Encouraging Private Hospital Empanelment Under Ayushman Bharat

As nations strive for universal health coverage, India too has taken an ambitious step towards it. The Indian Government launched the world’s largest healthcare scheme in September 2019- a beacon of hope for access to quality healthcare for millions of citizens. 

Ayushman Bharat Pradhan Mantri Jan Arogya Yojna (AB-PMJAY) covers non-primary medical and surgical treatment up to INR 5,00,000 per annum in its empanelled hospitals for economically weak and vulnerable citizens i.e. nearly 40 per cent of India’s total population. This is a huge leap from the INR 30,000 coverage of RSBY (Rashtriya Swasthya Bima Yojana). 

 A decade ago, more than 67 per cent of healthcare expenses were out-of-pocket spend which has reduced to 49 per cent today. While it is impressive progress, for a country like India, it becomes crucial to onboard more and more private hospitals. 60 per cent of our 18,00,000 hospital beds are in the private sector. 

This is compounded by the fact that the reputation of public hospital services has taken a significant beating, resulting in Indians opting for private healthcare. India has a total of more than 80,000 hospitals. Currently, more than 29,000 hospitals are empanelled under AB-PMJAY; comprising 14,781 public (51 per cent) and 14,501 private (13,118 for-profits + 1,383 not-for-profit) hospitals.

Although the uptake is gradually increasing, many private hospitals are still sceptical to be associated with the scheme citing that compensation rates are low; thus making it an unviable option for them. Though some states like Chhattisgarh, Gujarat, Rajasthan and Orissa have implemented similar parallel schemes which have found takers in private sector especially the smaller hospitals of 50-100 beds size. 

While the National Health Authority (NHA) has being proactive to listen to the on-ground of the corporate sector and motivate them, rationalising procedure tariffs based on private sector overheads and operational expenditure would immensely help its participation. 

Rates offered for procedures related to cardiology, nephrology and oncology (including radio-therapy and chemo-therapy) are rational and are higher than those offered in CGHS. There are nearly 2,000 treatment procedures across more than 25 specialities covered under the scheme. Allowing for selective uptake of procedures will further encourage the private sector. 

Super-speciality hospitals and single-format hospitals, like maternity hospitals, should be allowed to have elective choices. AB-PMJAY factors in most of the tertiary healthcare expenses like travel, OPD, diagnostics, etc. However, domiciliary care for 2-3 weeks for pre and post-hospitalisation is a significant expense which should be looked into.  

Another worry of private sector is delay in payment from government (as experienced in the case of CGHS and many state-run schemes). Timely reimbursement and maybe even reducing the credit period from 60 to 45 days can help assure the private sector. 

Majority of empanelled hospitals are in states with previous experience in public insurance schemes. AB-PMJAY can further strengthen this army by finely analysing some of the successful state health schemes like Ma Yojna of Gujarat, Arogyasri of Telangana, Biju Swasthya Kalyan Yojana of Odhisa, Swashtya Sathi of West Bengal, etc. 

In the United States, there is a physician payment system used by the Centers for Medicare & Medicaid Services called resource-based relative value scale (RBRBS). Similarly, AB-PMJAY could adopt a graded system to pay consultants based on their experience and achievements. 

This global practice could also be applied to diagnostics. For example, a 3 Tesla MRI costs exponentially more than a 1.5 Tesla machine. However, we have one rate for all MRI scans. An ungraded rate like this is discouraging for providers with sophisticated medical technology. 

Public and private healthcare need to work hand-in-hand to make the dream of universal health coverage a reality. 

Dr Vivek Desai

Guest Author The author is Founder & Managing Director, HOSMAC