Major Surgery Setback Looms For Kashmir's Private Healthcare Sector

The procedures in question-lap cholecystectomy, hemorrhoidectomy, appendectomy, and fissure in ano-are expected to be reserved exclusively for public sector hospitals, effectively barring private hospitals from offering them under the 'Golden Card,' the insurance coverage mechanism of the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY).

This shift comes on the heels of a meeting chaired by J&K Chief Secretary Atal Dulloo, where the State Health Agency (SHA) discussed the future of the AB-PMJAY and AB-PMJAY SEHAT schemes. The decision could have significant consequences for the region's already strained healthcare system, particularly for patients who rely on the private sector for timely surgical interventions.

Healthcare insiders fear that this move would exacerbate the already-overwhelmed public hospital system. With limited resources and staff, government hospitals could see a surge in demand for these procedures, leading to longer waiting times. One government official warned that patients may face waiting periods extending into months, particularly as the public sector already struggles to meet current demand.“The waiting lists for these procedures in government hospitals are already months long, and this will only make the situation worse,” the official said.

Private hospital owners are equally concerned about the implications of the policy change. One hospital owner, whose facility performs a significant number of these surgeries, shared that these procedures account for 57% of the surgeries carried out under the Ayushman Bharat Scheme.“In the past year alone, these surgeries helped us provide Rs 103 crore worth of benefits to patients. This policy change could be catastrophic for our operations,” a private hospital owner from north Kashmir, explained.

Another private stakeholder, wishing not to be named, has expressed concerns over the ongoing government health scheme, labeling it as“unviable” for the private sector. He criticized the scheme's financial structure, which he described as“cash-starved,” making it unsustainable for private healthcare providers to participate effectively.

“We have been requesting the government to review the scheme and increase the funding. However, to our knowledge, they are halting certain procedures and also reducing the 10% waiver, which will only worsen the situation,” he said.

He further emphasized that, under the current conditions, the private sector will not be able to continue offering services under the scheme.

Another owner of a south Kashmir based private hospital suggested that the government must categorize hospitals across the region based on their facilities and infrastructure, ensuring that the scheme is implemented more effectively according to the capabilities of each healthcare provider.

Beyond just the procedural restrictions, private hospitals are also facing a potential 10% reduction in the package rates paid for services covered under the scheme. Many private healthcare providers argue that this reduction will not keep pace with rising inflation, increasing costs of medicines, supplies, and wages for medical staff.“The financial pressure on private hospitals could force many to reconsider participating in the scheme altogether,” one private hospital owner in Jammu cautioned.

The effect on patients could be dire. With a capacity deficit in public hospitals, patients-particularly from poorer segments-could find themselves waiting longer for essential treatments or even facing the threat of complications from untreated conditions. A private hospital owner noted that patients, especially those suffering from conditions like pancreatitis, could face severe health risks if these procedures are delayed.

According to them one of the most pressing issues was the decision to remove four key medical procedures from the scheme for private sector hospitals. These procedures, which are critical to the treatment of various ailments, have left private hospitals grappling with financial losses. Furthermore, for other procedures, a 10% deduction has been implemented, further exacerbating the already poor reimbursement rates provided under the scheme. Dialysis, medical oncology, orthopedics, and ENT services-essential healthcare domains-are particularly hard-hit. The package rates for these services under the scheme are already insufficient, barely covering the costs incurred by hospitals. The added deductions and exclusions have left private hospitals unable to sustain these treatments without incurring heavy financial losses.

Is Ayushman Bharat Fulfilling its Promise?

While the Ayushman Bharat Scheme was designed to make healthcare more accessible and affordable for millions of Indians, the situation in Kashmir raises questions about the scheme's effectiveness in the region. The private healthcare sector, already burdened by insufficient reimbursement rates, is now facing additional pressures due to the exclusion of key procedures and the reduction of package rates.

For many residents of Kashmir, private hospitals are a vital lifeline, particularly in a region where public healthcare facilities are often overburdened and under-resourced. Should private hospitals opt out of the scheme due to these financial pressures, it would significantly restrict access to healthcare for a large portion of the population.

The impact on private hospitals' participation in the scheme could be profound, with a decrease in the number of available healthcare providers for the most vulnerable citizens. Private healthcare facilities have historically played a crucial role in filling the gap left by the strained public system, especially in areas where government-run hospitals struggle to keep up with demand.

A Call for Action

The government's decision is not just a matter of policy; it could have real-world consequences for the health of Kashmir's population. It is imperative that policymakers reconsider the current framework of the Ayushman Bharat Scheme in the region. Adequate funding and appropriate adjustments to package rates will be necessary to ensure the survival of private healthcare providers and, by extension, the quality and accessibility of healthcare for all Kashmiris. The stakeholders maintained that the vision of universal healthcare under Ayushman Bharat can only be realized if all stakeholders-both public and private-are adequately supported. Without addressing the concerns of private hospitals, the scheme risks becoming a hollow promise for the people it aims to serve. Private hospitals play a crucial role in filling the gaps left by the public healthcare system, particularly in regions like Kashmir, where government facilities are often overstretched and under-resourced. However, the current framework of the Ayushman Bharat scheme has created a financial strain that could force many private hospitals to reconsider their participation. This, in turn, would limit healthcare access for the very population the scheme aims to serve.“It is imperative that policymakers revisit and revise the implementation strategy of Ayushman Bharat in Kashmir. Adequate funding and realistic package rates must be ensured to support private hospitals, especially for critical specialties. Failure to address these concerns will not only jeopardize the survival of private healthcare providers but also compromise the quality and accessibility of healthcare for the people of Kashmir,” they said, adding“The vision of Ayushman Bharat is to provide universal healthcare, but without addressing these systemic issues, it risks becoming an empty promise in Kashmir. The government must act promptly to safeguard both the hospitals and the lives that depend on them.”

Government's Response

In response to these concerns, the State Health Agency (SHA) has maintained that no final decisions have been made yet. The SHA spokesperson emphasized that the government is still evaluating the impact of the proposed changes.“As the new policy approaches its implementation date, we are closely assessing its potential effects on both public and private healthcare,” the spokesperson said.

Sanjiv Gadkar, CEO of the SHA, acknowledged that while the agency has made strides in processing claims under the AB-PMJAY and PMJAY-SEHAT schemes, further refinements are necessary to ensure effective implementation. He confirmed that high-end and emergency procedures would remain prioritized, but offered little clarity on whether the exclusion of certain procedures from private hospitals would proceed as planned. The agency is also working to streamline the claims process and reduce administrative costs by hiring an insurance company to manage the scheme.

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