Ayushman Bharat: Hidden asymmetries and implementation challenges

Rural healthcare | Reuters Representative image | Reuters

The countdown to the launch of the world's largest healthcare scheme has begun. On August 15, Prime Minister Narendra Modi is expected to announce the launch of Ayushman Bharat – National Health Protection Mission. Popularly called as Modicare, the scheme is dubbed as the government's big-ticket reform that will guarantee a health cover of Rs 5 lakh for 10 crore families across the country. For an estimated 50 crore people, the planned cover for tertiary care is designed to be comprehensive as more than 1,000 treatment packages have been covered under the scheme.

The scheme itself is being monitored by the Prime Minister's Office, and last week, the PM was briefed by officials from the Union ministry of health and family welfare and NITI Aayog on the ongoing preparations for the launch. Hospitals must be clean, and frauds must be prevented, were among some of the directions given by the PM to the officials in the stock-taking meeting.

For the launch, Dr Indu Bhushan, CEO, Ayushman Bharat said that the Centre's preparations were on track—empanellment criteria for hospitals has been released, rates for various treatment packages has been worked out, and an IT system that would be the backbone for the pan-India scheme is being readied.

However, given that health is a state subject, the ultimate test for PM Modi’s “game-changer” scheme would be in its eventual roll out in the states.

Though most states have agreed to adopt the scheme, except Odisha and Telangana that have decided to wait, each state will have to battle out its own set of challenges in rolling it out, as well as dealing with its political fallout.

For instance, Rajasthan has had its own health insurance, under the Bhamashah scheme, which was started in the year 2015, and provides a cover of Rs 3 lakhs per family. The scheme has often been quoted among the "successful" state health insurance models.

There is a concern in the state, which is due to go to polls this year, about subsuming its own scheme under that of the Centre's. “For us, rolling out the scheme in Rajasthan will take time. Our concerns are around the use of a separate card for this scheme. Identifying the beneficiaries according to the SECC data is another task that is difficult in the state because of its large size and population. Besides, at any given point in time, anywhere from 5,000-10,000 people are getting treatment in the state under the Bhamashah scheme, costing Rs 2.5 crore in claims everyday, and if that is affected, there will be chaos," said Naveen Jain, CEO, Bhamashah Health Insurance scheme.

Jain claims that the state had figured out its own way around the teething troubles too. “We provide cover to those who fall under the National Food Security Act. Our data is robust. Beneficiaries don't require a separate card for the scheme, the Bhamashah card (used for the state government's direct benefits transfer schemes) is enough. As for private hospitals, there were concerns around the low rates, which we have been addressed by revising the rates," he said.

Though the scheme covered only treatment up to Rs 3 lakhs per family, Jain said that a provision for additional fund enhancement (an extra Rs 10 crore) had also been created where the CEO could sanction funds for treatment over the existing limit. Issues around raising awareness about the scheme were dealt with by utilising ASHAs (community health workers), who went door-to-door to tell people they could access free treatment. “The ASHA worker's status in the village rose because she was helping people access free treatment!” he said. The state scheme did away with the system of a TPA looking at insurance claims from hospitals, since TPA always favours the insurance companies. “Instead we constituted an expert committee to look into the claims," Jain said. A fraud detection mechanism was also installed, by pre-authorising several procedures, that were prone to misuse.

A merger with the Centre's scheme, thus, is bound to pose administrative challenges—shifting to the national software, and then, ensuring that all eligible beneficiaries are covered, too. As of now, the state health insurance scheme covers about 92 lakh families. Under Ayushman Bharat, the proposed coverage is 60 lakhs people, thereby increasing the beneficiary net. "Finance is not an issue. The Centre will pay 60 per cent of the money for the 60 lakhs people. The rest can be managed," he said.

However, to roll out the new scheme, a trust will need to be established to manage the operations. A scheme that had been running on a very low cost, since it was utilising the NHM, will now need additional manpower too. “We will need time to roll out the scheme, and the Centre has agreed to allow us that,” said Jain.

In Delhi, despite the centre-state differences, the state government has agreed "in principle" to go along with the scheme, a spokesperson of the Delhi government confirmed. However, there were issues that still need to be resolved, and hence an agreement had not been signed yet. "Given the higher rates of healthcare in Delhi, the state will have to pay more than what the Centre has prescribed," the spokesperson said.

In Punjab, the state government, that was earlier at loggerheads with the Centre, has come around now, and soon, will be signing the memorandum of understanding with the Centre. From lack of funds for the scheme, to claiming that this is a step in “advancing the state government's agenda for providing universal health coverage”, the state is trying to gain political advantage, too.

Currently, Punjab has two kinds of health insurance schemes – the Bhagat Puran Singh Sehat Bima Yojana, that provides a cover of Rs 50,000 per year for primary and secondary care, and the Bhai Ghanhya Sehat Sewa Scheme, which is self-funded and provides a cover of Rs 2 lakhs for tertiary care.

Dr Shweta Mohindru, insurance consultant, department of health and family welfare, Punjab, says the state is also working on various models of convergence with the Centre's scheme. “The Bhagat Puran Singh Sehat Bima Yojana expires by October, so the state will need to work on identifying the beneficiaries, that are yet not falling under the existing criteria for insurance cover," said Mohindru. Mohindru noted that enrolling people under the scheme, and then creating awareness about it, as the major challenges for the successful roll out of the scheme. Like most states, Mohindru says that a trust model or assurance model, as opposed to a market-driven insurance model would be the choice in Punjab. Mohindru also points to a unique mechanism where the state is able to access patient scans through tele-radiology and avoid frauds and unnecessary surgery.

Modicare will have to battle out another set of challenges when it comes to merging with the existing state health insurance schemes. The most taxing one would be to get the private hospitals on board, particularly with the issues around low rates being offered for several standard procedures. For the time being though, the Centre has placated the Indian Medical Association's concerns by assuring them that the rates would be periodically revised. However, a spokesperson for private hospitals said that there were concerns in the industry. "Large corporate hospitals may get empanelled in the scheme for the sake of it. But if the rates remain low and unacceptable to them, there is a big chance that it will find a way to refuse patients under the scheme," he said.

Health experts also point to other issues such as the inadequate healthcare infrastructure that might dampen the roll out of the scheme. “To address this, the government ought to utilise existing infrastructure in private medical colleges, that has been under-utilised because people can't afford it. To use these facilities, package rates have to be made competitive and at par with the market rates. The government says that volumes will help cover the costs, but that is only after some time. At this point, they need to get the crowds in, and make it viable for the hospitals too,” said former AIIMS director, M.C. Misra.