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HT Image

Better, upgraded version of health scheme in offing

PUBLISHED ON SEP 23, 2019 12:49 AM IST

The Narendra Modi government’s flagship health insurance scheme— Ayushman Bharat-Pradhan Mantri Jan Arogya Yojna (AB-PMJAY)— is ready in its 2.0 avatar within a year of its launch.

Taking the cue from its experience of implementing the world’s largest public health insurance scheme since its launch on September 23, 2018, the National Health Authority (NHA) has revised the package of diseases eligible for treatment under Ayushman Bharat, upgraded its information technology software and put in place better measures to prevent fraud and leakage of funds.

“The government hasn’t merely announced a scheme, but is also trying to meticulously implement it,” said Union health minister Harsh Vardhan.

AB-PMJAY provides medical coverage of 5 lakh per family per annum, and eligible families can seek treatment at any government hospital or at any empanelled private hospital. It was targeted at 107.4 million poor and vulnerable families.

“The upgraded version of the scheme will be much smoother to navigate, more precise in terms of disease packages and their rates. We are upgrading our IT system, to IT 2.0, making it more secure and better integrated with the National Digital Health Blue Print. It will have the ability to adapt to future innovations,” said Indu Bhushan, CEO, Ayushman Bharat.

Making steady progress

From 5,000 hospital admissions a day in the first three months, the number of admissions has gone up to 25,000 a day.

“The scheme has met with a tremendous response. It was learning experience for us as nothing of this magnitude has ever been attempted not just in India but globally. The admissions are growing at a fast rate; in the next couple of years, when the scheme stabilises, we expect to receive about 35,000 to 40,000 patients a day,” Bhushan said.

People who had never thought they could be treated at a private hospital have benefitted from the initiative.

One such happy beneficiary is Ram Dulari, 50, a labourer from Bihar, who recently underwent coronary artery bypass grafting (CABG) at New Delhi’s super-speciality Sir Ganga Ram Hospital . “I could only dream of this kind of treatment in a private hospital. There are huge queues in government hospitals and many just refer, so this scheme has been a blessing for me,” she says.

Focus on tertiary care

While 18,026 hospitals are currently empanelled under the scheme, of which 53% (9554) are privately run, the NHA’s focus is to get more tertiary care hospitals that provide super-speciality treatment under its ambit.

“We are looking to include more tertiary care hospitals in the list as the demand for super-speciality treatment such as cancer, cardiac and neuro surgeries and orthopaedics is on the rise. By the end of this year we should have at least 25,000 more hospitals empanelled under the scheme,” said Bhushan.

Cancer care will also find more space in the disease packages given the high disease burden.

“Oncology is a priority area and we are making changes in the package to make more additions. The tie-up with National Cancer Grid that has a network of cancer care centres across the country will help in our attempt design an efficient oncology package,” he said.

While government hospitals are by default a part of the scheme, private entities are still not showing sufficient enthusiasm .

“We are trying to convince them that it’s not going to be a loss-making proposition. Many don’t have confidence that the government will pay them on time or are comfortable with the high margins, low volume model. We see it as a challenge to break their comfort zone, and we did create some 24 expert committees that looked into disease packages and rates, which we are in the process of revising,” said Bhushan.

Getting everyone on board

The beneficiaries of the scheme were identified on the basis of socio-economic caste census data (SECCD). Almost 100 million electronic cards have been distributed so far.

However, as of now 32 states and Union Territories have signed up for the scheme. The ones who are yet to take up the scheme are Delhi, Odisha, Telangana and West Bengal.

Attempts are under way to convince them to come on-board.

“All these leftover states are important as a lot of patient load from the north-eastern states goes to Kolkata; south India prefers Telangana, and as for Odisha the eligible patients are travelling out of the state to seek treatment. In Delhi; we have empanelled about 20 hospitals to take care of the rush as a large number of people getting treated in Delhi are from outside states,” said Bhushan.

“Portability facility is an asset as about 40,000 people have been treated under the scheme outside of their state of birth. About Rs 7,500 crore has already been spent on treatment of about five million beneficiaries,” he added.

Integrating Health and Wellness Centres

Of the 150,000 health and wellness centres (HWCs) announced under the Ayushman Bharat scheme, 20,942 have already been made operational across the country within the past year.

“The government focus is not just on the treatment part but also includes preventive healthcare and health promotion at the community level,” said Harsh Vardhan. Everyone above 30 will be screened for common non-communicable diseases, receive palliative and rehabilitative care and first-level care for emergencies and trauma cases.

The government targets making all HWCs operational by 2022.

“This is what we call continuum of care, and we are looking at using the services at these centres for local follow-ups for our treated patients. The patients, for example, need not come to the hospital for suture removal or getting their plaster cut. These things can be done locally by a person adequately trained for it at the centre,” said Bhushan.

Crackdown on fraud

The biggest challenge in the successful implementation of the scheme lies in checking fraudulent claims.

Nearly 1,200 cases of fraud have been confirmed and action has been taken against 338 hospitals so far.

“There is zero tolerance towards fraud and we have filed an FIR {first information report} against six hospitals, de-empanelled about 97 hospitals and recovered an amount of Rs.1.1 crore from fraudsters,” said Harsh Vardhan.

The National Health Authority, which is the implementing authority for Ayushman Bharat, has decided to name and shame the culprits.

“We will not only formally lodge a complaint against defaulters, but will also put their names on our website. We also intend to blacklist them not just for the Ayushman Bharat scheme but also all other government scheme such as CGHS, ECHS, ESI etc.,” said Bhushan.

CGHS is short for Central Government Health Scheme, ECHS stands for Ex-Servicemen Contributory Health Schem and ESI for Employees’ State Insurance.

Harsh Vardhan said 376 hospitals currently are under investigation while the NHA has taken action in terms of issuing show-cause notices, and suspending, levying penalty or de-empanelling 338 hospitals.

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