Dr. Keiki R Mehta
Director, Mehta International Eye
Institute, Mumbai
Dr. SPS Grewal
Director, Grewal Eye Institute,
Chandigarh
Dr. Elenkumaran Pashupati
Director, Navshakthi Nethralaya,
Bengaluru
Dr. Krishnaprasad Kudlu
Director, Prasad Nethralaya,
Udipi, Karnataka
Medical insurance is inadequate and the coverage incomplete in India despite multiple government schemes to cover individuals, since most of these are aimed at those who have are economically disadvantaged. The majority of individuals above the poverty line still break into savings to meet healthcare expenses. However, the scenario is not as dismal as it was 2-3 decades ago and the concept of health insurance is catching steam. This is partly due to a shift in healthcare from the public to private domain and escalating costs of medical procedures. India, still continues to be among the countries with the most affordable healthcare, however, even these apparently low costs are prohibitive for many. Medical insurance has definitely helped the middle class afford better healthcare but this has come at a price for the healthcare sector itself. Statutory regulations and competition have made insurance companies keep low premiums (much lower than the west) and this has resulted in lower payouts to the healthcare providers. This was understandable a decade ago when insurance takers were few but with the high volumes now, there is a need for these payouts to increase. More so with insurance companies and third party administrators, mandating hospital accreditation prior to empanelment, the costs of healthcare delivery are going to go up. With regard to ophthalmology, this means a low payout for cataract surgery which is often a fraction of what an ophthalmologist would charge for the surgery from a patient paying cash. This means that despite the best effort, the
ophthalmologist cannot use the same high quality intraocular lens in a patient who is paying purely by insurance as against one who is paying from his pocket. The end result is either co-payments which are frowned upon or the use of a lower quality intraocular lens or choice of procedure. To take an example, if an ophthalmologist would charge
Rs. 35,000 for a phacoemulsification and implantation of an imported foldable hydrophobic blue blocking intraocular lens, and a patients’ insurance payout is only Rs. 24,000 (or even lesser), he can reduce his surgeon charges considerably (which is often the case) but still not provide the same intraocular lens, since the difference is just too much. These low insurance payouts are a result of collusion of many insurance companies together and with the regulatory authorities. Furthermore, the few private insurance firms outside this association, who do pay better for their patients are struggling to find takers due to higher premiums. In the western countries, where either the government funds the surgeries or insurance companies have complete payouts, this problem is not felt. It did take a stand on part of the ophthalmologists as a whole to get together and agree not to operate below a certain price, something not yet experienced in India except in a few places such as Mumbai. Societies at state level may need to bring about this movement and AIOS can be involved in advocacy with insurance association and IRDA to ensure improved payouts.
“A lot of patients have to make co-payments or go for reimbursement when it comes to wanting a better IOL for themselves.”
— Dr Pashupati
Dr. SPS Grewal, Director of Grewal Eye Institute, Chandigarh is a renowned high volume cataract surgeon in north India. He says “In my practice 20-25% patients undergoing cataract surgery have insurance. However, since the payouts are small, only 7-8% of revenue comes from these patients.” Dr Elankumaran Pashupati, director of Navshakthi Nethralaya, Bengaluru sees more insurance patients in his practice, “Nearly 70-80% of patients in my practice avail cashless facility through their insurance and over the years these insurance payouts have been shrinking” he says. Dr. Keiki Mehta, Director of Mehta international eye institute, Mumbai adds “In my practice about 30% of the patients have medical insurance and the payouts are small”.
When asked whether, they feel that premium IOL’s and advanced surgical techniques should be covered under insurance, all surgeons agreed. “The Term Premium IOL is wrong” said Dr Mehta. “Multifocal and toric lenses should be an option for everyone as they solve the issue for need of near glasses. Why use terms like premium to make these lenses appear similar to a luxury brand. It is not a luxury but a necessity for many patients.”
Dr Pashupati adds “A lot of patients have to make co-payments or go for reimbursement when it comes to wanting a better IOL for themselves. This should not be the case for someone who has been paying a regular medical insurance premium and now realises that it will not give him a good outcome without investing even more.”
Dr Krishnaprasad Kudlu, Head of Prasad Nethralaya, Udipi, Karnataka agrees with Dr Pashupati. He says “Cataract surgery is underpriced and the insurance companies are further underpricing it. In my practice where I see about 60% patients having insurance, most have no choice but to go for monofocal IOL’s as the payouts are dismal and copayment amounts appear large.”
“IRDA and insurance companies have to realise that these are not camp surgeries anymore where any IOL could do. People demand the best and I am sure if given a choice of slightly higer premiums to cover advanced surgeries, many people will gladly agree” opines Dr Pashupati.
When questioned regarding whether the insurance payouts should be similar for all eye hospitals, Dr Krishna Prasad agreed and stated that “There should be a uniform rate given by insurance companies to all ophthalmologists as it is the same surgery being done and requires a similar skillset.” However Dr Grewal and Dr Keiki Mehta disagreed with this point. “A cup of tea at the Taj Mahal Hotel in Mumbai costs much more than at the roadside tea shop in front of it” said Dr Mehta. “The infrastructure, ambience and presentation at the hotel is what people pay for, and those who want that along with their cup of tea are willing to pay more” he continued.
“When you travel to a destination via Vistara airlines you pay more than when you travel by a low cost carrier, even though both get you to the same destination. Each has their own clientele. Similarly, when someone wants to get operated a state of the art eye centre with good accreditation and best clinical practices, their insurance should have to pay a better sum than at a smaller centre” Dr Mehta emphasised. Dr Grewal echoed his opinion, albeit a little differently. “Insurance payouts should not be uniform” he said. “They should be linked to outcomes, accreditation and facilities of the centre” he added.
All surgeons thought that there is a need for AIOS to lobby for better payouts and inclusion of all forms of IOL’s and surgeries in the insurance framework. “There is a need for AIOS to form a committee to meet with the insurance companies and third party administrators to emphasise to them that there is a need for better payouts in order to provide the best options for cataract surgery.” Felt Dr Pashupati. Dr Kudlu added “AIOS also needs to advocate for inclusion of premium IOL’s in the insurance payouts. Multifocal IOL’s are the need, not an option, for many”. It was concluded that AIOS can work through IRDA and push changes down the insurance network. “I think we echo the views of all ophthalmologists of the country, when we say that insurance payouts need to improve and insurance needs to allow better benefits to the patients” said all surgeons in spirit and words.
Medical insurance is a certain part of the future of healthcare in India. There is a need for better payouts for ophthalmic surgeries including cataract and the only way to do so is advocacy. Of course, if nothing else works, all ophthalmologists can come together and decide not to accept payouts below a certain amount but it is probably best to let AIOS show the way forward.