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AB is a welcome step in the direction of achieving Universal Healthcare | Ashish Modi

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AB-NHPM (recently, re-christened as Ayushman Bharat: Pradhan Mantri Jan Aarogya Yojana) would be the largest government sponsored health assurance scheme that the world has ever seen, covering more than 50 crore individuals from economically weaker sections (EWS) of the society, identified through Socio-Economic Caste census (SECC). It also aims to improve the quality of primary healthcare infrastructure through creation of 15,000 health and wellness centres across the country.

AB: A bridge to achieve UHC

Universal health coverage involves access to quality health services – from prevention, treatment, rehabilitation and palliative care to all, without causing any financial hardship in the process. That is to say, access to quality healthcare services should not come as a financial shock that may push the family into debt-trap because of catastrophic out of pocket expenditure. AB aims to provide quality secondary and tertiary healthcare to about 40 per cent of India’s population through private as well as public empanelled healthcare providers to the extent of `5 lakhs per family per annum. Another key objective of this scheme is to induce health-seeking behaviour in EWS who did not have access to services of private healthcare providers till now because of prohibitive costs. AB is a welcome step in the direction of achieving UHC which also forms a part of safety needs in the Maslow’s need hierarchy.

Ensuing a paradigmatic shift

With implementation of government-sponsored secondary and tertiary healthcare at such unprecedented scale, discourse on public health management in India will see a paradigmatic shift from supply-side interventions to demand-side interventions. A balanced combination of the two is extremely important to ensure availability of quality services as well as its
accessibility to the poor and needy. Such a paradigmatic shift also poses immense opportunity for the medical insurance industry to penetrate deeper into the citizenry, much beyond only 10 crore lives insured through retail and group insurance till now.

Unstated goals

AB, apart from its stated goals, has many other inherent promising advantages in its design. Through standardised treatment guidelines and standard package rates, the differential cost of treatment at high-end private hospitals shall vanish. Administration of the scheme through a common IT platform promises a rich database on pan-India network of hospitals, nature and category of illnesses, preferred choice of treatment destination, etc. Such rich empirical data can be analysed to make well-founded policy interventions in future.

Implementation

AB, like many other in-patient healthcare systems across the world, shall be operationalised through an ecosystem comprising of beneficiaries, empanelled healthcare providers (EHCPs), insurance company (or Trust), TPA, IT service providers and the government as overall stage-setter and cost-bearer in the government-sponsored system. All the stakeholders in the system have their share of benefits. In the process, the beneficiaries receive quality healthcare (for IPD treatment) at no direct cost, EHCPs get business through increased foot-fall of patients, insurance company/TPA get business through insurance premium/ service cost paid by the government and lastly, the government achieves its objective of social good.

Systemic challenges

For the ecosystem to operate in a stable equilibrium and achieve its goals successfully, the interests of all the stakeholders must be properly accommodated without creating concerns for another. Firstly, a realistic pricing of insurance premium is sine-qua-non for the ecosystem to deliver through Insurance company/TPA. Secondly, package rates should be remunerative for the private EHCPs to board the ship. Unless private hospitals are taken on board, main objective of providing quality healthcare to EWS would suffer. AB has provisioning for quality of service and difficult area of operation, which shall compensate for the extra costs of operation. Thirdly, a herculean challenge is to design robust fraud mitigation and grievance redressal system brings in efficiency and satisfaction in the system for all stakeholders. Lastly, a well-designed IT platform for operation from beneficiary identification to claim processing is mandatory to ensure identification of ghost beneficiaries, timely pre-authorisation as well as hassle free claim settlement.

Operational challenges

A major challenge would be to bring the beneficiaries to EHCPs. A letter is being sent to all beneficiaries regarding their entitlement, but this may not be enough. The extensive network of ASHAs, ANMs and AWs should be used for the scheme to fly high. Further, there shall be many other operational challenges that AB may face at the field level. Some of them can be – fraudulent admissions, unnecessary hospitalisation, unnecessary/avoidable surgeries, charging money from patients even though the scheme is cashless, blocking of higher/multiple packages, connivance between beneficiaries and hospitals etc. However, the solution lies in making use of systemic support of robust IT platform, coupled with field level audit and detailed analytics at hospital/ doctor/ package levels, to identify such fraudulent practices and nip them in the bud.

Way ahead It is imperative that systemic and operational challenges are addressed, detailed protocols and guidelines are put in place and public discourse on AB is initiated in mission mode. The well-intended and much-needed scheme can, only then, bring in quality, transparency, standardisation and cost-efficiency in public healthcare management in India.

(Views expressed are entirely personal)

Next article: Insurance as a healthcare financing mechanism will always have a major role to play | Shreeraj Deshpande

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