It has two components which are complementary to each other.
- First component: Under this 1,50,000 Health & Wellness Centres (HWCs) will be created to deliver Comprehensive Primary Health Care, that is universal and free to users, with a focus on wellness and the delivery of an expanded range of services closer to the community.
- Second component: Pradhan Mantri Jan Arogya Yojana (PM-JAY) which provides health insurance cover of Rs. 5 lakhs per year to over 10 crore poor and vulnerable families for seeking secondary and tertiary care.
Provisions of PMJAY
- The scheme is the world’s largest publicly funded health assurance scheme providing a health cover of Rs 5 lakh per family per year for secondary and tertiary care hospitalisation to the bottom 40 per cent of the population of India.
- Costs of diagnostics and medicines are covered up to 3 days prehospitalization and 15 days posthospitalization and all preexisting conditions are covered.
- The Ayushman Card is like a pre-paid card worth Rs 5 lakh, which can be used to avail free treatment at more than 27,000 empanelled hospitals.
- Every hospital must provide Pradhan Mantri Arogya Mitras (PMAMs) to assist beneficiaries.
- This scheme has interstate portability.
- Aadhaar-based authentication for card creation and registration for treatment has been mandated under the scheme.
- The scheme is administered by the National Health Authority (NHA) which reports to the Ministry of Health and Family Welfare.
- The NHA has a governing board with representatives from the central government, domain experts, and states.
- NHA's call center contacts beneficiaries post-discharge (48 hrs) to assess treatment, followed by a second call (15 days) to check prognosis.
- It is an inclusive scheme as it includes transgender individuals among its beneficiaries. Approximately 50 packages were designed, specifically for the community, including offerings like Sex Reassignment Surgery (SRS).
- Under the scheme the National Anti-Fraud Unit (NAFU) designs, implements and oversees anti-fraud initiatives.
- There are Anti-Fraud Units at the state level as well.
Five years of Ayushman Bharat
Achievements
- Nudging of state: The scheme has nudged the states/UTs, who are accountable for ensuring effective public health as it is a state subject, to extend it to more beneficiaries.
- Effective fiscal management: it has reduced out-of-pocket expenditure (OOPE) and led to efficient utilisation of the government budget by reducing revenue losses.
- Bridge the gap: The scheme has bridged the shortfall between healthcare providers and service-takers by uniting them through government channels.
- Reduction in treatment cost: Treatment costs within AB-PMJAY are half compared to outside care, saving over Rs 1 lakh crore.
- Spirit of Inclusiveness: Notably, 48% of treatments are by women, and transgender individuals are also beneficiaries of the scheme. Service isn't denied if a beneficiary lacks an Ayushman card.
- Regularisation of process: To bring out the participation of private service providers, health benefit packages (HBPs) covering all in-patient treatment have been revised five times in the last five years.
- Early Claim settlement: Efforts are being made to settle the claims within a defined standard of 15 days. A few states like Uttarakhand have brought down the claims settlement time to less than seven days.
- Reward to Hospitals: Efforts are being made to reward hospitals with a trustworthy record with an upfront payment of 50 per cent of the claim amount immediately after submission of claims, without adjudication.
- Interoperability: Beneficial for migrants, especially in emergencies, the scheme aids the poor and marginalized. Its design mitigates healthcare access challenges for these sections through interoperability.
- Effective Monitoring: End-to-end digital service delivery eliminates bias. NHA uses internal monitoring and a public dashboard for transparent day-to-day scheme tracking.
- Fraud management: Establishment of institutions like NAFU has decreased the frauds in registration, verification and insurance claims.
- Use of technology: The NHA has been using Artificial Intelligence (AI) and Machine Learning (ML) technologies to detect suspicious transactions/potential frauds.
Issues
- Regional disparity: There is significant interstate variation in the quality of the infrastructure of health centers as well as the quality of care provided in them, with the better governed states doing better than the rest.
- Future Fiscal Burden: More focus has been given to insurance scheme but as coverage grows, hospitalization rates may rise, raising claims ratios and premiums. Insurers need profitable business, as higher premiums strain government finances.
- Infrastructural and man-power issues: Ten percent of Public Health Centers (PHCs) lack doctors, 56% of SCs lack staff washrooms, 73% lack separate washrooms, and 36% of PHCs lack gender-segregated facilities.
- Process and Outcome Gap: Data gaps for process and outcome indicators hinder improvement and patient-centricity in healthcare. Bridging this gap is crucial for identifying areas to enhance care delivery.
- Compliance Burden: Traveling to distant hospitals for medication significantly lowers compliance by over 80% in rural India, due to effort and expenses involved.
- Double Charging: Publicly Funded Health Insurance Schemes (PFHIS) are prone to double charging, where the hospital makes the patient pay for some or all services/medicines/diagnostics which are covered under the PFHI and also claim the reimbursement from the PFHI.
- Information Asymmetry: The inherently hierarchical nature of medical care provision coupled with its complexities amplifies the stark information asymmetries between the provider and the patients. Low awareness seems to lead to low utilization.
- Outpatient Care: it does not cover outpatient care which accounts for between 40% and 80% of OOPHE and is a significant cause of increasing health expenditure and subsequent impoverishment.
- Induced Demand: Several media reports have documented the phenomenon of supplier-induced demand in poorly regulated markets dominated by private insurers.
- Upcoding: Upcoding is the practice of fraudulent medical billing in which the bill for a medical service is more expensive than it should have been based on the service that was performed.
Issues highlighted by Comptroller and Auditor General of India (CAG)
- CAG has revealed that nearly 7.5 lakh beneficiaries were linked with a single cellphone number under PMJAY.
- Hospital Empanelment and Management:
- CAG included private hospitals performing procedures reserved for public hospitals.
- There are hospitals with pending penalties amounting to multiple crores of rupees.
- Issue of fraudulent database errors.
- Spending money on ineligible beneficiaries.
- Shortages of infrastructure, equipment and doctors at empanelled hospitals.
- Cases of medical malpractice.
- Beneficiary Identification and Registration: According to the report, in the absence of adequate validation controls, errors were noticed in beneficiary databases, such as invalid names, unrealistic date of birth, duplicate PMJAY IDs, and unrealistic size of family members in a household.
- Claims Management:
- It said that patients earlier shown as “dead” continued to avail treatment under the scheme.
- Parallel transaction management systems by some states which has resulted in a possibility of overlap of beneficiaries of PMJAY with the beneficiaries of State specific schemes
- Financial Management: The instructions of Government of India to track the expenditure flow through Public Financial Management System had not been fully complied with by NHA and State Health Authorities (SHAs).
- Monitoring and Grievance Redressal: Many states have not formed or delayed the formation of SHAs, Anti-Fraud Cell, or Claim review committees.
Suggestions for improvement
- To realise the scheme’s full potential, the National Health Authority (NHA) along with its counterparts in the states should aim to provide every possible beneficiary with an Ayushman Card.
- State governments which have not formed the SHAs, Fraud cells etc. should consult and through dialogue the bodies should be constituted to improve the interoperability of the scheme.
- The issue of upcoding, dead patients availing benefits, double charging should be addressed by reducing information asymmetries and increasing the awareness of the people.
- Parallel transactions management system creates ambiguities in management and ensuring accountability, states and Centre should come up with a unified and transparent system.