Private sector’s active participation is crucial in AB- PMJAY : Dr Indu Bhushan, CEO, AB-PMJAY

Initiating an interactive discussion, Dr Indu Bhushan, CEO, Ayushman Bharat, answered the questions asked by the private healthcare leaders. He informed the private players on their crucial role for the success of Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY). He spoke on the various measures being undertaken by the government to increase the participation from the private health segment in the scheme.

“The vision of AB-PMJAY is to provide financial protection from hospitalisation costs to 40 per cent of poor people in the country. Active participation from private sector will be the key to success. We urge your cooperation for implementing and trying to evolve the scheme. We know that the private sector will not actively participate unless the rates are viable and we are working on it,” Bhushan said.

He informed that in nine months, close to nine crore e-cards have been generated. About 33 lakh beneficiaries have taken treatment worth Rs 4,500 crores with complete portability available across 16,000 empanelled hospitals in the country. Eight thousand of these are private hospitals.

“Private sector has actively participated in the scheme and they have been part of the initial success of it. Even then, there is some reluctance in the segment and we have to jointly overcome that. As per our findings in the package rates – many are slightly generous which should be reduced, while some packages are unfairly low and we are looking at it carefully. Yet, with the overall existing rates, if a hospital is providing care based on mixed health conditions, they can gain, but we can further validate it,” he said.

He also added that scheme has taken a big leap towards Universal Health Coverage (UHC) as 32 states/UTs are on board and at least 17 of these have decided to extend PM-JAY benefit package to their own state-sponsored categories. It has taken the current coverage through PM-JAY to more than 13 crores families which translates to roughly 65 crore people. About 1,400 health benefit packages across 23 specialities have been designed with rates.

Talking about making it a favourable bet for private hospitals, Bhushan said, “We might help with reducing cost as far as PMJAY is concerned. In years to come, we can do collective bargaining with the suppliers of devices and implants, also with the pharmaceutical industry where we will try to negotiate these inputs to the hospitals favourably. So far, we have got a good response from the industry. Thus, we can provide better rates which can help in reducing the cost. Cost can be segregated based on devices and procedures separately, so that we can ensure reducing the package rates.”

Answering to a question on differential pricing being a pain point, he said, “We fully understand that differential pricing is an issue and we fully recognise it. It poses a big problem and layer complexity for us on how to determine prices at the national level. Prices across the country and health institution vary hugely. As a beginning, we have laid out certain conditions like if hospitals in metropolitan area, or hospitals which are NABH-certified or hospitals in an aspirational district, and hospitals which give training to doctors and paramedics, can get higher rate. This may not be enough. So, we are undertaking a review with the industry and other stakeholders. However, do not expect a huge change in the rates, as there is a trade between providing higher rates and sustainability of the scheme.”

Informing that the scheme is to stay, Bhushan concluded, “It is just a modest beginning and when the scheme matures, we will have two crore new admissions every year. The vision is clearly laid out in front of us and the support of all stakeholders is imperative. This scheme is not a sprint, it is a marathon and there is no stopping. Initial progress has been encouraging and humbling but there is a long way to go.”

1. PM-JAY is being implemented in the true spirit of cooperative federalism; convergence with the state schemes and the flexibilities being adopted by each implementing state. This puts PM-JAY in a unique proposition where it does remain as one scheme but an amalgamation of 32 different state schemes. At the central level, the objective of the scheme cannot be achieved without strengthening the digital ecosystem in the country. Thus, it was a challenge to design and develop an IT platform which was stable, inter-operable, secure and scalable.

2. A robust IT backbone has been developed and is being strengthened for success of the roll-out of the scheme across the country. The technology platform serves as a key enabler for ensuring that the scheme is implemented in a transparent and data-driven manner. IT platform enables in delivering portability across varied IT systems being used all empanelled hospitals in the country. The data so generated immensely helps in data analytics and fraud control.

3. Three main IT solutions, backed by scalable and inter-operable cloud based infrastructure, being utilised under Ayushman Bharat PM-JAY are as below:

a. Beneficiary Identification System (BIS): Used by hospitals/Common Service Centres to verify beneficiaries
a.i. Captures beneficiary demographics and matches against beneficiary list in back-end
a.ii. Generates unique NHA ID to track patient utilisation and claims
b. Transaction Management System (TMS): Used by hospitals to manage patient cases
b.i. Captures transactions including pre-authorisation request, treatment plan, claims submission and payment
b.ii. Displays pre-authorisations and claims status for action
c. Hospital Empanelment Module (HEM): Used by states and hospitals to manage the empanelment process
c.i. Captures hospital information on infrastructure, medical staff, specialities, compliance etc.
c.ii. Generates unique Hospital ID to track service utilisation and claims
4. States using their own IT platforms are linked with PMJAY IT system through API integrations with their data made available in NHA data warehouse.
5. With this huge base servicing more than 50 per cent of India’s families with portable benefits at any of 16,000 hospitals empanelled, currently the IT systems enables:
a. More than five beneficiaries per second are identified
b. More than 10 beneficiaries per minute are admitted to the hospitals
c. More than one lakh worth of treatment per minute is extended to the beneficiaries
How PM-JAY has the potential to revitalise the entire health ecosystem:

• Continuum of care: All Ayushman Bharat transactions are digitally recorded and stored in data warehouse under PMJAY. Thus, the programme not only provides an unprecedented opportunity to address the health needs of more than 50 crore citizens in a comprehensive manner but also to define the priorities for the health system as well as shape future policies by drawing insights from the large data sets that will be generated. Ayushman Bharat through the National Health Stack being envisioned by NITI Aayog, can go a long way in synergising the programmes with the help of backward and forward linkages of data to ensure continuum of care. In collaboration with NITI Aayog, NHA is also exploring the use of Artificial Intelligence / Machine Learning for fraud/abuse control and improving treatment protocols. This will eventually be path-breaking for bringing in efficiencies in healthcare financing in the country.
• Improving the ecosystem of health insurance: Joint working group of NHA and IRDAI has been formed to help synergise the data collection, analysis and actions taken in the health insurance sphere in the country.
  The working group will also work on areas of – hospital network management, data standardisation and exchange, fraud and abuse control and National Health Claim Portal: common IT infrastructure for health insurance claims management. This will bring the entire industry to talk the same language and enable sharing of insights seamlessly.
• Ensuring supply in a supply constrained country: With big data analytics, government can efficiently manage healthcare support to the last mile and deploy automated systems and predictive analytics that will enhance the quality of health care in the country. Thus, information generated under Ayushman Bharat can pave the way for:
• Advancement of personalised medicine in the country
• Identification of gaps in availability of access to providers, health benefit packages and capacity building requirements
• Birth of innovative means to cater to the huge population (eg Artificial intellilgence and telemedicine) given the paucity of healthcare infrastructure at the last mile
• Bringing in efficiencies in management through automation and access to real time information using artificial intelligence and smart devices
• Building a strong feedback mechanism riding on the call centre and mobile app, thereby empowering the people
• Improving quality and monitoring: Ayushman Bharat can go a long way in improving the governance of health facilities by providing crucial data on the quality of care they offer which can also be substantiated by tracking and identification of fraud and abuse to plug leakages, saving misuse of government resources.
• Promoting innovation and partnerships: There is a need to find a way to balance the increasing care expectations of patients in a connected world and the facelessness of technology-driven healthcare. Cost effective technologies for improving quality of treatment/ quality of life is the way how Ayushman Bharat can further its cause. NHA is keen in promoting and partnering with innovative startups and academic institutions or any other relevant organisations.