On September 23, the much-touted Ayushman Bharat, also called the Pradhan Mantri Jan Arogya Yojana (PMJAY), completed one year of its existence. The National Health Authority (NHA), set up in January 2019, is the nodal agency for the implementation of the public health insurance/assurance scheme. It offers a cover of Rs.5 lakh a year for every family for secondary and tertiary care through a network of public and empanelled private healthcare providers. The Bharatiya Janata Party (BJP)-led government at the Centre has publicised the scheme widely and even used it for electoral propaganda. Establishing a direct connect with the beneficiaries, or labharthis as they are called in Hindi-speaking States, Prime Minister Narendra Modi wrote them personal letters in order to make them aware of the entitlements, a method he seemed to have perfected in the run-up to the State Assembly elections last year and the Lok Sabha election this year.

However, notwithstanding the claims of success, an annual report released by the government highlights some of the very pitfalls that public health experts had been cautioning the government about regarding publicly funded and privately managed health insurance schemes. These range from fraudulent claims to a spike in the number of surgical procedures, particularly hysterectomies, the majority of which were found to be conducted in private hospitals. Significantly, most of the fraudulent claims and action taken in the case of private hospitals were in States ruled by the BJP.

The objective of the PMJAY is to ensure financial protection to the bottom 40 per cent of poor and vulnerable households in the country against catastrophic health expenditure and to provide them access to affordable quality health care. These households were identified on the deprivation and occupational criteria of the Socio-Economic Caste Census (SECC 2011) for rural and urban areas, the objective being Universal Health Coverage as recommended by the National Health Policy 2017. Though it is called Universal Health Coverage, it does not cover the entire population; neither does it cover all health expenditure resulting from various types of morbidity, mostly of the communicable kind. Only around 10.74 crore of the 24.88 crore households in India (as per Census 2011) were identified as beneficiaries. Delhi, Odisha and Telangana did not join the scheme and West Bengal withdrew from the scheme after joining it.

Even though the government uses terms like cooperative federalism frequently, the scheme makes it almost mandatory for State governments to “cover” eligible beneficiaries as identified in SECC 2011. As on September 2019, the government and the NHA, headed by the Union Health Minister, claimed that 32 States and Union Territories were implementing the scheme and 46.5 lakh people had availed themselves of treatment in hospitals under it.

The States that reported the most number of hospitalisations under the PMJAY are Rajasthan, Gujarat, Jharkhand, Chhattisgarh and Kerala. Admissions were higher in private hospitals than in public hospitals. The number of hospitals empanelled under the scheme was also higher in the private sector than in the public sector.

The PMJAY offers 1,393 treatment packages—1,083 surgical procedures, 309 medical, and one unspecified. This effectively means that the scheme applies only in conditions of hospitalisation and not the routine morbidity that is more common and also responsible for high out-of-pocket expenditure.

The feedback the NHA received on various aspects of the scheme were on inconsistencies in the nomenclature, duplication, unviable rates, large differences in rates of similar procedures, inclusion of implants in rates, and different rates for the same procedure in different specialities. In April 2019, following the recommendations of a review committee, the governing board of the NHA took stock of the anomalies and reviewed the scheme. On the basis of this, 554 packages were discontinued, the rates of 57 packages were reduced, and 237 new packages were added.

Action taken

According to the annual report, action was taken against 18 hospitals in Uttarakhand and recovery of Rs.1.05 crore made; in Uttar Pradesh, 30 hospitals were hauled up and recovery of Rs.2.7 lakh was made. As many as 29 hospitals in Jharkhand were found culpable and Rs.21 lakh was recovered from them. The most number of hospitals against whom action was taken were reported from Chhattisgarh (76), followed by Maharashtra (63), Gujarat (55) and Tamil Nadu (51). The recoveries from these States were Rs.4.13 lakh, Rs.53 lakh, Rs.12.6 lakh and Rs.1 lakh respectively.

The grievances were mostly about money collected from patients. The annual report also found that some top 20 hospitals in the country accounted for 17 per cent of high-value claims and 5 per cent of the total outlays. A large number of high-value claims were in brownfield States (where facilities already exist) and preference was for male beneficiaries. The report conceded that “broadening the geographical footprint of high-value claims, especially to greenfield States, and reaching out to a greater proportion of women” were “emerging as key priorities”.

Working paper on hysterectomy

The annual report contained the findings of some working papers that had been prepared exclusively to assess the impact of PMJAY in select settings. One of them, “Patterns of utilisation for Hysterectomy: An analysis of early trends from Ayushman Bharat PMJAY”, throws up worrying conclusions.

Hysterectomy, the authors of the working paper observed, had emerged as a particular area of interest regarding health insurance utilisation in India, especially in the light of its potential misuse. As a whole, surgical procedure comprised 2 per cent of all claims for women and 1 per cent of all claims in 20 States and Union Territories. Three-fourths of all hysterectomy claims were from the six States of Chhattisgarh (21.2 per cent), Uttar Pradesh (18.9 per cent) Jharkhand (12.2 per cent), Gujarat (10.8 per cent), Maharashtra (9 per cent) and Karnataka (6 per cent). These States also accounted for the most number of all claims in this regard.

Chhattisgarh reported the largest number of not only all claims but also claims made under hysterectomy. In both Chhattisgarh and Jharkhand, the most number of claims were made by private hospitals. The median age of women undergoing hysterectomy was 44 years. Around half of the women had undergone salpingo-oophorectomy, or surgery to remove the ovaries and fallopian tubes.

The paper examined the trends for women’s health and health systems, especially as removal of the uterus and ovaries led to premature menopause and had side-effects. Even though the percentage of claims was low in the three States of Uttar Pradesh, Haryana and Arunachal Pradesh, the authors recommended an in-depth review of the claims because the percentage of hysterectomy as a percentage of all hospitalisation for women was higher than the national average here.

Previous studies examining health insurance have found that the leading claim in a community-based health insurance scheme in Gujarat was for hysterectomy; the median age of women here was as low as 32. Other media and fact-finding reports from Rajasthan, Chhattisgarh and Bihar have reported the medically unindicated use of the procedure.

More than two-thirds of all claims submitted for hysterectomy under the PMJAY were in the private sector, which meant that a large number of hysterectomies, whether medically indicated or not, were being done in the private sector. Chhattisgarh (94.5 per cent), Jharkhand (96.7), Gujarat (94.8) and Jammu and Kashmir (74.2) accounted for the highest number of claims submitted for hysterectomy in private hospitals.

The authors of the working group suggested that the median age of claims for hysterectomy and the use of oophorectomy should be monitored closely under the PMJAY. They pointed out that it was difficult to assess the medical necessity of the procedures because of lack of data for medical indications for claims. In other words, it was quite possible that unnecessary hysterectomies may have been conducted in order to submit claims.

The National Family Health Survey, the authors wrote, had suggested that hysterectomy was widely performed for benign conditions, raising questions about the wide use of oophorectomy in claims. The package value for such procedures ranged from Rs.14,000 to Rs.20,000. Apart from the cost of the package, women who underwent such surgery in their forties could enter menopause almost a decade earlier than the median global age for menopause (51 years). This exposed women to a range of health conditions such as osteoporosis and cardiovascular diseases. The working group report recommended a review of the use of oophorectomy and the medical necessity of the procedure.

Neonatal packages

Another working group, which analysed the utilisation of neonatal packages under the PMJAY, found that the higher share of claims raised by private hospitals than public facilities was indicative of the limited availability of neonatal services in the latter. Private hospitals accounted for more advanced neonatal care packages with high-value claims.

Interestingly, the median length of stay in the higher cost packages was more in private hospitals compared with public health-care facilities. For example, the median length of stay for the Critical Neo Natal Care package was eight days in public hospitals whereas it was 12 and a half days in private hospitals. The cost of the Critical Neo Natal Care package in private hospitals was three times that in public hospitals. Even the cost incurred in private hospitals for the preliminary package of basic neonatal care was almost double that in public hospitals.

The main argument against the model of PMJAY is that government funds are being used to subsidise the private health sector where costs are almost double or even three times what is spent in government hospitals. Public health experts have always cautioned against the menace of fraudulent claims and the mammoth exercise of following up on them. The simplest solution would have been to strengthen the public health system, expand it and reduce the dependency of people on the private health-care sector.