AYUSHMAN BHARAT

Care and scares

Ayushman Bharat-Pradhan Mantri Jan Arogya: The misses

86-Prem-Singh Health, help: Thanks to PM-JAY, Prem Singh underwent a kidney stone removal surgery at Shree Hari Hospital in Karnal, Haryana | Sanjay Ahlawat

Prem Singh, 48, had learnt to live with pain. The villager from Sheikhpura in Haryana’s Karnal district was diagnosed with kidney stones earlier this year. A surgery would have cost him Rs35,000, apart from the cost of medicines. Singh earns only about Rs8,000 a month, doing odd jobs. His elder son is unemployed, and the younger son is in college. So, Singh lived with the pain. “Sometimes, I would just lie down,” recalled Singh. “At other times, I would take a painkiller.”

PM-JAY works through a portal, one that each empanelled hospital has access to with its own login id and password.
PM-JAY, dubbed Modicare, promises to provide an insurance cover of Rs5 lakh to 10 crore families.

In the last week of October, his family decided to take him to Pt Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak. Just then, a neighbour told them about a scheme under which Singh could have surgery at a private hospital a few kilometres from their village. So, they went to the 39-bed Shree Hari Hospital in Karnal with their ration cards and Aadhaar cards. Lying in the hospital’s general ward after the stone removal surgery, Singh said: “We did not have to pay for the surgery and medicines. I am feeling better now.”

In the next ward, Vijay Kumar, 26, was counting his blessings. His mother and sister were diagnosed with dengue, and he had spent about Rs4,000 on the initial treatment at a hospital in his village. When he was advised to go to a city hospital for better treatment and avail the benefits of Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PM-JAY), Kumar brought his mother and sister to Shree Hari Hospital. “We would not have been able to manage, had the treatment not been free,” said Kumar.

For both Singh and Kumar, the hospital followed a complex, multi-layered process of registration and obtaining approvals on the PM-JAY portal, the staff said. At smaller hospitals like Shree Hari Hospital, which operate with limited staff, it is a process they are struggling with. “We have to deploy one person with the PM-JAY patient, so that all the processes are completed properly,” said a staff member. An official of the State Health Agency in Karnal said the process was even more challenging in government hospitals, where doctors were busy and had no time to fill up forms and follow the scheme’s protocol.

PM-JAY, dubbed Modicare, promises to provide an insurance cover of Rs5 lakh to 10 crore families. It works through a portal, one that each empanelled hospital has access to with its own login ID and password. The designated staff for the scheme, called Arogya or Ayushman Mitra, begins the process by verifying patient details on the portal with an ID, and completes the process by getting their biometrics done, before sending it to the state authority for approval.

Once the hospital receives the approval, the patient is given a card, which can be used at any hospital. The doctors then diagnose the patient’s ailment and recommend treatment. The patient’s vital signs and other treatment details are then entered into the system under the relevant package, which is then sent for pre-authorisation (depending on the treatment packages and length of stay). Pre-authorisation takes a couple of hours, and if the treatment package is approved, the hospital admits the patient. In Singh’s case, a three-day package worth Rs25,000 was approved, and the amount will be reimbursed to the hospital in 30 days.

Twin troubles: Dr D.S. Rana, chairman, Sir Ganga Ram Hospital, Delhi, said PM-JAY will have to tackle the challenges of infrastructure and manpower | Arvind Jain Twin troubles: Dr D.S. Rana, chairman, Sir Ganga Ram Hospital, Delhi, said PM-JAY will have to tackle the challenges of infrastructure and manpower | Arvind Jain

But, for Kumar’s sister and mother, the treatment costs would not be reimbursed to Shree Hari Hospital. The hospital staff claimed there was a technical glitch—the package was pre-authorised by the system, and later, when the claims process began, it turned out that the package was reserved only for government hospitals. Dr Tarun Goel, director, Shree Hari Hospital, also recalled how he had to turn away a 28-year-old patient for a total hip replacement surgery as the package was reserved for government hospitals only.

The state has 270 such packages reserved for government hospitals. Even within the National Health Agency (NHA), the implementing agency for PM-JAY, there is a sentiment that this reservation is against the “spirit of the scheme that is based on demand”.

Said to be the world’s largest health insurance scheme, PM-JAY was officially launched on September 23. It is too early to judge a scheme of this magnitude, and in districts such as Karnal, implementing agencies are facing teething troubles regarding empanelling private hospitals and ensuring the staff is able to manage the portal and make eligible patients aware of the benefits when they reach the hospital.

At the NHA though, the mood is fairly upbeat. Sitting in his office in central Delhi, in front of a live dashboard that updates scheme statistics every 15 minutes, Dr Indu Bhushan, CEO, PM-JAY, is counting the early successes. Every day, six to eight lakh letters from the prime minister—complete with a QR code, names of family members and an identity number—are being sent out to the beneficiaries. The scheme is working well in Gujarat, Maharashtra, Chhattisgarh and Tamil Nadu, and efforts are on to focus on Kerala, Karnataka and Punjab. Delhi, Telangana and Odisha, however, are still not part of the scheme.

System support: Vijay Kumar, whose mother and sister were diagnosed with dengue, benefited from PM-JAY | Sanjay Ahlawat System support: Vijay Kumar, whose mother and sister were diagnosed with dengue, benefited from PM-JAY | Sanjay Ahlawat

On the live dashboard, claims are increasing almost by the minute, and the top categories include general surgery, general medicine, obstetrics and gynaecology, enteric fever and cataract surgery. Processes of evaluation and medical audits will also kick in soon, said Bhushan. A partnership between government and private hospitals would be initiated through the scheme, allowing government hospitals to provide for services through the private sector. Government hospitals have also been given directives on how to use the money from reimbursements—25 per cent would be paid to the staff to encourage them.

The processes might be in place, but the success of the scheme will depend largely on the private sector. “Around 90 per cent of tertiary care procedures are done in the private sector,” said Dr Girdhar Gyani, head, Association of Healthcare Providers of India. “The success of the scheme will hinge on adequate infrastructure. For instance, a state such as Telangana has 167 hospitals with more than 100 beds, whereas Madhya Pradesh, a state perhaps double its size, has only 80 such hospitals.”

Dr D.S. Rana, chairman, Sir Ganga Ram Hospital, Delhi, said the scheme would have to tackle the twin challenges of infrastructure and manpower. “The government would have to encourage the private sector to set up in rural, remote areas by providing soft loans, incentives and land subsidy to ensure that the infrastructure part is taken care of,” said Rana. “More medical colleges need to be set up to cater to the huge demand for doctors and paramedical staff.” He called for ramping up of existing health care infrastructure in the public sector, including primary and community health centres, which will help in reducing tertiary care procedures.

Any discussion of the private sector engagement with the scheme is bound to bring up the issue of package rates—the bone of contention between private hospitals and the government. Gyani said that though the government had agreed to revise the rates, the fresh costing exercise would take at least six months. In states such as Gujarat, Maharashtra and Tamil Nadu, where state health insurance schemes had been running successfully, issues around pricing might be less, he said, but “the problem will be compounded in states such as Uttar Pradesh, Bihar and even Delhi, which have no experience of an insurance scheme”.

Dr Dinesh Arora, deputy CEO, NHA, said within the existing rates, states could increase the costs up to 40 per cent. “Teaching colleges get an extra 10 per cent; NABH (National Accreditation Board for Hospitals and Healthcare Providers) accreditation gets an extra 15 per cent; backward areas get 10 per cent extra; and the state itself can raise the rates by 10 per cent,” said Arora.

One of NHA’s top priorities has been to ensure that frauds and system abuse do not occur. “The system has 100 fraud triggers,” said Arora. “For instance, we had a case of reimbursement claim for two deliveries in about six months. The system will catch the fraud.” In the next six months, he said, the large amount of data generated through the scheme will also allow experts to analyse trends—say, if a disease is being seen more in a particular area.

Most experts said the intent behind PM-JAY was good and it held promise, but it would take at least a couple of years before the successes and failures could be assessed. On the ground, it would mean that Kumar’s mother and sister would get free treatment, not because of a technical glitch, but because it was their right.

DR SUDARSHAN BALLAL

Chairman Manipal Health Enterprises Pvt Ltd, Bengaluru

Dr Sudarshan Ballal Dr Sudarshan Ballal

INTERVENTIONAL NEPHROLOGY SERVICES for patients with failing vascular access is a relatively new development. State-of-the-art cath labs and qualified interventional nephrologists and radiologists today offer a variety of services for failing vascular access, including placing day care tunneled dialysis catheters.

Pre-natal genetic analysis in diagnosing adult polycystic kidney disease is possible now. Genetic diseases like congenital nephrotic syndromes and Fabry disease are also being diagnosed, thanks to genetic testing.

In the last few years, there have been many advances in renal replacement and organ support namely haemodialysis, hemodiafiltration, continuous renal replacement therapies and slow low-efficiency dialysis. These newer dialysis modalities are beneficial in renal replacement for critically ill patients with haemodynamic instability.

Many innovations in the surgical field of transplantation like laparoscopic donor nephrectomy, single incision laparoscopic donor nephrectomy and transvaginal laparoscopic donor nephrectomy has resulted in scarless surgeries. Robot-assisted renal transplantation has also become quite popular and results in quicker recovery, less pain and smaller scar with quicker healing.

DR ANUPAM SIBAL

Group medical director and senior paediatric gastroenterologist, Apollo Hospitals Group

Dr Anupam Sibal Dr Anupam Sibal

OVER THE PAST 15 years, we have evolved from general paediatrics to a combination of advanced technologies and sub-specialities in paediatrics. There are 15 sub-specialties that can cater to general paediatrics and unusual ailments in children, like cardiology, neurology and endocrinology.

We have a new area called inborn errors of metabolism, which caters to inherited disorders in children and newborns. These inherited disorders are owing to absence of metabolism. Earlier, tests were not possible even for diagnosis in such cases. Now, we treat children with such disorders in several ways like with a special diet or in some cases through liver or kidney transplants.

Apart from this, the most advanced treatment now is the eNICU, where the baby’s bed is connected for real-time monitoring. The bed is connected to a central station, which gives the heartbeat rate and pulse trend from time to time.

DR PRAVEEN RAJ

Head and consultant, bariatric surgery, GEM Hospital and Research Centre, Coimbatore

Dr Praveen Raj Dr Praveen Raj

FROM THE DIAGNOSTIC standpoint, we now have endoscopy ultrasound and laparoscopic ultrasound, which could be used for better diagnosis. Then we have enteroscopy, which could go all the way into the small intestine. We also have breath analyser tests to diagnose bacterial overgrowth in intestines.

Today, constipation is a big issue. While a significant amount of constipation is linked to psychological issues, people are also not trained to use their muscles the right way. To understand this, we now have biofeedback mechanism, wherein we are able to tell patients whether it is a muscular or psychological abnormality and what they can do to correct it.

With regards to treatment, a lot of new things have come up. Laparoscopy, as you know, has taken treatment by storm. Even in laparoscopy, we have gone to the next level—3D laparoscopy—and are using the 4K technology, which helps in better magnification and precision. Hence, we will be able to operate much better. Then, there is robotic technology, which adds better dexterity in handling tumours and small tissues.

DR ARAVINDAN SELVARAJ

Executive director and chief orthopaedic surgeon Kauvery Hospital, Chennai

Dr Aravindan Selvaraj Dr Aravindan Selvaraj

FROM ORTHOPAEDICS, we have now moved on to a major advancement called orthogeriatrics, which is orthopaedic care for senior citizens. Osteoporosis and osteoarthritis are common among the elderly. Surgical treatment in the elderly is difficult and so a lot of research has gone into these two areas and in fracture fixation. Kauvery Hospital is the first in India to have an orthogeriatrics department.

Another development is joint conservation and preservation. Till a decade ago, knee or joint replacement was the only option. Now, we go for conservation by deducting the ailment at an early stage by way of self-therapy, which is treatment using the patient’s blood, bone marrow or stem cell or through a keyhole procedure. Instead of replacement, we inject plasma into the knee, which strengthens the knee. This is called orthobiologics, which is the future of orthopaedics.

DR S. RAJASEKARAN

Chairman, department of orthopaedics and spine surgery Ganga Hospital, Coimbatore

Dr S. Rajasekaran Dr S. Rajasekaran

ORTHOPAEDIC SURGERY HAS seen tremendous improvement in the last few years, and the focus has been on improving precision of surgery, better safety, less complications and better functional outcomes for the patient. For example, in spine surgery, intra-operative, computer-assisted navigation and robotic surgery have been used to precisely place the titanium screws in the spine, avoiding any injury to the spinal cord or the big blood vessels that are in close proximity to the spine.

Continuous spinal cord monitoring is another technology that is used to monitor the electrical impulse and continuity of the nerve fibres in the spinal cord to recognise and prevent paralysis or cord damage. The cell saver equipment collects and recirculates the high volume of blood that may be lost in major spinal operations. This avoids the need for multiple blood transfusions from different donors, making surgery much safer. Advances in metallurgy and implant designing has allowed highly anatomical and region-specific titanium implants, which provide stability and are MRI compatible.

DR THOMAS CHANDY

Director of orthopaedics, joint replacement and sports medicine Hosmat Hospital, Bengaluru

Dr Thomas Chandy Dr Thomas Chandy

IN HIP REPLACEMENT SURGERY, newer surfaces have been developed such as ceramics instead of metal for the ball of the hip and the use of a very high wear resistant, high-density polyethylene for the surfaces of the hip. The other development is in arthroscopy of the knee, shoulder, elbow, wrist and ankle. Tumour surgeries, too, have seen a lot of advancements. In bone tumours, say, at the knee joint, the tumour is removed and the adjacent bone replaced without having to amputate the leg. In the shoulder, a reverse arthroplasty is now common for severe rotator cuff tear.

Stem cell treatment is also coming into the picture. Ligament stem cell is in an experimental stage. For the spine, stem cells are being used to regenerate the discs. The other new development is partial joint replacement such as a partial knee replacement or unicondylar replacement, but it is only for patients between 45 and 60 years and only if one half of the joint is affected. In orthopaedics, 3D printing is very useful. Metal 3D printing is used to create specific, customised implants for patients.

DR SHARAN PATIL

Chairman and chief orthopaedic surgeon Sparsh Hospital, Bengaluru

Dr Sharan Patil Dr Sharan Patil

ORTHOPAEDIC SURGERY HAS gone through tremendous change in the last decade. Modern orthopaedics has matched the needs of the times.

Paediatric orthopaedics: We can now plan interventions based on the antenatal ultrasound scan for conditions like clubfoot and congenital vertical talus.

Sports medicine: It has transformed from routine generic ligament reconstruction of shoulder and knee joints into accelerated personal recovery and rehab.

Joint replacement surgery: Thanks to computer navigation and robotics for precision and implant quality for longevity, we can now promise patients 90 per cent survivability of implants at 22 years.

But, the future of orthopaedics is going to be shaped by artificial intelligence. In a country as diverse as India with variable access to quality health care, this would be very relevant as it makes it consistent, cost effective and reliable.

The other exciting researches are in the field of stem cell and cartilage regeneration. Early results are promising, but it still needs time before it can be established effectively in clinical practice.

Dr R. Bala-subramaniyam

Senior consultant, nephrology Kauvery Hospital, Chennai

Dr R. Bala-subramaniyam Dr R. Bala-subramaniyam

TILL A DECADE AGO, nephrology was limited to kidney disease. Earlier, we were not able to do transplants on patients with high blood pressure, but this has become a daily affair now. Likewise, transplants on patients with a different blood group was not possible all these years. Now, complicated transplants are done even when the blood groups do not match.

Also, transplants in infants is common now. The success rate in transplants is 95 per cent these days; a decade ago, it was less than 70 per cent. Also, a second or even a third transplant is possible for patients who have had a failed transplant.

With advancements in dialysis, the concept of critical care dialysis has improved. With continuous renal replacement therapy, we have lots of improved techniques for patients with multiple disorders or organ failure, who need dialysis.

Then, there is continuous ambulatory peritoneal dialysis, where dialysis is made possible through alternative routes. Other than these, kidney biopsy techniques have improved with treatment modalities.

Research methodology

The survey covered 17 cities (plus the National Capital Region). Top hospitals for 10 specialties were also ranked.

PERCEPTUAL DATA COLLECTION

A primary survey was conducted among health care experts—674 general physicians and 1,350 specialists.

The sample was selected ensuring proper representation of all cities and specialities. The experts were asked to nominate and rate the top five multispeciality hospitals in India and within their own city. Specialists were asked to nominate and rate the top five hospitals for their specialisation. Experts’ response for hospitals they are associated with were ignored.

VALIDATION OF FINDINGS

Data collected from the survey was validated using factual data from hospitals and other secondary sources.

Final list was validated by leading doctors. Specialisation rankings were validated by experts who are opinion leaders in their field. City rankings were validated by experts from respective cities.

The core research team met 120 senior doctors, apart from conducting telephonic interviews to validate the findings.

RANKING METHODOLOGY

The final rank for a hospital is based on the number of nominations received, ranks given, and the ratings on six parameters:

Overall reputation

Competency of doctors

Infrastructure and facilities

Patient care

Hospital environment

Research and innovation

NOTE: Ranking for a city is based on the perception of the sample surveyed from that city, whereas the All India ranking is based on the perception of the sample surveyed in the country. Hence, city rankings might be different from the All India list.

HOW TO USE IT?

The rankings make the opinion of health care experts available to the public and all efforts have been made to provide an honest assessment. While this list can be used as a guideline, decisions should be based on the needs of each patient.