India to expand health care coverage…and use of prior authorizations

How can India hope to afford expanding health care coverage to half a billion people?  The answer is that access to care may be restricted.  As The Wire reports:

India is embarking on covering 500 million people with state-sponsored health insurance. At this massive scale, the potential for huge distortions is real. The question is whether patients will still be the biggest beneficiaries, at the end of the process.

According to model tender documents for the new Ayushman Bharat-National Health Protection Mission (AB-NHPM), the government has proposed that insurance companies will vet all applications for medical procedures under the scheme. They will then pre-approve ones that seem fit. If they reject a procedure, it will then be forwarded to state authorities who will have to assess those cases. Approvals or rejections must happen within six hours…

“Pre-authorisation is important because there is a lot of incentive for healthcare providers to indulge in the moral hazard. But it is only one step and cannot be relied on entirely,” says Sakthivel Selvaraj, director of health economics, financing and policy at the Public Health Foundation of India.

Out of the 1,350 procedures across 23 areas for which the government has fixed packages and rates, 47% of them will have to undergo a pre-authorisation procedure.

The pre-authorization (in the U.S. know as prior authorization) will be especially common for cardiology, cardio-thoracic surgery, ophthalmology, interventional neuroradiology, plastic and reconstructive surgery and a number of other specialty surgeries.

The 6 hour time frame for approvals or rejections–while on its face attractive for patients–makes it unlikely that the prior authorizations will be able to be done in a rigorous way.  India’s concern over fraudulent surgeries under public health insurance is a valid worry.  However, patient access to life saving or life-improving surgeries risks being denied through a bureaucratic approval process.

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