How to make Ayushman Bharat Scheme More Viable?

Last year, after the launch of Ayushman Bharat Yojana, the world's most massive health insurance project, not a single private hospital in Mumbai wanted to enlist in it. Today, few hospitals in the maximum city have enrolled in the scheme, but the adoption rate is still minimum. HE asks associations and doctors about how to make it more viable.

Ayushman Bharat National Health Protection Mission—popularly aka PMJAY—was launched a year ago by Prime Minister Narendra Modi. Maharashtra, like several other states, already has a state-run-scheme- Mahatma Jyotiba Phule Jan Arogya Yojana. Yet, PMJAY is expected to be a game-changer for four lakh families in the city (83.71 lakh in total in the state).

PMJAY intends to incorporate payments for 1,350 medical packages comprising operations, medical and daycare treatments, including drugs, diagnostics and transportation, for 500 million taxpayers. The centre has earmarked Rs 2,400 crore for the initial six months of the scheme, and Rs 6,400 crore for 2019/20, for the programme.

In theory, the scheme looks good. Lalit Kapoor from the Association of Medical Consultants (AMC) points out that there are several hurdles for the smooth implementation of the programme. "The cost of running a healthcare facility is going up. On one side, when authorities are insisting merest charges for the recipients of PMJAY, on the other hand, they are also saying the minimum wage of a nurse should be Rs 20,000. Further, several insurance companies also ask for NABH accreditation for healthcare providers. An institution cannot deliver care for long if it incurs losses," he explains.

It's not just Kapoor's view. The Indian Medical Association (IMA) and the Association of Private Hospitals, which represents 50 of the 79 charitable hospitals in the city, is also wary of approving the packages.

Kapoor points out that there is also an enormous deficit of skilled employees in the Indian healthcare sector. He argues that the government should give subsidies to the hospitals if they insist on providing such low rates. "Most of the nursing homes have nurses who have diplomas. If you start insisting that you need to have only qualified staff, the operational expenditure of a healthcare provider will go up. Currently, the property tax has doubled. Bio-medical waste disposal is also becoming more costly. Unilaterally deciding prices for procedures won't work," reveals Kapoor, who is the founder of the medico-legal cell of the Association.

Process Gaps?

Organised players are vacillating between welcome and resistance, due to several reasons. The state IMA which represents almost 43,000 physicians, had proclaimed the rates unworkable in the past. One of the major accusations against the scheme was that the pricing was 20 per cent less than that of the state scheme. Further, the encounter with several state-run projects has not been favourable for many players. Earlier, many associations had collectively decided that unless the package is revised, they will not get empanelled. "The government will try to force. But in a court of law, they will lose the case, " explains Kapoor.

Unhealthy Push?

PM Bhujang, President of Association of Private Hospitals, says that the pricing must be realistic and factor in expenses like infrastructure, equipment, import duties, and even water and electric charges, which hospitals often pay at commercial rates.

Yet, he doesn't think like many others that the low package rates might breed corruption and jeopardise the safety of patients. "Ultimately, it is the responsibility of the hospital to provide excellent patient care and safety. I don't think hospitals will compromise on that," he explains.

Ayushman Bharat Mission CEO Indu Bhushan had rejected the criticism earlier. He pointed out in an interview that the government had decided the rates based on a median.

Obvious Price Differences?

Many often cite the price differences of procedures. A typical C-section as an example costs ₹35,000-40,000 in a private facility. Under Ayushman, a private hospital will have to perform the procedure for only ₹9000.

How can this meagre amount recover the use of facilities, expertise and a doctor's services?" asks Bhujang. Some of the hospitals under the umbrella of the Association of Private Hospitals have already enrolled in the scheme. , Dr PM Bhujang, president of the Association of Private Hospitals, says, "Members who were part of state-run projects and RSBY are already part of the scheme. Many charitable hospitals any way reserve 20 per cent of beds for the poor. They spend 2 per cent of their income. Nobody has approached us. If they consult us, We can arrive at a win-win situation. "

He says that out of the 52 hospitals, who are part of the organisation, few have already joined the scheme. "Most of the hospitals which are currently part of the project are public and small private establishments. Very few super-specialist private hospitals have empanelled because of concerns regarding pricing," he explains.

Fous more on Primary Care than Tertiary Care?

Vaibhav Gupta, a public policy expert, has a slightly different take on this issue. The cornerstone or necessary foundation for the health system for a country like India has to be a good primary healthcare system and preventive measures. "If the government focuses on that aspect alongside (which it is doing to some extent with the wellness centres), I think it will have an impact on what needs to be 'treated' in private hospitals. This may also have an indirect impact on the costs of such treatments," he adds.

Mimicking the US Health System Not a Good Idea?

Ravi Duggal, a public health activist, argues that insurance is not a solution for India's healthcare woes. However, if the government wants to go the insurance way, ignoring examples like the US, then it shouldn't get into deciding prices. "The government should not get involved in determining the rates of procedures. Instead, they should allow insurance companies to decide the prices, as they are better at negotiation."

He also adds that it's better even to include the middle class in the scheme. " I am sixty-five years old and if I have to buy insurance for my family, have to pay at least Rs 40,000. However, if the government provides a scheme, where I need to pay part of the insurance and the rest will be paid by the government, the volume of the project increases, and it will become viable for all players.

The bigger question, Duggal, adds, is the consultation with stakeholders. "It is essential to take the stakeholders into confidence. What one is seeing is the resistance of various players, and it's important to address it at an early stage," he concludes.