ECHS-ites

ECHSITIS

Written by Cdr R W Pathak with inputs from Members of ECHS Oversight group

In the Navy when equipment became faulty or something went wrong we would often say the cause must be "Fingeritis".

 After reading the Convening order 8608029/2/A (Coord) dated 25 Sep 2020 (Review of Medical cover for ESM) and 17 Jun 2019 for BOO (Examine Requirement of ECHS PCS in MH stations respectively) I noticed that both the letters are originated by Southern Command without any such requirement being indicated by any higher authority or the MoD at least in the convening orders and the word Fingeritis came to my mind and that is the genesis of the title of this piece. 

Let us understand the origin of the ECHS. Prior to Independence, medical cover for retired Fauji was provided by the military establishment itself and, in rural areas, where this was not possible, a monetary allowance was provided in lieu. This practice continued post-independence, because MH/military medical capacity was rarely ever stretched; besides the yeomanry was tough, and diseases limited, so the system worked. It is understood that way back when the CGHS was being considered in early 1950s,it was on file that the then Defence Minister had proposed to the Defence Forces also consider joining the scheme. The then Army Chief is said to have told the Defence Minister, rather pompously, that my doctors are capable of looking after our own or words to that effect. So the veterans remained under the care of our own for a long time. Over the years, owing to greater morbidity, limited diseases covered in MHs, and rising cost of treatment in civil hospitals, the Army introduced limited AGIS monetary cover to help defray burden on pensioners. But it was certainly felt that it was time to now have a scheme for veterans, tailored specifically to military pensioner medical needs as well as their spread across India. The bureaucratic system would have none of that and obviously wanted it modelled on the CGHS but with due modifications to meet our requirement and use of our own resources like the MH. Considerable statistical data was utilized while determining what were the medical needs of military pensioners. Four major differences were evident from those of CGHS beneficiaries: 1) service personnel had different type, scale, and degree of diseases, e.g. diseases brought about by service conditions, war injuries, battle casualties, paraplegic cases, HAA, CI etc, hence need for special medication; 2) whereas CGHS beneficiaries were mostly urban based (across 32 cities), military pensioners were mostly rural based (across 891 districts); 3) average life expectancy of military personnel was approx 20 years lesser than civilian counterparts; and 4) the numbers to catered for, once every pensioner joined (it was 23 lakhs in 2002, and approx 64 lakhs in 2016), would be far beyond that of CGHS. It was axiomatic that any PENSIONER HEALTH SCHEME (ECHS is a misnomer, since scheme was ONLY meant for those drawing pension, and NOT for every ex-serviceman) must be specifically tailor made; but bureaucracy would have none of it – Defence Services then settled for its own ECHS model, but rates of treatment etc to be governed like CGHS as ours was also a Government funded scheme.

This proposal was under discussion from 1984 till 2002 and there were numerous studies carried out; different models looked at before the scheme was sanctioned vide Ministry of Defence Government of India New Delhi No. 22(1)/01/US(WE)/D(Res) dated the 30 Dec, 2002. So a lot of background exists and yet the present lot of serving personnel wishes to reinvent the wheel, and that is why I call it "ECHSITIS".

 

To those that wish to reinvent the wheel, read & know the how, whys, and wherefores of the scheme, and what was enshrined at its start. ECHS is a scheme for PENSIONERS of the Defence Services (Recently non Pensioners have been also included of whom some pay and get free OPD but paid In Patient treatment in Empanelled hospitals on co-pay basis), where each new entrant pays for its membership. It is, as late PM AB Vajpayee said (or words to that effect), "This scheme is NOT a charity to the Defence Forces, but something owed & due to them by a grateful nation, for services rendered by our soldiers, sailors and airmen. Government shall provide whatever funds are needed to see that those that sacrificed their youth in service of the nation are properly cared for in their post-retirement period & old age. This scheme shall NEVER have to face shortage of funds that is my Governments promise". We must remember that ECHS budget, earlier funnelled through Army/ADG (FP), and now through DESW/MoD, is that "measure of nation's gratitude"; and that is non-negotiable.

 

The Scheme was designed to provide quality healthcare to Ex-servicemen pensioners and their dependents through a network of ECHS Polyclinics, Service medical facilities and civil empanelled/Govt. hospitals spread across the Country as per standards in service hospitals. The Scheme has been structured to provide cashless treatment for its beneficiaries. Treatment provided under ECHS is as per the allopathic medical system (recently alternate medicine has been introduced as an option) and it is a Govt. funded Scheme. (Now if the Gov (MoD) has not stated or is not quoted in convening orders to suggest an alternate why is the Southern Command initiating this study? This is Fingeritis and so my title ECHSITIS.

 

The ECHS Polyclinics are designed to provide 'Outpatient Care' which includes consultation, essential Investigation and provision of medicines. Specialized consultations, investigations and 'In Patient Care' (Hospitalization) is provided through spare capacity available in Service hospitals and through civil hospitals empanelled with ECHS.

 

Now first kill the issue of PCs as studied by the Board ordered in 2019. It can now be easily surmised that the board met its requirement of keeping some people busy for a while as nothing more has been heard on it.

 

Let us look at the latest board.

 

I would suggest that the BOO members read the article in Economic Times on the link https://economictimes.indiatimes.com/wealth/insure/health-insurance/health-insurer-not-paying-you-here-are-6-reasons-why-your-insurance-claim-is-not-being-admitted/articleshow/78842661.cms?from=mdr to understand Health insurance and its shortcomings. It is clear even there we would have the same problem of payments and over charging but without any back up of the service facility.

 

It is again a self-generated requirement for study with no one seeking it and as I understand it has not even been initiated by the medical branch.  

 

The first Para of the convening order reads "to study feasibility of Instituting a Group Insurance Scheme for ESM to replace existing ECHS scheme". On the social media a lot has been said in defence of this move but one can only go by what is in writing.

 

So can the ECHS be replaced by Group Insurance?

 

Every thinking individual is aware that no Insurance company provides limitless or cap less cover and has many exclusions. It is learnt that cases of Cardiac, Onco, Renal and Ortho patients make up about 35 percent of patients in the ECHS system. Add to this chronic hypertension and chronic Diabetes cases which make up another 15% of patients. How can any insurance company ever think of providing cap less insurance cover for this large section (50%) of the population in the group when all insurance companies have such exclusions?

 

So the question is even if a Medicare Insurance company does agree who will foot the heavy premium and would that be less than the present expenditure by the MoD in meeting the ECHS budget? The proposal seems dead from the start. Again with an annual increase of say around 15% new members in the scheme the burden on the insurer will go up.

 

Most Insurance companies who provided cover have their hospitals restricted to non-mofussil areas and most of our patients in ECHS are in mofussil areas.

 

I have yet to hear of an insurer who provides OPD cover and close to 90% of the ECHS members are OPD/Continue medicine cases. What provision would be there to cover this large base? Insurers need at least 24 hrs admissions for cover costs of OPD. Will this lead to extra costs in future premiums?

 

It can fairly be summarized that Group Health scheme is a "no go" territory as an alternate to ECHS.

 

It is however clear that probably there is a need to streamline working of ECHS for better management and to see how we would reduce expenditures and burden on the government.

Before proceeding further I would like to quote a senior Maj. Gen closely associated with the scheme long back and he states "You can certainly improve on a system, but you cannot throw away the whole lot, unless you have a better, viable alternative. Systems collapse where link in the chain is weakest – and it just so happens that this link in this case is the second hat of the Army Cdr, the admin chain of comd. Only a brave & committed person will admit that. We in the Oversight committee have ourselves had found examples where Sub Area/Stn Cdr & DDMS have made a difference both positive & negative. So don't blame ECHS, but those administering it.

Let us look at this graphic (Taken from DESW site)

 

 

 

Who is to blame for this? The same officer quoted above says "MoD is not to blame for this. It is the Areas/Sub Areas & DDMS which fail to supply medicines/equipment to PCs."

 

So it is an appeal to the present serving lot who would one day be seating on this side of the table to look at ways and means to improve the best Medicare system in the country rather than even think of throwing it out lock stock and barrel.

 

So let the authorities so keen to change over to Group Health insurance first see how they can improve the present ECHS system.

 

Here are some suggestions to IMPROVE the ECHS, not to change it – as they say "better a known devil, than an unknown friend":

 

1. Truly make ECHS digitized and user friendly. This will itself lead to costs savings
2. It may be worth looking at the role of SEMO in the scheme of things as at present he is offline resulting in a bottleneck. It would be far more efficient if a Medical specialist in reemployed at Regional centres and he is the equivalent of SEMO for the AOR.
3. There are many veterans who due socio economic changes wish to pay higher to get into Semiprivate wards. Do away with (Gen Ward category ) with additional Subscription of 30,000/- from all past, present and future veterans who are currently in this Gen Ward category or would be in it on joining
4. Rationalize subscriptions based on city classification so that higher costs of treatment in Class X cities in not cross subsidized.
5. Make two types of membership subscriptions. The primary rate of subscription be applicable to self, spouse and two children below 18 and additional membership subscription as a %age of primary subscription per head for every additional beneficiary
6. In future load the subscription  in both primary and additional membership rates for those suffering from disability (Except War Injuries or those attributable to service)
7. Currently due special circumstances LP of medicines are permitted on reimbursement basis. This arrangement could be made permanent in the sense that if a patient has a prescription from any ECHS polyclinic / Government or EPH/Government telemedicine sites he could buy his medicine and have it reimbursed. This would need changes to Online billing module as already suggested by me to the Managing Director ECHS. It would reduce load /footfall in ECHS clinics lead to better manpower rationalization and overall savings even if one would pay marginally more as % age of billing than in present system but will do away with NA medicine altogether and role of authorities involved in medical procurement and distribution. If implemented it would lead to 50 % reduction in DASR, 30% in PC Staff

 

I think at one stage the GOI did submit an affidavit in the SC that ECHS is a welfare scheme. I wonder how? As it even today advertises that "You will continue to enjoy the canteen and medical facilities as you did whilst in Service".

 

All said and done we must admit that even today non-government funds are being used in ECHS and this is no structured use of these funds.. If may be worth considering if a structured distribution for ECHS Only can be made under the Quantitative Discount distribution scheme of the CSD.

 

As per the guidelines of Utilization of the QD are given on the GOI MoD letter 8(19)/2013-D (MOD) dated 05 Mar 2014, a major chunk   of fund is meant for Welfare schemes. Can there be a better use of the fund towards welfare than using 20% of these funds for ECHS. If 20% is given to ECHS the scheme can be certainly self-sufficient.

 

The other issue that plagues the ECHS is the unwillingness of hospitals to join due difference between CGHS rates and Market rates. This could be mitigated if ECHS can be included in list of CSR for Tax Exemption and we may get more hospitals on our panel.

 

A few more new introductions would improve the overall efficiency of the scheme via true digitization and simplification of procedures. Our sole aim should be "improve & engender quality Medicare for retired members/dependants & widows, so that they lead a life of dignity". We will always support new, tech savvy methods that can stop leakages, improve delivery, widen coverage, and we must also to come down heavily on those misusing this scheme.

 

1.   Online coordination between ECHS authorities and MH

2.   Three week Trg Capsule for Dir RCs' at Central Org

3.   Formal Trg of OIC PCs', MOs', & JD (HS) at RC Level This will avoid mistakes in issue of Referrals & Processing of Med Bills

4.   Even though ECHS membership subscription is cut at the time of retirement the members do not apply for cards in many cases. Cards must be issued with the rest of retirement documents and ECHS card application must form a part of the Outgoing routine process

5.   Stricter Verification of FMA, Spouse,  Marital Status of daughters, Children born after retirement and strict  action on Primary Member by way of cancellation of ECHS Membership of Primary member.

6.   Closure of PCs' & RCs'/Up-gradation of PCs' / Additional PCs' may be authorised to  MD ECHS

7.   Authorization of funds/medical equipment may also be authorized Med Equipment be authorized based on DASR.

8.   Accessibility of all PCs' and impact on DASR. An example is of the Nagpur polyclinic which is located a few Km into to base making access difficult.

9.   Fresh Empanelment, Additional Facilities, & Up-gradation to NABH/ NABL status is time consuming  MD ECHS be authorised to  at least approve fresh Empanelment of hospitals that are willing to come back and were previously approved, Additional Facilities, & Up-gradation to NABH/ NABL status

10.    Regional Dir RC to be approving auth for all Unlisted Procedures & Diagnostic Tests up to one lakhs through JD (HS) and higher if he is provided with a Medical specialist (on Contract). This will cut down delays for up to 10 days at least.

11.     Increased Duration of Stay in EPH Written Justification by Treating MS/MO of EH should be sufficient instead of mandatory approval by OIC PCs' & Dir RC

12.     MO of Govt/EPH/NEPH be paid in cash for consultation at CGHS Rate by ECHS Member & subsequent re-imbursement for consultation & Medicine through Parent PC

13.     For Delay in approval of Medical Claims  Provision  be made for Financial Penalty on HCOs' for Delayed Submission of Med Claims and  CFA be auth to clear claims with financial penalty.

 

It is opined that the Services seriously consider a detailed study of all aspects of the ECHS operations and see how the ECHS can be improved, made cost saving and truly close to CGHS in how it is controlled and run. Even now the present BOO can reconsider the following and points raised earlier.

1.   It is said that too many cooks spoil the broth but in the case of ECHS TWO bosses are spoiling the broth. Can we have the ECHS under one hat?

2.   In the case when the SSCO were to be brought under the scheme the DFAFMS in a written affidavit had stated that the MH cannot meet the extra load that would come from these additions. It would be worth considering this affidavit seriously and see how the MH and the AMC plays minimal role in running of the ECHS scheme and expedite creation of ECHS hospitals.

 

The Navy at least even now maintains "You will continue to enjoy the canteen and medical facilities as you did whilst in Service" So I would like to close with a question.

 

HOW WOULD THE NEW GROUP HEALTH SCHEME MEET THE REQUIREMENTS OF THOSE WHO HAVE JOINED KNOWING WELL THAT THEIR MEDICARE IS LOOKED AFTER FOR LIFE?

 

Note: There was an ECHS Advisory Group, started in 2008 or thereabouts, which assisted Commands in various matters related to pensioners medical needs, but it sort of died away. ECHS "Oversight Committee "was formally created by Gen V K Singh but, after his tenure it too died its natural death in the war of the generals. Today the members of the committee function as a group to discuss ECHS related issues and take these up with authorities; issues that need to be looked into, and to help veterans as much as the OSC can.

Cdr Ravindra Waman Pathak I.N. (Retd)

Member Veterans Pension Group

1 Surashri,1146 Lakaki Road
Shivajinagar 

Pune 411016
raviwarsha@gmail.com
9822329340  

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