The Modi Government’s pilot project Ayushman Bharat or Pradhan Mantri Jan Arogya Yojana (PMJAY), kick-started in September 2018, is facing a major setback due to low rates. As a result, multi-speciality and big private hospitals are unwilling to join hands with the government under the scheme.
The Quint has learnt that Dinesh Arora, Deputy Chief Executive Officer of the National Health Authority has issued a notification on 30 May to constitute a committee under the Ayushman Bharat scheme to review “appropriate package costing”, “anomalies” as recommended by specialist committees. The ten-member committee is headed by Arora.
But why now? The Ayushman Bharat authorities did not give us a clear answer on ‘why’ but experts say, the trigger was when the Health Ministry found that most private hospitals refused to be a part of the scheme due to low rates. For eg: Ayushman Bharat yojana pays Rs 20,000 for the surgery of removal of chest wall tumour , whereas states are paying double the rate – Rs 40,000 – for the same surgery.
Too caught up to read? Listen to it instead.
An email, accessed by The Quint, reveals that on 2 November 2018, Dinesh Arora, wrote to several private hospitals in Delhi, accredited under the National Accreditation Board for Hospitals & Healthcare Providers, “to join hands and serve the underprivileged sections of our community and ensure access to the best healthcare facilities”.
But only 20 private hospitals in the National Capital agreed to get empanelled under the scheme, when there are around 1,000 private hospitals and nursing homes in Delhi.
The Delhi government also refused to be a part of the Ayushman Bharat scheme. Since Delhi has the highest number of hospital beds in India, with a bed density close to 2.7 beds per 1000, Arora wrote to Delhi private hospitals with the hope to rope in maximum private hospitals under the scheme.
“Even if Delhi residents could not be Ayushman Bharat beneficiaries, let’s not forget that a large population from Haryana, UP and Bihar come to Delhi for treatment. Hence it was indeed important that maximum private hospitals in Delhi get empanelled under the scheme.”Dr Girdhar Gyani, Member Secretary, Association of Healthcare Providers (India)
Major Hospitals Not Enlisted Under Ayushman Bharat Yojana
There are around 2000 tertiary care private hospitals in India. Sources have confirmed to The Quint that only about 1% of tertiary care or multi-speciality private hospitals have enrolled under the Ayushman Bharat scheme, which means hospitals like Max, Medanta, Fortis, Apollo etc have not agreed to come on board with the Ayushman Bharat Yojana. In fact, several nursing homes have also refused to get empanelled.
“The purpose of the scheme is defeated without tertiary care hospitals empanelled. The BPL category population were already getting free of cost medical treatment in all government hospitals. So getting multi-speciality hospitals with other private hospitals is the need of the hour.”Dr Girdhar Gyani, Member Secretary, Association of Healthcare Providers (India)
The Quint has written to the Ayushman Bharat Yojana authorities to get the exact number of tertiary care hospitals under the scheme. But we haven’t received their response yet.
Around 7,800 private hospitals across the country have been enlisted in the scheme. But did these private hospitals enrol because of Ayushman Bharat? NO.
Around 80-90% of these private hospitals are those which were already enlisted under the state health schemes, say experts. Most of these are small nursing homes/hospitals with 25 to 30 beds. Hence, they automatically got enrolled under Ayushman Bharat.
Ayushman Bharat Rates Less than CGHS prices
Around 1,300 medical procedures are covered under the Ayushman Bharat Yojana. Rates for most procedures are found to be unfeasible and it is believed that government is in the process of revising some these rates.
It is interesting to note that the rates under the Ayushman Bharat scheme are on an average 30% less than CGHS rates, which are considered low as per current industry standards, and the government is also believed to be working on their revision by about 20%. Hence, to bring the rates under Ayushman Bharat close to industry norms, these have to go up on average by 50%.
“The Health Ministry needs to hike the reimbursed rates by about 50% for most of the medical procedures under the Ayushman Bharat scheme to make it sustainable for the private hospitals. CGHS rates, which are not revised since 2014, are also due for upward revision by 20% as minimum. Government also needs to consider whether two schemes could have two different rates, which could always come under questioning, as both being run by central government.”Dr Girdhar Gyani, Member Secretary, Association of Healthcare Providers (India)
Except for Delhi, Odisha and Telangana, all other states have implemented the Ayushman Bharat Yojana family health insurance scheme. Some states like Maharashtra, Tamil Nadu, Gujarat, Karnataka and Rajasthan were already running their own health schemes for Below Poverty Line category of population. Now, these states have merged their health schemes with Ayushman Bharat Yojana.
The rates of medical procedure in these states are much higher than in comparison to Ayushman Bharat scheme. The Ayushman Bharat authorities allowed states to use their health scheme rates even when patients under Ayushman Bharat were treated. It led to two things:
- All private hospitals empanelled under the State health scheme checked Ayushman Bharat patients under the state health scheme because they were getting higher rates.
- In many circumstances it is not clear whether the patients were treated under the Ayushman Bharat scheme or the State Health scheme.
Specialists’ Recommendation On Rates
The Association of Healthcare Providers (AHPI), a not-for-profit organisation, is closely working with the Health Ministry on the Ayushman Bharat scheme. From the very inception of the scheme, AHPI had been raising the issue of rates with the Health Ministry.
One of the criterion to revise the rates of scheme, as suggested by AHPI, is to match Ayushman Bharat rates with the highest rate of medical procedures provided under state health schemes. AHPI prepared a list of medical procedures rates comparing them between Ayushman Bharat Yojana and the rates applicable in Telangana, Maharastra, Tamil Nadu and Karnataka.
For eg, the rate of temporary pacemaker implantation under Ayushman Bharat scheme is Rs 5,000, whereas under Telangana’s health scheme the rate is Rs 13,000. Hence, Ayushman Bharat should increase the rate to at least Rs 13,000. Similarly, the rate of permanent pacemaker implantation under the state health scheme in Tamil Nadu is highest, ie Rs 80,000 and under the Ayushman Bharat scheme, it is as low as Rs 50,000. Again, Ayushman Bharat Yojana should pay at least Rs 80,000 for this particular procedure.
These are just two examples of several medical procedures provided under the Ayushman Bharat yojana.
“The government for the first time has initiated exercise to work out costing of medical procedures. Our specialist doctors are working closely with Department of Health Research to work out care paths for various procedures, based on which cost can be worked out by health economists. Once the rates are increased we are hopeful that several multi-specialty hospitals will agree to join hands with the scheme.”Dr Girdhar Gyani, Member Secretary, Association of Healthcare Providers (India)
Govt Will Have to Pump in Cash Flow Post Revision of Rates
Under the Ayushman Bharat, the beneficiary family gets Rs 5 lakh of medical insurance per annum, which will remain unchanged. But since the rate per medical procedure will increase, the government will have to increase cash flow to reimburse the bills of the hospitals.
Experts say, the Health Ministry has to deal with this problem initially after the revision of the rates but with time, the system will fall in place.
The Modi government has claimed that Ayushman Bharat scheme will provide health insurance to 10 crore poor families, meaning roughly 50 crore people will be benefitted under the scheme with Rs 5 lakh insurance per annum. The government claims in nine months over 29 lakh people have benefitted under the scheme – less than 1% of the total beneficiary.
(At The Quint, we question everything. Play an active role in shaping our journalism by becoming a member today.)