While hailing the Union Government’s approval to expand health coverage for all senior citizens aged 70 and above regardless of their income, under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), senior healthcare industry members opined that the effectiveness of the expansion depends on ensuring sufficient reimbursement rates and timely payments to the participating hospitals.
As per the expanded program, senior citizens belonging to families already covered under AB-PMJAY, are eligible for an additional top-up cover up to ₹ 5 lakh per year for themselves. Other eligible senior citizens, whose families are not covered, will also get a cover up to ₹ 5 lakh per year per family. This expansion is expected to benefit around 4.5 crore families, including 6 crore senior citizens, by providing them with free health insurance coverage of up to ₹ 5 lakh per family.
Terming the new expansion as a significant policy move in addressing the healthcare challenges faced by the elderly in India, Priyadarshi Mohapatra, Founder & CEO, CureBay, said, “With around 90 million people aged 60 or above, and nearly 23 percent living below the poverty line, the cost of healthcare is a critical concern. Many seniors, who often suffer from chronic conditions like diabetes, hypertension, and heart disease, spend up to 20 percent of their annual income on medical care. This scheme expansion can surely prove to be helpful in these areas of concern.”
Endorsing Mohapatra’s views, Dr Harsh Mahajan, Chair, FICCI Health Services Committee and Founder & Chief Radiologist, Mahajan Imaging, stated, “As our elderly population grows, so does the need for specialized geriatric care. This expansion will enable more families to access essential services without the burden of overwhelming medical expenses.”
Offering universal health coverage to senior citizens can surely empower them to seek timely medical intervention without placing a financial burden on their families. It will also help them become more self-reliant, while reducing their dependence on their family members. “This significant step aligns with our core belief that equitable access to healthcare is a fundamental right, especially for the elderly, who often face increased health challenges,” opined Shashank Avadhani, CEO, Alyve Health.
“This initiative not only promotes the overall health of our population, but also provides financial liberty, ensuring that high-quality healthcare is available and affordable, regardless of social or economic background. It’s a critical step toward building a healthier, more inclusive India,” stated Ravi Hirwani, Senior Vice President, Bhailal Amin General Hospital, Vadodara.
Boost to different types of healthcare services
Industry leaders felt this new policy decision will help boost the geriatric care services business across India. “We’re likely to see more investment in elder care homes, in-home care services, and assisted living facilities. The policy creates a more viable market for innovative eldercare solutions, tailored for seniors, which can also include tech and AI-driven health monitoring devices,” explained Saumyajit Roy, Co-Founder & CEO, Emoha.
Healthcare providers, including hospitals and clinics focusing on elderly care, can expect a surge in patient volume as more seniors are likely to seek regular and preventive treatments. This can result in more hospital visits and a greater need for expanded infrastructure, such as hospital beds, especially in urban centers. Additionally, the inclusion of elderly patients with pre-existing conditions, such as diabetes, heart disease, and cancer, without exclusions, makes this policy particularly beneficial for comprehensive geriatric care.
However, Sanjeev Jain, Founder and CEO, NEMA Eldercare, felt the expected boost will depend on payment structure for quality hospitals that is being designed by the government. “Very low fees will not encourage corporate hospitals to enroll into the system,” he emphasized.
Moreover, other types of healthcare services and businesses are also expected to benefit from this expansion of AB-PMJAY. Elaborated Dr Vivek Desai, Founder & Managing Director, HOSMAC, “Smaller hospitals and nursing homes, which often lack access to tertiary care resources, will see an uptick in elderly patients requiring care. Diagnostic services will also benefit, as they will be able to serve a larger and more health-vulnerable population. Also, the home healthcare industry will expand as more elderly individuals will seek care from the comfort of their homes, opening up new markets and revenue streams.”
Diagnostic centers, pharmacies, and medical equipment suppliers may also see increased business as seniors become more proactive about their health, according to Jasdeep Singh, CEO of CARE Group of Hospitals. He said, “Additionally, the policy could incentivize the development of new geriatric care technologies and products, such as wearable health monitoring devices and specialized medical equipment.”
Likely bottlenecks and their solutions
However, in spite of the hopes raised by the AB-PMJAY and the expected positive impacts, industry leaders felt there are enough reasons to tread with caution, and for healthcare entities to be well-prepared for some imminent bottlenecks.
For example, there is limited coverage for pre-existing conditions which reduces the efficacy of the scheme, believed Dr Suman Katragadda, PhD., Founder & CEO, HEAPS Health Solutions India Pvt. Ltd, Hyderabad. He said, “Many health insurance plans have exclusions or waiting periods for pre-existing conditions, which can be a significant problem for seniors who may have underlying health issues. This can leave them vulnerable to significant out-of-pocket expenses if they require treatment for a pre-existing condition. This can create a need for hospitalization and repeat hospitalizations.”
Another concern raised by the industry is that of reimbursement rates and their timely payment. “To make this expansion truly effective and sustainable, it is crucial that reimbursement rates under the scheme remain fair and that payments are made in a timely manner. This will help ensure that healthcare providers, especially smaller hospitals and clinics, can continue to participate actively and deliver the high-quality care that our elderly citizens deserve,” pointed out Dr Santy Sajan, Group Chief Operating Officer, Paras Health.
Another valid concern among industry seniors is that while the financial coverage in the new scheme is substantial, it may not fully cover all expenses related to complex treatments or extended hospital stays, which can lead to out-of-pocket costs for families. Addressing these concern would require a more cohesive approach, including infrastructure development, professional training, and wide-ranging care options beyond the hospital settings.
What is required is an effective preventive care coordination, that is, a care management system that can help coordinate preventive care services, such as regular check-ups and screenings. This can help identify potential health problems early on, leading to more effective treatments and reduced medical costs.
To sum the discussion up, while this policy is a big step in the right direction, there are a few areas that can be further improved. First, ensuring that the benefits reach the most vulnerable seniors, particularly those living in rural areas, will be crucial. Second, it will be important to monitor the impact of the policy on healthcare costs and ensure that providers are not charging excessive fees. Finally, the government may need to consider expanding the coverage to include other age groups or specific health conditions in the future.
