Ayushman Bharat – A Not To Be Missed Opportunity
After a long time, healthcare is back on the tables of political and social discussion, since the announcement of the National Health Protection Scheme or Ayushman Bharat. The scheme promises a health insurance cover of `500,000 per family per year to over 40 percent of India’s population, making it the world’s largest non-contributory public health insurance scheme. The scheme is different from other health insurance schemes in multiple respects. It offers a high insurance cover, covers many more people, and covers all pre-existing medical conditions. It is independent of the number of family members, is based on SECC data – meaning there is no formal beneficiary enrollment, and is primarily aimed at lower order cities. Further it has well-defined operational guidelines in terms of beneficiary identification, hospital empanelment, transaction management, and claim settlement.
The scheme also marks an important transition toward demand side financing with increasingly more funds allocated for purchasing of services from the private providers, instead of building public infrastructure. Further, this marks a step toward Universal Healthcare which will cover the entire population and provide for all kinds of health services. However, the real challenge lies in executing this scheme, given its magnitude and the federal nature of healthcare in the country. More than 20 states have opted for the trust model which makes the scheme easy to regulate and monitor from a transparency perspective. However, this model is deprived of an important layer of fraud analytics checks which commercial insurance companies have developed over a period of time. Further, the payments might be delayed once the funding is exhausted by the trust.
Hospital empanelment is a challenge given the rates offered are lower than CGHS rates. While more than 9000 hospitals have expressed an interest, the actual number of hospitals that will eventually get empaneled might be lower. Residual concerns remain over delayed payments given the experience from previous public health insurance schemes. Further, the scheme requires a basic setup of IT infrastructure, requiring a certain capital and technical cost. It remains unclear how the hospitals will cater to this requirement, especially the public hospitals. The scheme promises higher insurance rates for hospitals with NABH accreditation. However, given that less than 1000 such hospitals exist, which are mostly large corporate chains and primarily based in metro and tier I cities, not many hospitals will be able to benefit.
While the IEC strategy is a well-defined component of this scheme, the on-ground execution, issuance of cards, making sure that the patients are not charged balance payments or are not denied admissions, and making sure that the scheme scales up across all the districts will require a right implementation support. The scheme provides for establishing 150,000 health and wellness centers. However, the exact nature of these centers and upgradation from existing SHCs need to be established. Further, given the lop-sided distribution of the healthcare workforce and beds in metro and tier I cities, human and physical infrastructure will also need to be set up. It is estimated that around 1.5 lakh new beds will be required for making the scheme fully functional.
The scheme mandated pooling of different state health funds. Most of the states presently have multiple insurance schemes which vary in terms of target beneficiaries, amount insured, percentage of co-pay or premium, and the kind of services insured. The most common of such schemes is RSBY, which provides for a cover of `30,000 to approximately 18 crore people. These schemes have evolved over the years based on varying political and socio-economic and demographic situations. How different state governments will enable this transition toward a single common pool remains to be realized. Despite these multiple challenges, the scheme marks a paradigm shift in the Indian healthcare policy. It promises to usher in an era of standardization of treatment guidelines, package rates, disease codification, and EMRs. It also provides an opportunity to provide healthcare accessibility and affordability to a large section of the society. Hence it is imperative that the scheme is executed via a well-thought through implementation roadmap with important checkpoints and milestones defined.
