Ayushman Bharat: States with existing schemes did well in enrolling hospitals

At first glance, the number of hospitals empanelled under the Centre’s flagship Pradhan Mantri Jan Aarogya Yojana (PM-JAY) — or Ayushman Bharat scheme — within 100 days of its launch appears heartening.

But dig a bit deeper and it transpires that States that already had health insurance schemes have done well on empanelment. Thus, of the over 16,200 hospitals empanelled, as per PMJAY, just five States — Gujarat, Tamil Nadu, Uttar Pradesh, Chhattisgarh and West Bengal — account for half the number.

Barring UP, the rest already had health insurance schemes and these have been dovetailed with PMJAY. With basic systems, infrastructure and operating procedures in place, it was easy for these States to implement PMJAY.

In greenfield States, with no existing health insurance scheme, such as Madhya Pradesh and Haryana, the hospital empanelment number is just 200-300.

“Other than in M.P. — where it was decided to limit empanelment to NABH (National Accreditation Board for Hospitals and Healthcare Providers) accredited hospitals — all other greenfield States have done well in enrolling hospitals,” says Dinesh Arora, Deputy CEO, National Health Agency.

Gujarat, which tops with 2,700 hospitals empanelled, already had a medical care scheme, Mukhyamantri Amrutum Yojana, providing cover of up to ₹3 lakh per family per annum to Below Poverty Line families (launched by Narendra Modi as Chief Minister in 2012). Transitioning into Ayushman, which offers a cover of ₹5 lakh per family, was thus easy.

Chhattisgarh, where about 1,300 hospitals are on board, had two schemes — Rashtriya Swasthaya Bima Yojana for unorganised workers and Mukhyamantri Swasthaya Bima Yojana (MSBY) offering cover of up to ₹50,000 per family per annum (up to five members).

The 40 lakh beneficiaries under MSBY were moved to Ayushman and recent figures reveal that over 55 lakh PMJAY cards have been issued.

Tamil Nadu, which ranks No 2 with 1,700 hospitals, integrated its Comprehensive Health Insurance Scheme (CMCHIS) — offering a cover from ₹1 lakh per year to ₹2 lakh for specified procedures for people with annual income of less than ₹72,000 — with PMJAY. West Bengal integrated its ‘Swasthya Sathi’ with PMJAY.

“Obviously, in States with existing schemes, the progress has been healthy. In some greenfield States such as UP, too, it has been good. In metros, bigger hospitals may be reluctant to come on board, given the higher cost of services, but we are not seeing any issue in hospitals with 50-100 beds,” says Arora.

Hybrid model

Under the insurance model, the insurance company administers and pays the claim. Under the trust model, each State forms a trust to manage the scheme. Under hybrid, up to a specific amount, the claim is processed under the insurance model and amounts over the cap via the trust.

Market players explain that in States which already had schemes, and in those that adopted the hybrid model for Ayushman, empanelling bigger hospitals has been easier. This is because to some extent fraud-prevention is taken care of. Jharkhand is a greenfield State that has adopted the hybrid model and is doing well.

“In Chhattisgarh, a claim package of up to ₹50,000 is taken under the insurance model and above that under the trust model. Since the claims ratio is high (9-10 lakh claims a year), a higher cover under the insurance model will mean a higher premium. But to handle large number of claims under the trust model, more resources are needed, and may be difficult for all States to implement,” says the State’s Health Director R Prasanna.