Hospitals seek reforms, send SOS for timely payments under ABPMJAY

With the national Democratic Alliance (NDA) securing another term, all eyes in the private healthcare sector are on the potential reforms to the flagship health insurance scheme, Ayushman Bharat.

The ambitious scheme, launched in September 2018, aims to provide health coverage of Rs 5 lakh per beneficiary family per annum to over 500 million citizens and has been touted as the world’s largest health protection programme. Although Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PM-JAY) claims to have reduced out-of-pocket healthcare expenses for millions of families, it has faced operational challenges.

The industry says one of the major issues is delayed reimbursements to private hospitals, which has led to cash flow problems and hampered their operational efficiency. The delays in reimbursements have discouraged some hospitals from seeking empanelment under the scheme. Private hospitals have swiftly reached out to the newly-appointed Union Health Minister Jagat Prakash Nadda to convey their concerns and advocate for more efficient payment processes.

Girdhar J. Gyani, Director General of the Association of Healthcare Providers in India (AHPI), a body representing private hospitals across India, emphasises the significance of timely payments. “The original PM-JAY scheme included a clause to pay 1% interest if payments were delayed by more than one month. Implementing this clause would ensure timely payments and encourage more hospitals,” Gyani states.

As Modi embarks on his third term, stakeholders in the healthcare ecosystem are hopeful that addressing these concerns will not only streamline the scheme but will also encourage broader participation from private hospitals and ensure quality healthcare reaches every corner of India. Rate decisions continue to be another pressing issue, with Gyani advocating for rates to be determined based on scientific studies and linked to inflation, with annual revisions. He highlighted that the current rates are generally low, necessitating a thorough review with inputs from private industry representatives.

“The National Health Authority (NHA), the implementing agency of Ayushman Bharat, should consider allowing co-payments. This would enable beneficiaries to seek treatment from specialist hospitals for serious ailments,” says Gyani. He also recommends standardising the empanelment process across states and issuing smart cards for interoperability.

To make PM-JAY more effective in smaller towns, Gyani proposes incentivising the private sector to establish 100-bed tertiary care hospitals in Tier-III towns.

Per the latest data on the PM-JAY website, over 340 million Ayushman cards have been issued, and about 68 million hospital admissions worth Rs 90,204 crore have been authorised through a network of 30,001 empanelled healthcare providers, including 12,971 private hospitals.

In states or UTs where AB-PMJAY has not been implemented, the NHA has directly empanelled hospitals to ensure beneficiaries can still access healthcare facilities. Beneficiaries of state schemes merged with AB-PM-JAY can also use healthcare services in any empanelled hospital nationwide under the portability feature of the scheme. The scheme also focuses on strengthening primary health centres. At Ayushman Bharat Health and Wellness Centres, comprehensive healthcare services are provided free of cost, covering maternal and child health, non-communicable diseases, essential drugs, and diagnostic services.

In its manifesto for the General Elections, the BJP pledged to further expand the scheme to include senior citizens and transgender persons. Prime Minister Narendra Modi has promised to strengthen the health and wellness centres, upgrading district hospitals, and enhancing secondary care centres. The ongoing efforts under the PM-Ayushman Bharat Health Infrastructure Mission aim to build a robust infrastructure, especially at the primary level, the manifesto stated.

“The government faces high expectations in the healthcare sector, with a multifaceted agenda aimed at improving access, affordability, and quality of care,” says Sabine Kapasi, Advisor, Public Health and Healthcare Services Strategist at the United Nations. She stresses the importance of broader financial protection, adopting a ‘One Health’ approach, and strengthening public-private partnerships.

Kapasi says the new government should prioritise ensuring cash inflow into insurance infrastructure, subsidising insurance costs for higher penetration, standardising health treatment prices to prevent exploitation, and achieving full saturation and adoption of the Ayushman Bharat Digital Mission. Business Today