000-₹8,000 on an antibiotic for one patient was unimaginable at a government set-up before CMCHIS. The same applies to orthopaedic implants, cardiac stents, cochlear implants and artificial limbs — all made possible because of CMCHIS. But there are certain issues that need to be ironed out,” said a doctor working at a government medical college hospital in central Tamil Nadu.

Hospitals becoming totally reliant on funds generated through CMCHIS and dwindling allotments through the Tamil Nadu Medical Services Corporation (TNMSC) seem to have precipitated the shift from the core objectives of the scheme. As the doctor pointed out, “This has resulted in forcing patients to get CMCHIS cards to even get treated at government hospitals.” A. Ramalingam, secretary of Service Doctors and Post Graduates Association, added, “CMCHIS was started for life-saving procedures and treatments at government hospitals. We, government doctors, accepted it enthusiastically for the benefit of patients as it facilitated the procurement of costly drugs and materials that were otherwise not available. But the scheme was slowly extended to other diseases, and doctors are being pressured to generate money through the scheme. Doctors are forced to act like agents with admitted patients.”

A government hospital doctor said, “On the one hand, doctors are reviewed every week for their ‘insurance performance’ and pressured to generate more money under CMCHIS. Patients are made to run from pillar to post to get their CMCHIS cards so that they can undergo elective surgeries, which were previously done free of cost at the same government hospital. On the other hand, we are seeing a lot of claims denied on flimsy and clerical grounds. ‘Uploaded after 48 hours’, ‘MRI to be prescribed only by a super-specialist’, ‘Seal not clearly visible’ are some of the reasons and the list is endless,” he summed up.

There are growing instances of patients, who are not enrolled under CMCHIS, being denied treatment or getting delayed treatment at government hospitals. A patient who was diagnosed with stage IV cancer and on palliative therapy was refused treatment because of issues in CMCHIS at a government hospital in Chennai. At another hospital, it took 25 days for a patient, who had a fibroid in the uterus with severe bleeding and anaemia corrected with transfusion, to get admission as she was not enrolled under CMCHIS. She had to return to her native district to get enrolled under the scheme.

“When a patient from a district is sent back to get enrolled under the scheme, it takes at least 10 days for the process to be completed as the village administrative officer needs to sign on the certificate. This is causing delays in initiating treatment,” a young doctor said. In another instance in Chennai, a woman with uterine prolapse was denied admission as she was not enrolled under CMCHIS. A staff member said the woman was later admitted for prolapse repair on the condition that she pay ₹10,000, the doctor said. Doctors recounted several other instances of patients being told to pay up for treatment. “I know two patients who had to pay ₹8,000 for orthopaedic implants at a top government hospital in Chennai,” said an assistant professor. Another surgeon said that while basic medicines are free, patients had to pay in some instances: “In orthopaedics, if surgery is needed, the implant is procured with the insurance money and not through TNMSC. So, if a person does not have coverage, he/she has to buy the implant costing ₹3,000 to ₹4,000...” according to the type of implant needed.”

A number of patients faced issues at private hospitals empanelled under CMCHIS as well. Doctors said there are instances of private hospitals refusing to admit patients because the insurance approval does not come through easily and even if approved, the amount is too low to cover the expenses. Eventually, patients have to pay the rest out of their pockets. Karpagam, 31, is from the Narikuravar community at Devarayaneri near Tiruchi. Her husband was undergoing treatment for kidney disease at private hospitals until he was advised to go in for a transplant. She was selected as the donor. “Once we enrolled in CMCHIS, we were told that only half the insurance amount due for the operation would be used, that too, after we got identity proof and other forms signed by local administration officials. It took us one-and-a-half months to get the signatures. We had to arrange the rest by taking loans,” she added.