Private hospitals fleecing ESIC patients for cardiac stents: CIC

New Delhi: Taking a serious view of private hospitals “fleecing” patients for cardiac stents, the CIC has directed the Employees State Insurance Corporation to disclose the number of patients referred by it to private hospitals for the implants and the prices paid to those hospitals. It is alleged that private hospitals empanelled with the ESIC are overcharging patients by almost 2.5 times for stent implants and other cardiac procedures.

RTI applicant Pawan Saraswat approached the Central Information Commission (CIC) after he failed to get a response for his queries on the number of patients referred by the ESIC to the private hospitals, and the prices paid by the ESIC to those hospitals for the same.

Saraswat claimed that while deciding the costs of treatment at private hospitals, the ESIC goes by the CGHS rates, and when those are not available AIIMS rates are followed and if both are unavailable ESIC rates are followed. In the rarest cases which are not listed either in CGHS or AIIMS or in ESI rate list, the outsourced empanelled “hospital rate minus a discount” is paid, he alleged.

Information Commissioner Sridhar Acharyulu said the question is why the ESIC refers thousands or lakhs of patients to private hospitals knowing fully that they have to shell out 2.5 times the actual price under the CGHS. “The government/ESIC reimburses the inflated costs of the implants/devices as and when the empanelled private hospitals are referred by the ESIC,” he said.

Acharyulu said “a big business” is being transacted through these references. “The ESIC should have complained to the health ministry or Union government about inflation of prices. Instead, it facilitated it for years continuously leading to unjust enrichment by the private hospitals and stent makers probably with kickbacks to other key players. Hence there is a huge public interest,” he noted.

He said if the allegation of complainant of inflated rates of the stent is prima facie proved, a criminal cheating case in each implantation of stent has to be booked and probed.

“This is a serious and widespread crime happening with the knowledge of entire state machinery,” he said. Acharyulu said it is a serious regulatory lapse and there is nobody to check the stents coming in the boxes.

“Private hospitals are exploiting this ambiguity, which is sustained by vested commercial interests of corporate medical industry, unethical doctors and deliberate silence by the regulators. This could be mass violation of consumer rights making the ESIC a conduit,” Acharyulu said.

Directing the ESIC to disclose information sought by Saraswat, Acharyulu recommended Department of Consumer Affairs to incorporate speedy remedial measures to stop exorbitant pricing and unjust draining of public resources.

He also recommended the health ministry to consider taking strict action against the hospitals, distributors, doctors or any other concerned medical personnel if found to be involved in inflated pricing manipulations.

“The Commission requires the ESIC to inform the appellant and the Commission whether any probe was ordered into the overpricing issue, if so, what is current status,” he said.

Acharyulu said it is sad that even after repeated complaints and representations from the appellant, the ESCI could not inform him whether any probe was conducted.

Saraswat claimed that although the National Pharmaceutical Pricing Authority recently slashed the prices of lifesaving coronary stents by upto 85 per cent and fixed a ceiling price of Rs 7,250 per piece for bare metal stents, and allowed a maximum retail price of Rs 29,600 for drug eluting stents, yet this policy is not being implemented.

“The Commission finds that mere capping of the price of the implanting devices will not end the exploitation of the patients, the government should also consider capping the cost of entire operation, diagnosis, process and post-implantation consequences,” he said.