Around 20 states have so far signed memoranda of understanding to implement Ayushman Bharat National Health Protection Mission which aims to provide health protection to around 10 crore poor families in the country.
It is fated such as these that the Pradhan Mantri Rashtriya Swasthya Suraksha Mission aka National Health Protection Mission seeks to avoid, by giving an annual health cover of Rs 5 lakh to 10.74 crore families. With the first meeting of the Ayushman Bharat-NHPM Council slated for June 14 and the model tender documents just out, preparations clearly are entering the last lap. Nobody though will yet talk about an August 15 launch.
The National health Agency headed by a full-time CEO will be the nodal agency for the implementation of the programme. States and Union Territories will devise their own modes of implementation – the one suggested by the Centre as a model is through state health agencies (SHA). They can use either an existing trust or society or not for profit company or a state nodal agency or can set up a new entity. Like in case of the National Health Mission, responsibility for the implementation of NHPM will lie with the states. It is their call whether they choose to implement through a trust model, an insurance model or in the mixed mode.
The funding for the scheme will be shared – 60:40 for all states and UTs with their own legislature, 90:10 in NE states and the three Himalayan states of Jammu and Kashmir, Himachal and Uttarakhand and 100% Central funding for UTs without a legislature.
The states are also free to continue with their own health programmes. That would take care of the concerns of states like Maharashtra about the existing beneficiary list already being bigger than what the SECC data entails. The “dovetailing” means that if as per SECC data, 2 lakh people in the state are covered by NHPM, while the state scheme already has 3 lakh, people, the Centre would pay 60% of the premium amount for 2 lakh people. For the state, it would mean some savings. For states particularly ambitious and willing to pay it is even possible for them to make the beneficiary base additive, at least theoretically. It also means that Naveen Patnaik has not only stolen the Centre of bragging rights by announcing a Rs 5 lakh health scheme, a time may soon come when 60% of that premium amount is paid by the Centre.
There will be 100% portability within the country. Package rates of the hospital where benefits are being provided will be applicable while payment will be done by the insurance company that is covering the beneficiary under its policy. State Governments will enter into an arrangement with all other States that are implementing AB-NHPM for allowing sharing of network hospitals, transfer of claim & transaction data arising in areas beyond the service area.
So far 14 states have signed the MOU. Of these, the ones that will use a trust model for the mission are Andhra Pradesh, Telangana, Madhya Pradesh, Assam, Sikkim and Chandigarh. Gujarat and Tamil Nadu have opted for mixed mode implementation. Implementation in trust mode would mean a setup like the Central Government Health Scheme where bills are reimbursed directly by the government without any third party. In the insurance model which is how RSBY started its journey, the government pays a fixed premium to an insurance company which then pays the hospitals.
Andhra Pradesh, Telangana, MP, Assam, Sikkim and Chandigarh will use a trust model while Gujarat and Tamil Nadu will use “mixed mode implementation”. In a trust model, bills are reimbursed directly by the government. In an insurance model, the government pays a fixed premium to an insurance company, which pays the hospitals.
As is the case with any health scheme in India, the first signs of trouble for NHPM have been around the question of money. The initial Niti Ayog estimate of Rs 1082 premium per family per year was rejected by insurance companies in the initial consultations when they held that nothing less than Rs 2500 is feasible. However, estimates have “rationalised” since then but the NHPM tender has come with a catch. In category A States the administrative cost allowed is 10% if claim ratio less than 60%, 15% if claim ratio between 60-70% and 20% if claim ratio is between 70-80%. In Category B States administrative cost allowed will be 10% if claim ratio is less than 60%., 12% if claim ratio is between 60-70% and 15% if claim ratio is between 70-85%. The document also lays down that for a claim ratio of up to 120 per cent states will not pay any additional premium. If the claim ratio is beyond 120% the state will pay 50% of the additional premium. The rest will have to be borne by insurance companies.
For the purpose of administration of the scheme states have been divided into categories A and B. Category A states include s Arunachal Pradesh, Goa, Himachal Pradesh, Jammu and Kashmir, Manipur, Meghalaya, Mizoram, Nagaland, NCT Delhi, Sikkim, Tripura, Uttarakhand and 6 Union Territories (Andaman and Nicobar Islands, Chandigarh, Dadra and Nagar Haveli, Daman and Diu, Lakshadweep and Puducherry). Category B state includes Andhra Pradesh, Assam, Bihar, Chhattisgarh, Gujarat, Haryana, Jharkhand, Karnataka, Kerala, Madhya Pradesh, Maharashtra, Odisha, Punjab, Rajasthan, Tamil Nadu, Telangana, Uttar Pradesh, West Bengal.
It is now however private hospitals which are up in arms against the package rates that have been announced. The 1350 packages that have been announced have been found to have lower than CGHS rates and private hospitals have made no bones about their unhappiness. Ever on the ball, the AB secretariat has responded with an analysis of rates comparing CGHS in Delhi with NHPM, Mukhyamantri Amrutam rates in Gujarat, Chief Minister’s Comprehensive Health Insurance Scheme rates in Tamil Nadu and the Bhamashah Swasthya Bima Yojana in Rajasthan.
That is also why concerns about “moral hazard” procedures have been repeatedly raised in stakeholder consultations. Moral hazard” in health insurance parlance is the tendency of people who are insured to buy/be sold additional healthcare interventions irrespective of their actual needs leading to expenses that do not necessarily add to their own health or wellbeing but bleeds the insurer. Sector experts have been cautioning about potential moral hazard challenges in NHPM since it is essentially a tertiary care programme. Though Ayushman Bharat has a preventive health component in the form of health and wellness centres, the two are de-linked.
With the NRHM scam not so long back, the government is very keen that the scheme that prime minister Narendra Modi hopes will bear his name for posterity has a very strong mechanism to ensure that the scheme is not milked by unscrupulous service providers. That is why in the model tender document uploaded on Tuesday night 636 of the 1350 packages or 47% of all treatments covered require pre-authorisation. This includes all packages for cardiology, ophthalmology and oncology. Many procedures including emergency ones are government hospital only.