As the car screeches to a halt in the naxal-affected Khunti district of Jharkhand, the unpretentious building in the middle of nowhere hits you. Not only because it houses a 65-bed eye hospital, but also because (a staff casually mentions it as I get fidgety) beyond this point lie the naxal-hit forests of the Khunti district.

Situated about 55 km from the State’s capital city of Ranchi, the SGVS Hospital on the national highway has done close to 160 eye surgeries under the Ayushman Bharat scheme since October last year.

“I travelled nearly 60-70 km from the Lapung district to get my eye surgery done here. One of the people close to our village who had done operation for his child told me about the scheme, and that’s how I’m here,” says Manuwel Beck.

Many others, fluttering outside the hospital warming their hands and sipping hot tea — having travelled over 200-300 km for treatment — seem quite aware of the benefits under the Centre’s Ayushman Bharat, which offers a cover of ₹5 lakh per family.

At the Ranchi Institute of Neuro-Psychiatry & Allied Sciences, where mental illness is treated — bipolar and Schizophrenia are the most common disorders — Ayushman has made a big difference.

Abhishek Shrivastava, the additional ED of the Jharkhand State Arogya Society, which implements Ayushman in the State, explains that the scheme has helped the poor acknowledge the importance of treating mental illness and brought in more awareness.

Jharkhand, a greenfield State, has been an exception where the progress under Ayushman has been heartening so far. Of the 580-odd hospitals empanelled so far, over 60 per cent are private entities. Also, about 86 per cent of the empanelled hospitals are active (where at least one pre-authorisation claim has been raised). Over 46,000-odd claims have been raised so far, of which 80 per cent are from private hospitals. This is in sharp contrast to the meagre 5,700-odd claims raised in Bihar so far.

While both are greenfield States, Bihar has adopted the trust model, whereas Jharkhand has been one of the nine states that have adopted the hybrid model to implement Ayushman.

This has made a huge difference in the way the scheme operates and delivers in both States.

Trust vs insurance model

There are basically three models by which the Ayushman Bharat scheme can be implemented. Under an insurance model, the premiums are paid to the insurance company, which administers and pays the claim.

Under a trust-based model, each State forms its own trust to manage the scheme and claims will be disbursed from a corpus created from central and State government contributions.

Under the hybrid model, a part of the claim comes under the insurance model while the balance gets processed under trust.

For States that have adopted a hybrid model, empanelling bigger hospitals has been easier, as the risk is ring-fenced with the additional presence of an insurance player.

“In a hybrid model, frauds are minimised because the insurance player is incentivised to keep the claims low. If the claims’ rejection is legitimate, then we support it. But if the claims are rejected on flimsy reasons, we try to control it. In the longer run, the revenue outflow will depend on the fraud detection built into the system. If the insurance player raises issues on fraud then we will look into it and de-empanel hospitals wherever need be. This balance is not there in a trust model,” explains Divyanshu Jha, the Executive Director of Jharkhand State Arogya Society.

Watch the full interview here

Instrumental in ramping up the scheme in the State, Divyanshu explains that States have been given the flexibility to adopt the model that best suits them to implement Ayushman, which is a key positive.

“The hybrid model helps limit the State’s revenue outflow for the scheme, while satisfying the need for direct State intervention. There is an insurance coverage of upto ₹1 lakh, while ₹4 lakh is under trust model. The idea was that the bulk of the claims will come within the initial ₹1 lakh. Since the State did not have the capacity, we wanted to start with insurance, learn the ropes and then ramp up,” he adds.

Vast resources

The project office of the Pradhan Mantri Jan Arogya Yojana (PMJAY)-Ayushman Bharat that I visited houses three third-party administrators (TPAs) —MDIndia, Medi Assist and Safeway.

The vast team of TPAs (roped in by the insurance player) helps ensure minimal pendency of claims and bring in a robust process in place.

In particular, emergency requests from hospitals are approved the same day, with zero pendency.

Data suggests that over 70 per cent of claims raised have been paid so far in the State. Compare this with the poor resources in Bihar, and the lacunae in adopting a pure trust model becomes evident.

The TPA in Bihar is MedSave which quoted a price of just ₹1.83 per household, to take care of pre-authorisation of claims, claim approval, MIS, etc.

The quality is poor, and the manpower is not adequate to handle the flow of claims under the Ayushman Bharat scheme, explain the officials in the State.

(To be continued)