Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB – PMJAY) happens to be one of the few schemes in the country, which is 100 per cent data-driven and analytics-oriented from the day one of implementation, reveals Dr Indu Bhushan, CEO, Ayushman Bharat, to Akanki Sharma, in an exclusive interaction
With regards to Ayushman Bharat, how is India building a strong capability in digital health?
India is on a journey towards equitable and Universal Health Coverage (UHC) where healthcare expenditure is being covered for more and more Indians with every passing day. Delivering this requires the country to develop an efficient digital health ecosystem, especially, health claims processing – using technology to enhance the efficiency, and also bring down the cost of processing a health claim from over Rs 500 approximately by 10 per cent of the same, or even less. The National Health Authority (NHA) and Insurance Regulatory and Development Authority of India (IRDAI) has proposed a new ‘Health Claims’ platform that will bring a stock exchange-like system for health claims processing to India. We work with over 20,000 of the top hospitals in the country. Today, if the hospital is giving you a paper report, we are working on getting an electronic version of that into your health record. Soon, doctors and modern AI systems will be able to use your health history and records to make better decisions about your care.
What are your plans to implement telemedicine and other digital health applications to cover up the shortage of doctors?
We are in the process of implementing what we call IT 2.0 – it shall be our step forward to create arguably the world’s finest digital health assurance ecosystem – with everything that seems to be important to be made fully automated, paperless and standardised. We are working on seven pillars for the same, which are complete e-health assurance system, standardisation of data, artificial intelligence (AI), convergence, analytics, fraud control and security and privacy by design. We expect the healthcare ecosystem to use the key enablers we are developing in terms of low-cost claim processing and health records to improve how care is delivered to beneficiaries.
India’s non-communicable disease (NCD) burden is growing and the best way to tackle it is to identify beneficiaries who are most at risk, and work on preventive approaches with them so that they don’t need surgical interventions or hospitalisation. Our digital health applications and interventions will focus on this and enable the use of technologies like telemedicine.
Last year, the Union Ministry of Health and Family Welfare had released the National Digital Health Blueprint (NDHB) to ‘manage and analyse’ the big data generated by Ayushman Bharat. Can you tell us how and what all has been managed and analysed so far? Any examples?
Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB – PMJAY) happens to be one of the few schemes in the country, which is 100 per cent data-driven and analytics-oriented from the day one of implementation. The NHA has been using analytics extensively in policy design, fraud control, operational monitoring, etc. – not just in a reactive manner, but also in a proactive fashion.
Analytics has helped us in deciding on benefits such as packages and pricing, and keep a strong check on the same. The revised 2.0 benefit packages are now being adopted by states, which are finalised on a completely data-driven approach. Analytics has helped identify suspected beneficiary fraud and fraudulent claims — NHA has been able to notify the concerned states and ensure action is taken on these cases.
Analytics is also helping us identify why claim processing gets delayed for a few cases between hospitals and insurers. Our teams are then able to improve the process which is how we can ensure hospitals are getting their money on time. It shall be fair to say that data and analytics have been the key to achieve efficiency, effectiveness, reliability, accountability and transparency in the scheme.
Is the Ayushman Bharat software 100 per cent secure? If yes, how do you justify/ensure that? If not, why, and what steps have you taken to ensure its authenticity?
The software from NHA is an enabler that makes it easy to find onboard beneficiaries and helps hospitals and states in raising and processing of claims. Most of these activities involve human judgement and decision making. However, the system is designed with several checks and balances to ensure the least amount of errors occur during processing. Specialised analytics support the human processors by providing just-in-time alerts and proactively pointing out possible issues in a claim. Our approach to proactively monitor and control transactions using electronic checks has been working efficiently and we continually strive to make it better with our IT team’s efforts.
How do you plan to convince private hospitals to get themselves empanelled under the Ayushman Bharat Scheme since they do not seem to be keen enough to participate?
It is not correct to say that hospitals are not keen to participate. We have 22,000 hospitals empanelled under the scheme out of which nearly 50 per cent are private. It is heartening to know that these private hospitals are at the forefront of providing care to the beneficiaries as is evidenced by the fact that 51 per cent of services have been provided by the private hospitals.
We have put in a slew of incentives for hospitals, especially hospitals in remote areas, aspirational districts and medical colleges. We have also put in place Bronze standards certification, in partnership with the Quality Council of India (QCI) to motivate and enable non-accredited hospitals to adopt higher quality standards.
There is a tool called ‘Zero’. Can you share some details on it?
We are not using any such tool. What we have built is the RADAR which enables monitoring of PM-JAY utilisation across states through data such as the utilisation by hospitals, top specialities/ procedures, etc. This is a tool developed by NHA to monitor the scheme’s performance regularly and enable evidence-based decision-making.
Since Ayushman Bharat involves e-governance, how do you ensure IT systems continue to work and there are no glitches?
Not just e-governance, NHA is also committed to m-governance to be fully in place. We view the IT software as mission-critical in the delivery of services to our 500 million beneficiaries – and we are 100 per cent technology-driven by nature. We have ensured that the true flavour of e-governance and m-governance is leveraged to provide benefits till the last mile – with 32 states and union territories, diverse demographic and geographic conditions.
Even though there are internet-connectivity challenges, multi-language-based documents and real-time requirement of monitoring, we have still been able to perform ever since the initiation of the scheme and have grown exponentially to be able to provide equitable health assurance to our beneficiaries across the country. With over 88 lakh health transactions comprising benefits over Rs 12,000 crores delivered to our beneficiaries in less than 18 months – the performance of the systems talks for itself. The system has been architected to provide high availability and there are strong controls to ensure security and privacy of the data. We have a strong IT team in place – including key technical experts who ensure on-going support and improvements of the system.