Why 75% of PMJAY claim value goes to private hospitals? Dr Vipul Aggarwal, Deputy CEO, NHA, explains | Interview

Private hospitals are playing an important role in the effective implementation of Central Government’s Ayushman Bharat-PMJAY scheme. Interestingly, even as only 50 per cent of the empanelled private hospitals under PMJAY are active, they account for 63 per cent of the total PMJAY claims and 75 per cent of the total claim value, according to a recent policy brief prepared by National Health Authority (NHA), the nodal agency for implementation of the scheme.

As many as 56 per cent of all hospitals empanelled under PMJAY are private, of which 72 per cent are located in just seven states – Uttar Pradesh, Rajasthan, Tamil Nadu, Gujarat, Maharashtra, Punjab and Karnataka.

The policy document shows that the average claim size is Rs 17,260 in private hospitals and Rs 9,869 in public hospitals, reflecting different case mix treated across both sectors. Moreover, patients seeking care a private hospitals tend to be older and a larger share is of males than those at public hospitals.

In an exclusive interview with FE Online, Dr Vipul Aggarwal, Deputy CEO, NHA, explains the disparities between private and public hospitals and the steps being taken to ensure more priavte participation in PMJAY.

Why only 50% of the empanelled private hospitals are active? What is NHA doing to make more of these private hospitals active?

Generally, hospitals that are empanelled with us have the intention to provide services under the scheme. However, there are several demand and supply factors which affect the participation of service providers in the scheme.

Private sector healthcare providers attract beneficiaries based on their capacity to deliver quality services. The distribution (excess/limited supply) of private hospitals in a geography has a clear bearing on the uptake of the scheme across service providers. Urban areas have more private hospitals due to which hospitals may have to compete for beneficiaries. Also, many times, several hospitals may not have spare bed capacity at the time the patients arrive. Some hospitals also want the approved rates for health benefits packages to be further increased. Though I will tell you that NHA has recently implemented the Health Benefits Package 2.0 after a series of stakeholder consultations. This resulted in several changes to the existing set of packages including upward revision in the rates of 270 packages subject to the ceiling of 10%. This move has already further improved the confidence of hospitals in the scheme. NHA is implementing other confidence building measures including seamless settlement of claims within stipulated turn around time of 15 days of intra-State claim submission and within 30 days in case of portability (inter-State) claims.

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Why private hospitals account for 75% of total claim value even as the number of active private hospitals is less than public hospitals? Is it because public hospitals are not well equipped for surgical packages and super specialties?

If you actually observe the participation of hospitals in terms of authorized hospital admissions, the private-public bifurcation stands at a far more equitable 54%-46%. However, in terms of amount it is a bit more skewed towards private hospitals due to the fact that a large portion of government hospitals that have been empanelled under AB PM-JAY are either district hospitals or smaller hospitals such as Community Health Care Centres that may not be equipped to handle the far more costlier super specialties or treatments involving major surgical packages. People often visit private hospitals for these.

Further, it has also been observed that many a times beneficiaries do not book their services under AB PM-JAY at public hospitals due to lack of information. However, since they cannot avail free/subsidized services at private hospitals they utilize the AB PM-JAY card.

Many a times, there are waiting periods for elective surgeries in public hospitals which otherwise can be readily availed in private healthcare facilities under the scheme.

The policy brief says that over 72% of all private empanelled hospitals are located in just seven States. Why are more private hospitals in other states not becoming a part of PMJAY?

There is a wide variance in the distribution of presence of private hospitals across the country. NHA is putting sincere efforts to onboard maximum number of eligible hospital under the scheme. In this direction, NHA has asked SHAs to continuously engage with private hospitals to empanel them under the scheme. The SHAs have also been provided flexibility to relax the empanelment criteria in those States/districts where there is a paucity of private hospitals which meets the criteria.

As you may be aware, AB PM-JAY has a special feature called portability – which allows the beneficiaries from one State to avail treatment at a hospital empanelled in another State.

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Patients seeking care at private hospitals tend to be older, and a larger share is male than those at public hospitals. Why?

When we see the overall ecosystem of AB PM-JAY, it has been observed that utilization under the scheme is poised equally between male and female beneficiaries. Around 48-49% of the total authorized admissions under the scheme have been availed by female beneficiaries.

However, to address your point. I would like to take you back to your own observation in question # 2 wherein you noted that private hospitals tend to account for a higher share of super-specialty care and treatments involving surgical packages. I feel it’s quite obvious that the majority of such treatments are availed by elderly patients and this could be a reason for their higher share. One reason could be that females tend to stay back in their native places in rural India where AB PM-JAY services are predominantly offered through the public healthcare system. On the other hand, males often migrate, in search of work, to cities and towns where they can exercise their choice with respect to private and public service providers.

However, I would like to convey that the AB PM-JAY has been in existence for a period of little over 2 years and the utilization trends in the scheme shall gradually stabilize over a period of time.

What are the fraud detection measures being taken by NHA to keep a check on private hospitals?

National Health Authority (NHA) has setup a dedicated fraud and abuse control unit at National level, National Anti-Fraud Unit (NAFU) which continuously tracks instances of fraud/abuse with respect to utilization data, generation of ecards through monitoring tools on real time basis across India. NAFU works closely with State Anti-Fraud Units (SAFUs) to implement the anti-fraud framework established by the NHA.

NHA has partnered with a renowned analytics firm to leverage artificial intelligence and machine learning models to identify suspect transactions. The AB PM-JAY IT platform is enabled with anti-fraud triggers and alerts. A comprehensive set of Anti-Fraud Guidelines have been laid down with strong checks and balances for prevention, detection, and deterrence of different kinds of fraud that could occur in PM-JAY at different stages of its implementation. The hospital transaction data is monitored on real time basis through advanced analytics and interactive dynamic dashboards.

Regular medical audits are also conducted by NAFU along with SAFU for all suspected cases identified through data analysis. We have acted upon several hospital and imposed penalties against the erring entities as per prescribed guidelines