Universal healthcare was initiated through Ayushman Bharat Yojana or Pradhan Mantri Jan Arogya Yojana (PMJAY) in February 2018. It is a matter of national pride to see that the underserved and unserved sections of society have been thought of and access to healthcare is being provided to them through the Ayushman Bharat scheme under the trust or insurance schemes of the states.
Since the Cabinet approval in March 2018, the execution of PMJAY scheme has been on a fast track, which reflects in the enrolment of 1.7 crore people till February 12, 2019. If state health insurance beneficiaries, who switched to PMJAY are added, the total list adds up to 5 crore, as per the National Health Authority (NHA). In the first five months, one million patient admissions through 14,771 empanelled hospitals with authorized disbursements of Rs 1,544 crore was a stellar achievement.
However, as with any large scheme, which is rolled out in larger interest of people but as it goes along the glitches appear and they need to be addressed. PMJAY is at a similar phase. It’s crucial for the industry to work with the government to co-create PMJAY version 2.0 keeping patients at the centre of well-defined clinical outcomes and elements that needs to change as we progress towards universal healthcare.
These inputs need to come from six different stakeholders that hold responsibility of the last-mile healthcare delivery to patients like hospitals and diagnostics providers, pharmaceutical industry, medical device/ technology industry, health insurance firms, diagnostic industry and private equity firms invested in healthcare companies.
The current version of pricing procedures under Ayushman Bharat PMJAY is based on two fundamental assumptions:
- Acceptable quality of care
- Episodic care giving to patients
Acceptable quality of care is very subjective in nature and have a significant impact on patients, if the care swings to other extreme for worse. Episodic care would have direct financial consequences on the long-term sustainability of the scheme with rising premiums from every repeat procedure for patients. All this, while the patients undergo severe consequences on their quality of life, basis suboptimal outcomes, stemming from acceptable quality.
AB PMJAY version 2.0 needs to carefully consider these impact areas. Some of the recommendations for universal healthcare as well as PMJAY version 2.0 to make it inclusive, successful with private participation and to drive employment, along with encouraging Make in India and Skill India are:
1. Revise procedure price rates from 1993 to 2019: Revisit Central Government Health Scheme (CGHS) 1993 prices and revise procedure cost to accommodate for inflation over time and develop a reasonable new 2019 procedure price guide.
2. Separate device-procedure costs: Separate device and procedure costs as per the CGHS model and based on the revised CGHS pricing. In PMJAY 1.0, devices are subsumed within procedure cost at 20% lower than current CGHS procedure prices making it unattractive for healthcare ecosystem.
3. Cost quality equation: Outcomes of any policy takes 3-4 years to show results. Patients treated with “acceptable quality” will come back into the system for repeat surgeries after 3-4 years costing the exchequer huge amounts.
PMJAY 2.0 needs to move away from “acceptable quality” to “good quality @ right procedure/ product value”, thereby moving away from short term fix – episodic care to better outcomes in longer term, avoiding repeat surgical costs for the exchequer/ insurance companies depending on trust/ insurance model.
4. Skill building: Private sector should be provided with sops to embrace and adopt the Allied and Healthcare Professions Bill, 2018 passed in Parliament in December 2018. This could lead to healthcare sector being the largest creator of future jobs for the next generation.
The investments linked to support this bill may though be linked to reasonable profits being generated by the healthcare industry, which is subject to approval of the above three recommendations that will make PMJAY 2.0 sustainable and reproducible.
5. Innovation: PMJAY 2.0 should include innovation and latest therapies needed by patients irrespective of their socioeconomic status at the right costs.
6. Ease of Doing Business: Creation of a nodal healthcare regulator, which will be a one stop shop, is needed to facilitate ease of doing business. Keeping the interest of the patients at the centre, the regulator with internal government departments will influence policy making/ regulations for all industry stakeholders. It should be fully empowered to take independent decisions, with arbitration recourse.
This could be the single largest strategic initiative to foster a transparent, predictable, inclusive environment for businesses and to usher in stability.
The positive environment created by these steps would accelerate “Make in India” campaign and generate additional employment driven by the demand push under PMJAY version 2.0.
(The author is Chairman, FICCI Medical Device Committee and Managing Director, South Asia & South East Asia, Smith & Nephew Healthcare Ltd.)
