How the Government can collaborate with the private sector for successful implementation of Ayushman Bharat Scheme
By Rita Dutta
The Government of India in its budget proposals for year 2018-19 has announced the Ayushman Bharat – National Health Protection Mission that will have a defined benefit cover of Rs 5 lakh per family per year as well as the opening up of 1.5 hundred thousand health and wellness centres. A beneficiary covered under the The National Health Protection Scheme (NHPS) will be allowed to take cashless benefits from any public/ private empanelled hospitals across the country. To control costs, it was announced the payments for treatment will be done on package rate (to be define by the Government in advance) basis. For giving policy directions and fostering coordination between Centre and States, the Government has proposed to set up Ayushman Bharat National Health Protection Mission Council (AB-NHPMC) at an apex level chaired by Union Health and Family Welfare Minister. And states would need to have State Health Agency (SHA) to implement the scheme.
Indu Bhushan, CEO, Ayushman Bharat-PMRSSM, has stated: “We need to design the scheme to ensure that the targeted beneficiaries get maximum benefits and we can expand access to quality health services in rural areas and tier-II and III cities.”
Accessibility to rural healthcare needs to be looked at.
Looking at the quantum of work load, it would be imperative that resources available with public and private sector are pooled, utilised and managed to achieve the desired goals- under the overall gambit of universal health coverage (UHC). Firstly, this can happen for the launch of 1.5 hundred thousand Health & Wellness Centres (HWCs) to bring promotional, preventive and primary healthcare system closer to the homes of people. These centres will provide comprehensive healthcare, including for non-communicable diseases and maternal and child health services. These centres will also provide free essential drugs and diagnostic services.
Reference to the HWCs was made in the national health policy released on 15th March 2017. A few states including Haryana, Punjab and J&K are known to have initiated converting some of their sub-centres in to HWCs. The Haryana and Punjab governments have planned to train community health officers, who would manage these centres, with specialist doctor from nearby PHC or CHC visiting HWCs on a regular basis.
Says Dr Girdhar J Gyani, Director General, Association of Healthcare Providers (India), “The private sector has an opportunity by adopting few sub-centres as HWCs. AHPI has proposed to the Government that its member hospitals will be willing to manage some of the HWCs within the same budget, which the Government provide for existing sub-centre. The manpower would be fully deployed by the private sector provider, with provision of specialist doctor visiting on a need basis from main hospital or consulting through telemedicine as appropriate.” The entry of private sector will also generate healthy competition as well as cooperation between public and private sector.
The private sector has a massive role to play in the Pradhan Mantri Rashtriya Swasthya Suraksha Mission (PMRSSM) that has been designed to provide financial protection and prevent catastrophic healthcare expenditures to over 10 crore poor and vulnerable families and endow a cover for cashless hospitalisation services of up to Rs 5 lakh per family per year.
If there were adequate public sector hospitals, then scheme could have been delivered through a network of CHCs, district hospitals and Government teaching hospitals. “But considering that about 60% IPD beds are with the private sector, it is inevitable that private sector will have an important role in NHPS. The scheme, however, should ensure self-sustenance of hospitals,” says Dr Gyani.
It is estimated that the scheme will nearly require 20,000 hospitals/ nursing homes to be empanelled. Most of secondary care procedures could be delivered by Government district hospitals and small hospitals. For tertiary care procedures, the Government will need support from private specialist hospitals. The MOHFW is working on simple empanelment criteria. The government is also planning to incentivise private hospitals under the scheme to ensure that more quality hospitals come up in aspirational districts. Hospitals certified by the NABH for entry-level would get 10% more as incentive and those certified for advanced level would get 15%.
Hospitals offering MD and DNB would also get 10% more. Hospitals set up in as backward and rural districts would get an additional 10%. The scheme would target poor, deprived rural families and identified occupational category of urban workers’ families, 8.03 crore in rural and 2.33 crore in urban areas, as per the latest SECC data.
Says Dr Dharminder Nagar, Managing Director, Paras Healthcare, “For years healthcare stakeholders involved in public and private care have pondered over the road map to achieve Universal Healthcare Coverage and finally an ambitious scheme that covers 41.3% of the population and provide Rs 5 lakh health coverage for the entire family looks like a good beginning to a marathon leading to ‘Swasth Bharat’. With the new 1% health and education cess funding the project of more than Rs 11,000 crore and empowering the poor common man with specialized treatment with premiums at Rs 1,100 per family, the union government has set the stage by increasing the federal health budget by 11.5% for 2018-19.” He added that one should give priority to empanelment of private hospitals in tier II and tier III cities. To ensure access, the NHPS team needs to ensure that the entire focus should be on the tier II and tier III cities.
The centre has included 1,354 packages in its ambitious plan under which treatment for coronary bypass, knee replacements and stenting among others would be provided at 15-20% cheaper rates than the Central Government Health Scheme (CGHS). The rates for over 20 specialties, including orthopaedics, cardiology, cancer care and neurosurgery were included in the packages. The document also details the minimum number of days of hospitalisation required to make a claim as well as pre-surgery and post-surgery investigations needed for approval.
Under the 205-page draft model tender document which was shared with the states, knee and hip replacements were fixed at Rs 9,000 each, stenting at Rs 40,000, coronary artery bypass grafting (CABG) at Rs 1.10 lakh, caesarian delivery at Rs 9,000, vertebral angioplasty with single stent at Rs 50,000 and hysterectomy for cancer at 50,000.
According to Indu Bhushan, the rates of packages were finalised after analysing the Rashtriya Swasthya Bima Yojana (RSBY) and CGHS rates and are on average 15-20% lower than that of the CGHS.
According to experts, the Government needs to suggest a more viable tariff. Says Dr Harish Pillai, CEO – Aster Hospitals and Clinics (India), Aster DM Healthcare, “The tariff suggested by the Government is not viable specially for a state like Kerala where the capital cost is high due to the Minimum Wages Act for nursing staff. The Government needs to engage with various industry bodies to arrive at a viable tariff rate after a scientific study. How the Government has different DR allowances for different cities, so should be the case with the tariff for different cities under the PMRSSM programme.”
According to healthcare consultant, Lalit Mistry, “Designing acceptable PMRSSM tariffs to be offered to providers based on availability of health services, quality of infrastructure, geographic location, cost of operations and demand of services. Various health system such as the UK have undertaken scientific pricing approach to assess the cost of operations/ services and permissible margins for providers that enables to build transparent and acceptable system for both Government and private providers.”
Incentivising providers and doctors for setting up and providing services in rural areas would also mitigate the challenges of lack of healthcare resources. “Timely reimbursement by state health authority/ insurance company would be critical for buying and sustaining private providers to PMRSS, ” says Mistry.
According to Dr Nagendra Swamy, Group Medical Director, Manipal Hospitals, “For successful implementation of the programme, identification of appropriate service providers from both the Government and private sectors with healthy PPP model is essential.” He added that there has to be stringent monitoring of the programme through technology intervention to avoid misappropriation. Also, proper audit mechanism is required to prevent misuse. According to experts, NHPS may designate an independent quality regulator who would lay out clear guidelines with respect to re-use of single use device, use of generic medicines and others applicable for all empanelled providers under the scheme.
The NHPS system would be digitised, where hospitals can submit bills on-line and even the payment should be made on-line. For the scheme to be viable, experts suggest it would be essential that the payment to the hospitals should be reimbursed in a time-bound manner. “Experience from central Government schemes like the CGHS has been unpleasant and the industry will look to have better arrangement. In case of delay, there should be provision to pay interest,” says Dr Gyani. This aspect is important as present schemes have failed largely on the account that payments are delayed for months. State government schemes like the ones in TN, Telengana and AP have transparent and efficient system of digital tracking of patients and treatment line which can be studied and adopted for NHPS.
Experts suggest that private providers need to design delivery models with focus on PMRSSM and weave volume based model to ensure low cost of operations and sustainable margins. “The private providers will have to move away from capital intensive and high-end facilities to low cost healthcare models. Also, there is a need to reconfigure existing facilities to cater to the demand generated by the scheme,” says Mistry.
Additionally, private providers could play a role in training and skilling of healthcare workforce for PMRSSM, mainly deployed in rural areas. Private providers could also be leveraged to develop clinical protocols, provide tele-medicine, remote ICU and monitoring support to existing district hospitals, lacking extensive clinical expertise.