The Golden Card People

Despite the internet blockade, Jammu and Kashmir has utilized the golden card under Ayushman Bharat scheme to the best possible level: 11000 procedures for Rs 23 crores in one year. Now the society is exhibiting a huge card surge, reports Saima Bhat

SKIMS, Soura, Srinagar

On August 5, the parliament unilaterally scrapped the special status of Jammu and Kashmir State and downgraded it to two union territories. Immediate, Kashmir was under a clampdown freezing all forms of communication. The only people seen on roads were mostly patients and their attendants who could dare to come out of their homes because they had no second option. It was in that period, a rare protest inside one of Srinagar’s private hospitals took place. It was not reported as nobody knew about it. They were protesting for the revival of Ayushman Bharat Golden Card, the only source of their life!

Muhammad Yaseen, 62, was diagnosed with chronic kidney failure in 2017 and his doctor put him immediately on dialysis.

Yaseen, an artist by profession, is living in his modest home in downtown Srinagar with his wife and two daughters. “I was not shattered by the news of having kidney failure but by the burden of financial expenses that my treatment would cost,” Yaseen said. “We live in a hand-to-mouth situation and never desired more from our lives. This disease broke the backbone of my family.”

Yaseen was in dilemma, caught between his desire for treating his disease and retaining his modest savings for his daughters’ future.

It was at the peak of that crisis that one of his neighbors informed him about an NGO where poor patients were provided dialysis at minimum costs. “Some of the medicines are low cost but doctors sometimes put me on iron injections and it costs more than Rs1000,” said Yaseen, who has to undergo dialysis twice a week. He tried to visit a government run hospital but was provided with a date after a month. His doctor was suggestive of starting it as soon as possible after his medical reports showed the emergency. Two sessions of dialysis per week would cost him around Rs 2000.

One fine day, in the summer of 2018, an angarwardi worker visited Yaseen and gave him a number asking to visit a nearest Khidmat centre, a quasi-government help desk, to get an Ayushman golden card for Rs 30. Or with this number, he could visit the nearest government hospital and get his golden card issued without any cost.  He did so but didn’t know how this card was going to help him.

While having his treatment in November, Yaseen saw a few fellow patients with the same golden card and he got curious to know its use. He was informed the card helps them in getting treatment at any hospital of their choice without any payment and instead the government pays their bills.

The Ayushman Bharat golden card was launched by the government of India under Pradhan Mantri Jan Arogya Yojana (PMJAY), in November 2018. This scheme has its roots in the UN resolution of ‘Right to Health’ in 2010. According to this resolution, there should be universal health coverage in every country. And after around 13 deliberations, in 2014, sustainable development groups (SDGs) were formed and in 2018 the Government of India also adopted it and branded it Ayushman Bharat Yojana.

This scheme under national health mission was launched at central as well as state levels under national health authority (NHA) and state health agencies (SHA) respectively. Under this scheme, a family gets an insurance cover of Rs 5 lakh per year on floater basis, sharing between family members.

The card, a cashless and paperless scheme, is available only in empanelled hospitals including public as well as private hospitals across India except for some corporate hospitals. But presently it can be availed by people living in rural areas and in urban areas; it is limited to socio-economic castes, as per the data base of census 2011.

In Jammu and Kashmir, the set target was 6.13 lakh families. “We are getting many people who fall under such categories but have not been issued these cards,” said an official working with the scheme in J&K. “We cannot help them because the state office is not authorised to give these cards. We can add or delete members only.” The service is available for indoor hospital services only and not for outdoor patients department in hospitals.

In J&K, all public hospitals, community centres, government hospitals are supposed to provide services under this scheme including a few private hospitals, who have been authorised by the SHA.

“The private hospitals having multi-speciality and most importantly 10 bedded facility are empanelled after proper inspection,” said Dr Wasim Akram, nodal officer of Ayushman Bharat Yojana in J&K. “Khyber Hospital, Florence Hospital, Noora Hospital, Ahmad’s Hospital, Kidney Hospitals and around seven dialysis centres are presently working with us in Srinagar district alone to provide treatment to the beneficiaries. They are all empanelled.”

Dr Wasim informed that a few private hospitals, who are exclusively dealing with gynaecology and obstetrics, have not applied for empanelment because they believe the fixed rates for surgeries under this scheme are too low. Besides, the scheme permits a caesarean delivery at a private hospital only if a government hospital refers to the cardholder to them.

The card is quite popular with people. Till November 2019, around 49,175 beneficiaries – 36006 from Kashmir and Ladakh divisions and 13169 from Jammu, have availed this scheme with more than 11000 admissions. And, up to 162 patients also went to hospitals in Pathankot, Amritsar, Chandigarh, Delhi and Rishikesh for treatment.

In the first six months of launching the scheme, the officials claim J&K was figuring among the top states for having 12.63 lakh individuals as gold card beneficiaries.

As on December 01, 2019, Rs 23.3219 crore stands spent in Jammu and Kashmir from 139 centres including Rs 15.1372 crore in Kashmir (including Ladakh) and Rs 8.1847 crore in Jammu division. Around 38,368 claims, worth Rs 19.7 crore have been cleared, till date. Popular procedures under the scheme in J&K are dialysis, gall bladder removal, breathing disorders, kidney failure, cancer care, cardiac stenting, and total hip replacement.

In the post-August 5 situation, however, when the internet was suspended in Jammu and Kashmir and continues to be blocked, this internet-driven scheme stopped working.

“It became impossible to update the servers and when we couldn’t do it, it meant that we have to suspend this scheme,” said Shahnawaz, the hospital administrator at Khyber hospital.

Left in the lurch, the attendants of the patients held a protest for the restoration of this scheme and the officials were moved to get in touch with their insurance company, Bajaj Alliance. They got a separate internet connection so that the client hospitals would update their database of the patients twice a week from a set location, which was otherwise done on daily basis by the hospitals from their own premises.

Khyber Medical Institute, Khayam Srinagar.
Khyber Medical Institute, Khayam Srinagar.

But after the hospitals were given access to the internet from the insurance company, Shahnawaz said for August they are paying back their patients who had to pay from their pockets.

“Internet is still not functioning in public and private hospitals. We have to either courier documents of claims after speaking for pre-authorisation with the insurance company on phone or physically come and submit papers. All of this takes at least a week’s time,” said Shahnawaz.

Mahroz Begum, a resident of rural Pulwama, a golden card beneficiary developed cardiac ailment and her family quickly shifted her to Khyber hospital in Srinagar for specialised treatment. She had to undergo pulmonary resynchronisation therapy and luckily same day there was a workshop going on in the hospital in which a few international doctors were participating.

Mahroz said she was operated by a German cardiac surgeon. Her treatment cost Rs 4.90 lakhs. She said she did not pay a single penny in the hospital. Instead, her attendant was requested to fill up a form and the payment was made automatically and she was discharged.

At almost the same time, a lady from Ladakh was admitted in AIIMS in Delhi for a brain tumour. The estimated cost for her surgery was Rs 5.30 lakhs but the officials at SHA said they negotiated for Rs 30000 and Rs 5 lakhs was paid through the golden card.

Dr Akram says that many private and a few corporate hospitals in India were not happy with the rates set under health benefit package-I developed by NHA but the deliberations went on successfully for the implementation of health benefits package II, after which he is hopeful that many corporate hospitals will get empanelled including TATA, providing specialised treatment for cancer patients.

The scheme has costs attached to the diseases and their treatment. These are fixed and unchangeable.

The present rate for surgeries was decided by the leading team of doctors from the World Health Organisation (WHO), private doctors and hospital administrators. “These rates are more than central government health scheme (CGHS) rates,” said Dr Akram. “I can say they are cost-effective packages.” All diseases, however, are not covered under the scheme. Cosmetic surgeries, immunisation, family planning, drug de-addiction and treatment for some rare diseases are not included under the scheme.

For celebrating the success of this scheme on its first anniversary, Dr Rashid Para, former medical superintendent of district hospital (DH) Pulwama, said he was invited to the event where his hospital was awarded for best achievements under public institutions.

Para said this scheme has empowered people to avail health benefits at better hospitals and has set hospitals in a competition mode. This, he said, improve medical care.

In DH Pulwama, around 550 beneficiaries have availed the facility getting around 28 lakhs to the hospital kitty when the set target for this district was Rs 88000 only. They have covered around 46000 beneficiaries. “This amount was an additional resource to the hospital which we used for the development and better infrastructure of the hospital so that our hospital could compete with the private hospitals in the region,” said Dr Para.

The Khyber Hospital in Srinagar, which is now one of the leading private hospitals in north India under this scheme, claims that they have treated more than 6000 cardholders which fetched them a revenue of around Rs 2.5 crore.

The hospital records, a copy of which lies with Kashmir Life, shows treatment cost in one case of cardiac management as Rs 62871 but Ayushman Bharat paid only Rs 27000. In another angioplasty surgery, the cost of his treatment was Rs 13,1209 but the scheme paid them only 90,000.

“We have agreed for this scheme under our CSR project otherwise the rates of surgeries put under Ayushman do not fit with our specialised services,” said Shahnawaz Ahmad, the hospital administrator. “Before this scheme, we used to give free dialysis to 109 patients per month and I was allowed to give chemotherapy equivalent to Rs 5000 per day to cancer patients by the Khyber Hospital Trust.” Part of this load that the hospital was doing on its own is now being managed through cards.

Noora Hospital, Umarabad HMT Srinagar.
Noora Hospital, Umarabad HMT Srinagar.

Dr Showkat Shah, the head of emergency services at Khyber Hospital informed that the scheme has benefitted many people including the dialysis and cancer patients. “We are witness how poor people suffer under the burden of costly and continuous treatments under dialysis and cancer diseases,” he said. “We are getting card beneficiaries from every corner of Kashmir including areas near the LoC.”

Before the communication lockdown, Dr Shah had raised the issue of providing free drugs to cancer patients on social networking sites getting the higher health officials across India in the loop and was expecting a change on the ground. For lack of the service, the project is in induced dormancy.

For the smooth functioning of this scheme, two units are working – the national anti-fraud unit (NAFU) and the state anti-fraud unit (SAFU) to check if somebody at some level is resorting to fraud.

“It is an IT-based scheme which means fraud can happen but we work at two levels, at beneficiary identification system and Transaction management system (TMS), so that there is no fraud at all,” said Dr Akram. “It is a two-tier system that minimises chances of fraud.”

But he accepts in district Budgam, one hospital was fined with a penalty of Rs 19 lakhs as their operator had developed 3 to 5 cards illegally. Those cards were instantly cancelled. Dr Akram said in entire India, J&K is the only place where there are no fake golden cards.

Yaseen, meanwhile, is taking dialysis from Khyber hospital. “If this card would not have been there, I would have stopped my treatment after August 5 when I could not earn a single penny.”

(All the names of the patients have been changed on their request.)


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