Ayushman Bharat is National Health Protection Scheme, will cover over 10 crore poor and vulnerable families (approximately 50 crore beneficiaries) providing coverage up to 5 lakh rupees per family every year for secondary and tertiary care hospitalization. Ayushman Bharat – National Health Protection Mission will subsume the on-going centrally sponsored schemes – Rashtriya Swasthya Bima Yojana (RSBY) and the Senior Citizen Health Insurance Scheme (SCHIS). At the national level to manage, an Ayushman Bharat National Health Protection Mission Agency (AB-NHPMA) would be put in place. States/UTs would be advised to implement the scheme by a dedicated entity called State Health Agency (SHA). They can either use an existing Trust/ Society/ Not for Profit Company/ State Nodal Agency (SNA) or set up a new entity to implement the scheme. States/ UTs can decide to implement the scheme through an insurance company or directly through the Trust/Society or use an integrated model. In Budget 2018, the government had made these announcements: (a) On a National Health Protection Scheme (NHPS) providing insurance cover of Rs 5 lakh per family; (b) Having an initiative to establish new government medical colleges and hospitals, and upgrading existing district hospitals under the programme; and (c) Setting up of over 1,50,000 health and wellness centres throughout the country. An integrated approach in implementation of all the three initiatives can steer the country towards having universal healthcare. The success of the flagship NHPS, aimed at making available secondary and tertiary care to the needy could largely depend upon how successfully the other two initiatives are implemented. The two major concern areas identifiable in the existing government health insurance schemes are enrolment and abuse or overtreatment or unnecessary hospitalizations. There are situations of fictitious enrolments, unnecessary hospitalizations or unnecessary hysterectomies, and other such instances. An integrated approach to implementing all the three initiatives would have far-reaching effects on the country’s healthcare scenario, and we could see a healthier India. Rationalizing treatment or surgical procedures, and use of medicines and diagnostics will bring in reduction in healthcare costs. This would also lead to stabilizing the premiums of NHPS and ensuring continuous improvements in terms of coverage. The government is expecting a challenge in rolling out the National Health Protection Mission (NHPM) to the urban poor after completing the first round of data cleansing earlier this month. Billed as the world’s largest health assurance scheme, NHPM aims to provide free health insurance of Rs 5 lakh per family to nearly 40% of the population-more than 100 million poor and vulnerable families based on Socio Economic Caste Census (SECC). ABNHPM as Modicare: In March 2018, the Cabinet cleared the Ayushman Bharat National Health Protection Mission, dubbed Modicare. The Union cabinet signed off on Ayushman Bharat National Health Protection Mission (AB-NHPM), the ambitious social welfare programme announced in the Union budget for 2018-19. It set the stage for the rollout of the scheme that has come to be dubbed “Modicare” (like the medical plan for the poorest in the US came to be called Obamacare) and is estimated to cost anywhere upwards of Rs12,000 crore annually. At the minimum, this scheme aims to provide healthcare to 500 million poor and vulnerable people by funding their secondary and tertiary healthcare costs-for beneficiaries it will be a cashless and paperless transaction. Undoubtedly this is the most ambitious social welfare programme being attempted by the Prime Minister. It is something that is long overdue-to be sure, versions of it already exist at the state level and even the Union government-and one that the Union government can’t afford to botch up in implementation. A successful rollout of Modicare will accelerate the healthy healthcare system. It is clear that while indeed Modicare is a social cause, the associated political stakes too are equally compelling. NHPM, often called Modicare, is set to significantly lower the cost of healthcare at private hospitals by scaling up the healthcare market. NHPM will bring a huge supply side response. The fact that the scheme will be available across the country will bring private sector healthcare providers to Tier-3 and Tier- 4 towns and expand operations there. Today, 1.3 billion plus Indians are served by 10,00,000 registered doctors instead of 15,00,000, if one were to comply to WHO’s recommendation for optimum access to health and quality care for all. Shortage of 5,00,000 doctors is a herculean supply gap to catch-up with, when the number of new doctors made in India per year is merely 65,000 (total MBBS and BDS enrolments in public and private medical colleges). 2500-3000 leaves for foreign shores every year for post-graduate education or for work. The healthcare market will expand hugely and it will have the potential to bring prices down because of its scale. Also, the protocols that will be signed between health insurance companies and healthcare providers will become benchmarks for other private providers. That will also help in bringing prices down. One will also see a shift towards use of generics from costly branded drugs. The whole healthcare paradigm will radically transform. World’s largest health Insurance Cover: The NHPM, labelled the world’s largest health assurance cover, aims to provide health insurance to nearly 40% of the population-i.e. more than 100 million poor and vulnerable families-with the premium paid by the government. The finance ministry had initially announced an outlay of Rs 2,000 crore. The Union health ministry announced an allocation of Rs10,000 crore to Modicare for next two years. With NHPM, it is very likely that investment in mid-size hospitals with more than 50 beds and more will increase. This may cut the costs of the health services considerably. NHPM will be an entitlement-based scheme based on data from the deprivation criteria in the Socio-Economic Caste Census (SECC). Beneficiaries under NHPM can avail of benefits in both public and empanelled private facilities. Health policy experts claim that the scheme will prove to be a game changer with poor families benefiting the most. The NHPM has included people on the criteria of profession. The urban space is geographically diffused and the poor population in urban areas is fluid. The population keeps on coming in, going out and migrating within as well as outside the urban space. There may come some inherent difficulties in communicating with this chunk of urban population. As this is a national scheme and has to be implemented in partnership with the states, they will have to find out ways to reach out to the lowest quintile of their areas. The expenditure incurred in premium payment will be shared between Central and State Governments in specified ratio as per Ministry of Finance guidelines. The total expenditure will depend on actual market determined premium paid in States/ UTs where Ayushman Bharat – National Health Protection Mission will be implemented through insurance companies. In States/UTs where the scheme will be implemented in Trust/Society mode, the central share of funds will be provided based on actual expenditure or premium ceiling (whichever is lower) in the pre-determined ratio. Poor people will not fall back into utter poverty due to a health emergency and they can be assured that the scheme will take care of their health needs. The scheme is a game changer in the health sector and it should be rolled out in a manner that ensures the best possible coverage. Private health and insurance industry experts also expect new jobs to be created. The scheme will also create lakhs of new jobs in the country as new healthcare facilities will come up in smaller districts and villages. The government also has a provision of extending free treatment to the poor by reserving some beds in private hospitals. However, most private hospitals claim they don’t get enough poor and underprivileged patients for free beds. The health ministry is currently detecting, correcting and deleting inaccurate records from its database for targeted beneficiaries. While contacting rural beneficiaries to inform them about their entitlement for NHPS has been strategically planned, the major task for the government now is finding the actual whereabouts of urban beneficiaries. The NHPM is an entitlement-based scheme and the biggest challenge is to reach out to poor and tell them that they are entitled for this scheme. Delivery mechanism of the scheme: Ayushman Bharat – National Health Protection Mission will target about 10.74 crore poor, deprived rural families and identified occupational category of urban workers’ families as per the latest Socio-Economic Caste Census (SECC) data covering both rural and urban. The scheme is designed to be dynamic and aspirational and it would take into account any future changes in the exclusion/ inclusion/ deprivation/ occupational criteria in the SECC data. 1950, the year India became a republic, was also the year when several nations acknowledged the need to join forces on issues of health. Since then, 7 April has been celebrated as World Health Day, also the anniversary of the World Health Organization (WHO). WHO’s theme for this year’s World Health Day is universal healthcare, an exact match with Indian government’s vision of Ayushman Bharat, powered by the National Health Protection Scheme (NHPS) announcement by the Union finance minister in his 2018 budget speech. NHPS has faced a mix of admiration and criticism from policy makers, politicians, healthcare workers and academics. Sceptics have raised questions on its contours, assumptions and implementation. Earlier, this author too had pointed out NHPS’s limitation towards achieving its objective of “health for all” as it excludes coverage for outpatient services availed in the private sector by its intended beneficiaries, the largest chunk of their out-of-pocket expenditure on health. Quality of healthcare delivery is another concern. In public healthcare organisations, one finds well-qualified, over-worked, under-rested junior doctors and residents, who tirelessly work in order to eventually land up a more organized and better-paying job within India or abroad. The pitiable and unhygienic conditions in which they work and government’s commitment to increase its expenditure to 2.5% of GDP by 2025, more than double the current spending, is very encouraging. Making it an easy to use scheme: Insurance that is difficult to use will not be used. Therefore, there is aneed to streamline both the enrolment process and access to care once enrolled. The number of forms people face to enrol in NHPS must be minimized. Aadhaar makes it easy to verify eligibility and enrol. Maybe all you need is Aadhaar and no other forms or hassles to enrol. For this, Aadhaar should be made readily available to demographics where it does not exist. This would require continuous and active collaboration between ministry of health and family welfare and Unique Identification Authority of India (UIDAI). In the case of children, the UIDAI authorities should take a more proactive approach and increase their coverage-as of today, data shows that of all the Aadhaar numbers issued so far, less than 5% are for those under five years of age, which is a gross undercounting of children. Once enrolled, access to care should be provided where people live. This is a challenge in rural India but can be addressed with innovative models. For example, in Karnataka, health camps organized by super specialty hospitals were successful in improving access to care. Hospitals in Bengaluru would send cardiologists and other specialist to camps in villages. Patients identified as needing additional care were offered free transportation for patient and companion in Bengaluru. Other models are also being piloted, such as telemedicine in Uttar Pradesh where patients at primary health centre are connected to specialist doctors in Andhra Pradesh for virtual OPD care. The NHPS will have access to health information of 500 million people. This is an unprecedented amount of data and if curated well, it can have far-reaching applications. It can be used for comparative effectiveness research or understanding which treatments work in the real world rather than just in clinical trials. Treatments and interventions can be highly contextualized to local conditions. Nearly 75% of out-patient department care and 55% of in-patient department care in India is exclusively from the private sector. Therefore, private hospitals and clinics provide care to a large fraction of the population and they need to be part of NHPS. Yes, private hospitals will try to exploit NHPS. But the solution is not to exclude them but to monitor them and create the right incentives for them. There are several options. First, not all hospitals should be eligible for NHPS. Only hospitals that meet certain quality standards should be allowed to serve NHPS beneficiaries. Quality should be measured not only by the infrastructure available at the hospital but also by actual patient outcomes achieved. Second, NHPS should institute prior authorization for expensive medical procedures and surgeries. NHPS doctors should review the medical records of NHPS beneficiaries to make sure that the surgery in medically warranted and meets evidence-based guidelines. Third, NHPS should reimburse hospitals using “bundled payment” so that the hospital receives a fixed amount per episode of care that covers all services provided by the hospital. This lowers incentives for the hospital to provide care just to make more money. The bundled payment can also be tied to quality metrics, creating further incentives to improve quality of care. Challenges ahead: Design and implementation challenges facing NHPS are even greater. Hospitals will have an inherent interest in pushing patients towards more expensive procedures or towards procedures not even required. Any lack of clarity in delineating the included and excluded procedures will become a source of abuse. The state nodal agencies will have to have sufficient resources and technical and administrative capability to monitor and check such abuse. Also, while the idea of ‘One Nation, One Scheme’ is enticing, we should not lose sight of the fact that we are a diverse nation. While the scheme can be one, it has to have students to choose healthcare over other career options that promise a faster and more reliable route to job satisfaction. The existing evidence shows that providing insurance to the poor not only saves lives but is also “cost-effective”. That is, it provides good value for money as the benefits of insurance far outweigh the costs. However, cost-effective health coverage must cover primary care. This is where the second feature of Ayushman Bharat Programme-creation of 150,000 wellness centres across the country-is a very significant and welcome announcement. Sub-centres (and primary health centres) are the first line of contact of citizens to the public health system in India. Strong primary care is fundamental to keeping overall access to healthcare equitable and affordable in the country. The biggest constraint to making this happen is not shortage of capital or infrastructure, but an acute shortage of human resources. Most public healthcare facilities (primary, secondary and tertiary) have significant shortage of doctors, nurses and other health workers, often higher than 50%. Many states are already running their health insurance schemes like Aarogyasri in Andhra Pradesh, Mukhyamantri Swasthya Bima Yojana in Jharkhand & Uttarakhand, Biju Krushak Kalyan Yojana in Odisha and Comprehensive Health Insurance Scheme in Kerala. Whether the states would continue to run these programmes, or adopt Ayushman Bharat, is not clear yet. When the price discovery is made through the tender process, the premium will be high for states where utilisation is high. Experience under the decade-old Rashtriya Swasthya Bima Yojana (RSBY), which enrolled more than 30 million families below the poverty threshold, varies from state to state. In terms of the mode of implementation, state governments will be allowed to expand AB-NHPM both horizontally and vertically. They can implement it through an insurance company or directly through a trust/society or a mixed model. However, it is likely that most states will employ an insurance model wherein companies will be chosen through a process of tender. Out of pocket (OOP) expenditure for healthcare in India is over 60 percent, which leads to nearly 6 million families slipping into poverty due to catastrophic health expenses. The AB-NHPM is expected to have an increased benefit cover for nearly 40 percent of the country’s population. Authored By: Jagendra Kumar Ex. CEO, Pearl Insurance Brokers JAIPUR   References: 1. https://www.india.gov.in/spotlight/ayushman-bharat-national-health-protection-mission 2. https://www.thehindubusinessline.com/economy/policy/cabinet-nod-for-national-health-protection-mission 3. https://economictimes.indiatimes.com/topic/ayushman-bharat-national-health-protection-mission 4. https://timesofindia.indiatimes.com/india/government-nod-to-launch-of-ayushman-bharat 5. https://www.moneycontrol.com/news/business/cabinet-clears-ayushman-bharat-national-health-protection-mission 6. IRDAI Annual Report 2016-17 7. Newspapers & Journals

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