Our focus is to ensure that poor are able to access curative care across hospitals

In a freewheeling and an exclusive interview, Dr Indu Bhushan, CEO, NHA, AB-PMJAY, who has been spearheading Ayushman Bharat Pradhan Mantri Jan Arogya Yojna, a healthcare programme of huge magnitude and complexity, talks to Prathiba Raju about rolling out the initial phase of the scheme, the challenges and achievements

What was the major achievements and challenges according to you in the first 157 days of implementation of PMJAY?

We have been able to issue more than two crore e-cards to beneficiaries in less than six months into the scheme’s implementation. In the same time, more than 16 lakh beneficiaries across the country have availed free treatment worth Rs 2,000 crores for serious illnesses. Our biggest challenge and focus so far has been, and continues to be beneficiary empowerment through awareness generation. While we have issued more than 2.6 crore e-cards to beneficiaries, we still have to reach out to more than 10 crore households in the country. We need to empower them by making them aware of the features, benefits and their rights as beneficiaries under the scheme and we are doing that by various kinds of Information, Education and Communication (IEC) campaigns.

Can you let us know which procedures patients mostly use under PMJAY? Any disease pattern tracked till date.

In general, India is seeing an upward trend in the incidence of NCDs (non-communicable diseases) as lifestyle-related diseases are on the rise and the state of preventive healthcare and level of nutrition is becoming relatively better. This is also getting reflected in the data coming from the scheme though we need to analyse it further and deeply.

So far, how many private hospitals have been empanelled in PMJAY? The private hospitals are not happy with the packages. Your comments.

So far, 14,876 hospitals have been empanelled under PM-JAY. Private hospitals will always want more. We will never give them the rack rates and are working and trying to move them from low volume to high margin to large volume to low margin. They are not happy. We understand that there are some issues and we are working on them. The main objective and focus of Ayushman Bharat is to bring quality in secondary and tertiary care to 50 crore poor and vulnerable individuals comprising the bottom 40 per cent population of the country. It is to ensure that the poor are able to access curative care at both public and private hospitals for treatment of serious illnesses.

Many private hospitals have been in news for rising billing costs, unethical practices as well. How do you keep a tab on them when it comes to implementation of the scheme?

Our focus of the scheme is to ensure quality of care for the beneficiaries through a large network of public and private empanelled hospitals, while at the same time controlling any fraud and abuse. Various mechanisms and measures were undertaken to build the very design of the scheme. Even before the scheme’s launch, we have launched policy guidelines for hospital empanelment, claims processing, beneficiary identification, and anti-fraud, where there can be potential to defraud the system. We have also put in place a technology-led fraud and abuse control cell to prevent fraud and to look into triggers that can lead to fraudulent practices and dishonest dealings.

What measures have been taken to prevent frauds and make sure that the scheme is reaching the beneficiaries? Any examples.

For a programme of such scale, magnitude and complexity as that of Ayushman Bharat Pradhan Mantri Jan Arogya Yojna, it is critical to put in place a strong anti-fraud mechanism not only from financial perspective, but also to safeguard people’s health from unethical practices. National Health Authority (NHA), the nodal agency for implementation and oversight of the scheme, has taken a number of steps to safeguard the programme from the inception. Some of the key actions taken in this regard are listed below.

Policy and design level

• Transparent tendering process implemented for empanelment of insurance company, implementing service agency and service providers.
• Tightly worded legal contracts for service delivery as per pre-defined SLAs have been developed with penalty clauses and punitive action to deal with fraudulent activities on the part of any agency involved in delivering services under PMJAY.
• Hospital empanelment process has been developed with two-tiered structure approach involving district level and state level committees, having due representation of senior officials – civil surgeon, chief medical officer and nodal officers of the district.
• The entire process is web-enabled wherein a hospital can track the status of its empanelment from application to approval stage.
• IT system and processes have been designed with checks and balances along with defined roles and responsibilities, role-based logins and audit trails for all processes – beneficiary identification, transaction management system, funds flow, claims payment etc.
• Further, all pre-authorisation and claims transactions are carried out online for efficiency and complete transparency.
• The process of pre-authorisation has been designed to ensure maximum efficiency while avoiding abuse and fraud.
• Minimum requirements for claims investigation and medical audit have been laid down.
• The tendency of healthcare providers to overcharge, bill extra and other related issues has been taken care by introducing all-inclusive package rates. However, sufficient flexibility has been given to treat patients requiring medical management and the list for procedures shall be enhanced as more experience and insights are gained.
• Comprehensive anti-fraud guidelines were released by Minister of Health & Family Welfare on August 27, 2018 for laying down detailed strategy, processes, systems and manpower for anti-fraud both at the national and state level
• Whistle Blower Policy adopted at NHA level in December 2018, shared with the states for adoption on similar pattern.

Operational and system level

• NHA had issued anti-fraud advisory notes requesting states to expedite the creation of their anti-fraud unit to identify and investigate suspect cases in December 2018.
• Capacity building workshop for fraud control and medical audit organised for SHAs, ISAs and insurance partners on December 14 to 15, 2018 in New Delhi
• Fraud investigation and medical audit manual released in December 2018
• Monitoring and analysis of utilisation trends done through regular MIS and dashboards, watch over abuse prone packages, suspect transactions/hospitals watchlist being prepared for sharing with SHAs on regular basis from January 2019. Cases were shared with Jharkhand, UP and Chhattisgarh so far.
• Medical Audit Capacity Building Training and Field Audits conducted in Jharkhand on January 21-23, and feedback shared with SHA. Show-cause notices were issued by SHA to – Nagarmal Seva Sadan and PVTG Hospital on February 7, 2019.
• Top analytics firms- Fraud Analytics- Proof of Concept initiated with top analytics firms — SAS, MFX, Lexis Nexis, Optum and Greenojo on January 7 for triggering suspect transactions and entities through rule engines and artificial intelligence layer. The teams have started creating triggers and results being shared with the states on a regular basis from February 28, 2019.
• Mobile App – Kaizala by Microsoft has been customised for field investigations and medical audit, test deployment done in January 2019. It will be rolled out soon.
• Procedure-specific documentation and checklist being developed for controlling abuse and leakages, integration with IT is under progress.
• Adjudication guidelines and capacity building workshop for SHAs/ISAs processing teams — scheduled for UP, Bihar, Haryana, J&K, Uttarakhand, Himachal Pradesh on February 21-22. Rest of the states will be covered soon and such workshops are being conducted round the year.

Since the announcement of the scheme, there has been criticism by many state governments, but as of now out of 33 states, you have successfully implemented it in 31. How are you handling politics over smooth implementation?

The objective and focus of Ayushman Bharat is to bring quality secondary and tertiary care to 50 crore poor and vulnerable individuals comprising the bottom 40 per cent population of the country. Our focus is to ensure that the poor are able to access curative care at both public and private hospitals for treatment of serious illnesses, which they have not been able to do since they are unable to afford expensive hospital care. In the absence of such capability, the poor either accepted their fate and procrastinated treatment or were forced to sell off their assets or undertake huge debt that pushes six crore people into poverty every year.

The objective of Ayushman Bharat is to help change this healthcare, seeking behaviour among the poor regardless of region, state or politics and that is how we have been able to get most of the states, especially led by opposition parties, and UTs on board. The scheme by its very nature and design rises above politics and ideologies to appeal to all administrations and regimes.

As far as IT implementation in states is concerned, it is provided in a hosted manner. States like Jharkhand, which did not even have a health insurance scheme, have managed to empanel 600 hospitals and treat 95,000 patients for free within six months of launch. It also provided the flexibility — for example Jharkhand offers PM-JAY coverage to anyone with a BPL ration card in the state. The open API approach ensured states could rapidly integrate and configure the IT system to meet the states’ needs. Existing states that converged the scheme with PM-JAY like Tamil Nadu and Karnataka have managed to integrate in a couple of months. Portability has also been a big benefit brought out by the scheme. Technology has helped people with cancer, cardiac and other tertiary care diseases to seek care outside their state in some of the top medical institutions in the country. This was not possible prior to PM-JAY.

How will the scheme benefit through the tie up between IRDAI and Insurance Information Bureau of India (IIBI)? What would be the outcome of the joint working group? What kind of SOPs will be brought in?

To support the implementation of AB-PMJAY with the active involvement of various stakeholders and to further strengthen the health insurance ecosystem, a working group with IRDAI and NHA has been constituted to work on key areas of mutual interest and cooperation. These areas will include, among others, network hospitals management, comparative study of packages and their rates and mapping to uniform codes, defining standards and indicators for safe and quality healthcare, data standardisation and exchange, fraud and abuse control, common IT infrastructure for health insurance claims management. The working group may consult experts from insurance industry, healthcare providers, NABH, IT, third party administrators etc. in the course of their deliberations.

Any update on the integration of Health and Wellness Centres (HWC) and PMJAY and how will IT be used to create this seamless integration?

To ensure the envisioned paradigm shift from illness to wellness of beneficiaries, we at NHA believe that healthcare should be well-integrated and there should be continuum of care from primary (preventive) care to secondary and tertiary (curative) care. This continuum of care is not only imperative for streamlining access to care for beneficiaries, but also pivotal in providing timely, quality care to beneficiaries by creating a digital feedback system across different levels of care. It is important that there is a good coordination between tertiary hospitals and HWCs. We can help MoH&FW integrate HWCs with PM-JAY so that appropriate beneficiary follow-ups backed by IT are done, so patients can get continuum of care. We have written to the ministry about this and are currently waiting for their response.

Do you think states have enough awareness on the scheme? How do you ensure the same? Can you give us a feedback on how states are performing in imbibing the scheme?

As mentioned before, one of our main focus areas is currently beneficiary empowerment through awareness generation. While we have issued more than 2.6 crore e-cards to beneficiaries, we still have to reach out to more than 10 crore households in the country. We need to empower them by making them aware of the features, benefits and their rights as beneficiaries under the scheme and we are doing that by various kinds of campaigns.

The first round of Additional Data Collection Drive covered rural areas and was successfully implemented in 22 states with its initiation on April 30 as ‘Ayushman Bharat Diwas’. Similar exercise was also organised in urban areas in the month of May to verify the eligible families and collect additional information from them. The objectives of the drive were two-fold — to inform the eligible beneficiaries about the programme, its benefits; and to validate the existing beneficiary list and collect additional information wherever necessary, from each beneficiary family. 94 per cent of all targeted families reached across 25 participating states/UTs.

NHA has signed MoU with Common Service Centres (CSCs) for beneficiary identification and is utilising over three lakh village level entrepreneurs for identifying beneficiaries. So far, more than 2.6 crore beneficiary e—cards have been generated through the CSCs, and by Pradhan Mantri Arogya Mitras at empanelled hospitals.

Personalised beneficiary identification letters signed by the Prime Minister with family card have been sent to all the identified families in the villages and towns across the country. So far more than 7.7 crore letters have been delivered to the beneficiaries’ doorsteps. This will drive awareness among the beneficiaries and further ease the identification process when they visit points of care or CSC centres.

We have also launched a mobile app ‘Ayushman Bharat (PMJAY)’ for citizens to get access to information on PM-JAY, check the eligibility and find hospitals nearby and get assisted help. The app is available for download on Google Play Store. It has crossed more than 2.25 lakh installations with a rating of 4.3.

Will there be trimming of existing packages, which is currently 1393?

NHA is going to undertake a Health Benefit Package (HBP) revision exercise. This will include rationalisation of the package list also. It will be the job of specialist committees to examine the packages offered under their specialty. Depending upon their recommendations, the number of packages may go up or down.

You had discussions with National Pharmaceutical Pricing Authority (NPPA) to negotiate special rates for implants or other devices that are used under PMJAY to further bring down the cost. What would be the new cost if they accept?

It is too early to predict anything on this front. At present, NHA is holding discussions with NPPA on how to take up this initiative, the detailed methodology for the same will have to be worked out and after that field studies can be done. Only then some scientific conclusions which are acceptable to the stakeholders can be made. To say anything on this subject at present will be speculative.

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