Prime Minister Narendra Modi launched the Ayushman Bharat–Pradhan Mantri Jan Aarogya Yojana (AB-PMJAY) in Ranchi, Jharkhand on 23 September. Billed as the world’s largest government-funded healthcare programme, the scheme, also called ‘Modicare’, aims to provide insurance cover of up to 5 lakh per family per year to more than 500 million socio-economically deprived Indians for secondary and tertiary care hospitalization.

Union minister of health and family welfare J.P. Nadda in an interview with Mint talks about the implementation of the scheme and how his ministry will ensure its success. Edited excerpts:

What is the progress of scheme after its launch?

We have sent letters to over 60 lakh beneficiaries so far. Beneficiaries under AB-PMJAY will be entitled to 1,350 benefit packages across 23 specialties. Over 38,585 e-cards have been issued and 22,110 beneficiaries are admitted in various hospitals. We have authorized 35.8 crore for hospital admissions till 29 September. Also, we have received 30,510 applications from hospitals to be a part of the scheme.

How will you prevent frauds and maintain privacy of patients in AB-PMJAY as fraud has been a common affair in previous insurance-based health schemes?

A robust IT (information technology) system has been implemented at each empanelled hospital to form the backbone of AB-PMJAY. A beneficiary identification system accurately identifies entitled citizens, a transaction management system facilitates smooth cashless and paperless patient registration and claims processes, and a fraud management system with advanced analytics is being designed to minimize malpractice under the scheme. Moreover, the IT system enables portability, ensuring that entitled citizens can avail services across India regardless of which state they come from. Steps have been taken to ensure data security and privacy also.

How do you think AB-PMJAY will impact the landscape of healthcare in India and what makes you confident of its success, when outcomes of most of the health insurance-based schemes in India have been poor?

Prime Minister Narendra Modiji’s vision is to provide affordable, accessible and equitable healthcare services to the most needy and deprived. This vision has translated into the innovative and visionary AB-PMJAY scheme. Poised to be the largest public-funded health insurance scheme in the world, it is a major step towards universal health coverage and aims to reduce catastrophic out-of-pocket expenditure on health services for the poor and vulnerable sections of the society. The Prime Minister envisions a nation where people do not fall below the poverty line due to these excessive expenditures. It will cater to the unmet needs of the population which remained hidden due to lack of financial resources. Poor people living in any part of the country shall be able to access quality health services across the country.

Photo: Mint
Photo: Mint

How will India, which is one of the economies spending least on healthcare i.e. below 2% of GDP, able to handle the huge costs involved in the scheme?

Let me assure you that there are ample funds. 2,000 crore was just an initial allocation to start the things this year and this amount will be sufficient for the initial phase. If needed, states can demand more funds at the revised estimate stage. As I have said on many platforms, we are poised to proceed with all our schemes and funds are not an issue.

Government has promised almost 40% of Indian population free and cashless healthcare services under AB-PMJAY. How will the country that already has a shortage of doctors and beds handle more patients to be covered under the scheme?

AB-PMJAY is designed to protect vulnerable populations against the financial shock arising from healthcare emergencies. However, there is a large demand- supply gap in the healthcare sector that we need to address. AB-PMJAY itself incorporates a few solutions to this problem—it provides financial incentives to empanelled healthcare providers to increase their infrastructure and improve their quality of care. The scheme also sets spending guidelines for public hospitals designed to increase capacity and bridge the demand-supply gap. Even with these provisions, we acknowledge that a shortage of healthcare providers is a significant challenge that needs special focus. As such, our government has launched several initiatives beyond AB-PMJAY to tackle the healthcare supply problem. Shortage of beds cannot be discussed under the ruse of AB-PMJAY. Our country needs more beds and we are making consistent efforts towards same. First, the ministry has taken several measures to facilitate the setting up of new colleges. These measures include rationalizing the norms for medical colleges, dispensing the minimum land area requirement in notified urban areas and allowing companies to set up medical colleges. Currently, at 502, India already has the highest number of medical colleges in the world. The recent steps taken by the ministry will significantly increase the number of medical colleges and help address the supply gap.

Photo: PTI
Photo: PTI

There have been reports of private hospitals refusing treatment under the Central Government Health Scheme (CGHS) over delays in payments. How will the government ensure to avoid such delays and tussles with private sector in AB-PMJAY?

Under AB-PMJAY, all empaneled healthcare providers (EHCP) will be paid directly through the insurance company or the trust after the treatment and discharge. As per claim settlement guidelines, all EHCPs will make use of IT system of AB-PMJAY, to manage the claims related to online transactions and all stakeholders are advised to maintain online transactions preferably to ensure the claim reporting in real time. Under these guidelines, the payment for treatment has to be made to the provider within a period of 15 calendar days (irrespective of the number of working days). For claims outside the state, a time of 30 calendar days will be provided. The trust/insurer shall make claim payments to each EHCP against payable claims on a weekly basis through electronic transfer to such EHCP’s designated bank account. The insurer is then also required to provide the details of such payments against each paid claim on the online portal. Further, as package rates have been set to include cost of pre-hospitalization, hospitalization and post-hospitalization expenses, delays or confusion will be avoided. The trust/insurance company will need to update the claim settlement data on the portal on a daily basis and this data will need to be updated within 24 hours of claims payment. Any claim payment which has not been updated shall be deemed to have been unpaid and the interest, as applicable, shall be charged thereon.

As most of the private hospitals empanelled under AB-NHMP are not accredited by National Accreditation Board for Hospitals (NABH), how will government ensure quality healthcare?

As per guidelines set down for hospital empanelment, the State Health Agency (SHA) through State Empanelment Committee (SEC) will empanel private and public healthcare service providers in their respective states/Union territories. Post a verification of documents submitted through the online empanelment application, district empanelment committees (DEC) are mandated to conduct a physical verification using a qualified medical professional or a selected insurance company under the insurance model. To ensure quality healthcare services, all hospitals are mandated to obtain a NABH pre-entry level accreditation within one year of empanelment with a provision of two one-year extensions. Furthermore, hospitals with NABH accreditation are encouraged to improve their quality of services through financial incentives for achieving quality milestones. In case a hospital’s application is rejected due to quality concerns, the hospital will be intimated the reasons for the rejection through the web portal and will have an opportunity to address quality concerns the next time they apply.

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