Successful Implementation of World`s Largest Health Insurance Scheme (Ayushman Bharat) at an Indian Tertiary Care Center- Our 3 Year Experience

Abstract

INTRODUCTION- The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PMJAY) was launched on 23^rd September 2018 asa flagship program of the Government of India with the aim ofachieving Universal Health Coverage in our country. Under this scheme, each under-privileged family was provided with annual health insurance coverage of Rs. 5 lakh for hospital-based treatments, including 1,669 procedures in 24 specilties. In this article, we present the 3-year experience of implementing this scheme at our tertiary care center in New Delhi.

MATERIAL AND METHODS- A dedicated Ayushman Bharat section was created in our center, comprising of specialist doctors, staffand Ayushman Mitras (AMs). Kiosks were establishedto screen all in-patient admissions via Beneficiary Identification (BIS) portal. The patient treatment wasinitiated,and the necessary implants/stents/medications/consumables were provided by Amrit Pharmacy. Treatment records were obtained for initiating the claims process via Transaction Management System (TMS) portal at the time of discharge. This data was collected and analyzed based on the medical specialty and the state of origin of patients.

RESULTS- During the 3-year period, a total of 1,775 beneficiaries were identified in our center and1,255 claims were initiated, of which 1,210 claims have been settled. Beneficiaries from across 12 states availed of benefits under this scheme, the highest number being from Uttar Pradesh (38.8%), Bihar (32.9%), and Haryana (8.7%). Most claims were initiated for the specialty of Neurosurgery (28.9%), followed by Orthopedics (20.8%) and then Cardiology (17.1%). Cross-subsidization was done for 21 packages whose cost exceeded the ceiling of package rates prescribed by the National Health Authority (NHA). A total of 32 unspecified surgical procedures were also performed under the scheme after taking due permission from the authorities. There was no denial of services to beneficiaries.

CONCLUSION- The AB PMJAY scheme is a boon for vulnerable families who cannot afford costly medicines & specialized surgical procedures. Though it possesses the potential to mitigate India`s healthcare woes, the greatest challenge lies in its smooth implementation via the dedicated IT platform, training healthcare staff and constant rationalization of &updation of treatment packages based on expert views and standard treatment guidelines.