New Delhi: A leading private hospitals association has written to the health ministry flagging a growing crisis in the treatment of advanced cancer patients of those covered under the Central Government Health Scheme, as the scheme’s reimbursement policy threatens to disrupt access to life-saving immunotherapy drugs.
At the heart of the matter is a reimbursement cap that limits hospital payments to 70% of the Maximum Retail Price (MRP) for high-cost oncology medicines, a policy issue that hospitals say is pushing them to the financial breaking point and more critically, putting patients at serious risk. AHPI, which is an association of over 20,000 private healthcare companies, has written to the health minister identifying nine drugs that are out of reach of the patients.
These drugs include Keytruda 100 mg/4 ml INJ, imfinzi 500MG/10ML INJ, Enhertu 100MG/ML INJ, Imjudo 300MG INJ, Zoladex LA 10.8MG PFS INJ, Adcetris 50MG INJ, Imfinzi 120MG/2.4ML INJ, Tagrisso 80MG TAB (1X10), Zoladex 3.6MG PFS INJ.
“This is a peculiar situation, which arises out of the necessity to use these patented drugs only,” reads the letter by Dr Girdhar Gyani, director general Association of Healthcare Providers (India) AHPI.
“We will be grateful, if you may kindly direct CGHS to reconsider its decision regarding the reimbursement (for these limited sets of drugs) to the hospitals at 70% of the MRP. Instead, the CGHS may kindly consider reimbursing the hospitals on the MRP itself,” the letter said.
The CGHS currently offers hospitals three pathways to claim reimbursements for these drugs. The hospitals can ask the CGHS beneficiary to procure these medicines from the CGHS system, and the hospitals will just administer the medicines and bill for the services provided and the hospitals can bill CGHS on the MRP of these drugs. However, the CGHS will pay the hospitals only 70% of the MRP value.
Hospitals argue that each of these options is either legally untenable or medically dangerous.
Many hospitals procure patented immunotherapy drugs through bulk contracts with multinational pharmaceutical companies; contracts that explicitly prohibit disclosure of negotiated prices to third parties. Submitting purchase invoices to the CGHS, hospitals warn, could expose them to breach of contract claims, and the drugmakers can initiate legal proceedings or stop the supply of these medicines.
Asking patients to source their own medicines is equally fraught. These drugs require strict cold chain maintenance during transport, and patients must be able to certify their origin and integrity conditions that are nearly impossible for most to meet.
Doctors, wary of administering medicines whose handling they cannot verify, are increasingly reluctant to do so, hospitals said.
The CGHS supply system, the third option, has proven unreliable in practice. Patients have repeatedly reported delays and shortages, leading to broken treatment schedules and, in some cases, significantly suboptimal outcomes.
Thus, hospitals are left with no choice but to submit invoices to the CGHS on the MRP of these drugs.
Since these drugs are very expensive patented, the hospitals do not have high margins (limited to only 10-15%) and are thus forced to pay out of pocket for each such infusion. “It is quite impossible to sustain this,” AHPI said.
