 "Ayushman Bharat will serve a population larger than the US: Indu Bhushan")
Ayushman Bharat, which has been designed to attain the ultimate goal of universal healthcare, is the world's largest healthcare infrastructure scheme, covering 500 million people, or roughly 40 per cent of India's population. The onerous task of spearheading the scheme was entrusted to Indu Bhushan, the former Rajasthan cadre IAS officer, who was specially recalled from Asian Development Bank (ADB) for the purpose. The CEO of Ayushman Bharat, also known as Pradhan Mantri Rashtriya Swasthya Suraksha Mission, holds a Masters in Health Sciences from Johns Hopkins Institute and a doctorate in economics.
All eyes are on him he prepares the framework for the massive rollout that spans India. Corporate healthcare players expect an announcement from the Ramparts on August 15. Bhushan and his team have been clocking long hours. Are they ready? Excerpts from an exclusive interview with GIna Krishnan:
It has been less than 100 days since you took on setting up Ayushman Bharat. At what level of preparedness is the scheme?
The cabinet has approved the funding.
It is true that we are working at a very fast pace. All the guidelines regarding the administrative verticals -- state coordination, benefit packages, hospital empanelment, IT support, demand and IEC, monitoring, etc -- are in place. Positions are being advertised.
One of the most important components is to get the software up and running. TCS (Tata Consultancy Services) has the mandate as of now. It should be ready by the end of July with the first module on hospital empanelment ready in a week. Field testing in some villages will also begin in July. The software will have a database of beneficiaries, empanelled healthcare providers, and state governments linked to the Ayushman Bharat site. The core software has modules on database of beneficiaries, hospital empanelment, transactions, grievances, etc.
MoUs with 23 states have been signed, and a few are expected in the next few weeks.
A lot has been done in terms of rolling out (the scheme) at the state level. States are at different levels of preparedness. Some already have ongoing schemes, so it is much easier for them to scale up. They just need to deepen what they are doing.
Others, such as Uttar Pradesh, Bihar and Madhya Pradesh, do not have any scheme -- no structure, expertise or experience. They are populous states, so we have to work hard at providing resources, establishing a programme management unit which can help the states service the scheme.
National portability for us is the most significant part of the scheme and a core feature. Healthcare will be available to a beneficiary in any part of the country, so states just need to add that and deepen what they are already doing.
Some states like Odisha do not want to join. Will they be independent providers of healthcare without joining into the National programme?
Since health is a state subject, states have to choose how to provide services to the people. If they decide not to join because of technical concerns about the scheme, we can address and solve those, but if they are not joining for political reasons, then we cannot comment.
It is true that Odisha is not yet joining the scheme, (but) we are still pursuing discussions with the state and haven't given up. We want all states to be part of the programme. When we talk about a national level scheme that covers 500 million people, we want all states to be part of it so that we can all together move towards the ultimate goal of Universal health coverage. We will continue to have a dialogue with Odisha. Delhi signed on last week, West Bengal is interested and Punjab too has indicated it will join in. We are hoping that sooner or later all 36 states will join. But by end July, we hope at least 28-30 will be a part of the scheme.
How was the enrolment done?
We don't call it enrolment because this is an entitlement-based scheme--it is identification or validation, because these people are already there and have been identified in the SECC database.
We have done this drive in rural areas of the 23 states and we have been able to identify and validate 80-85 per cent of the population in these states. In urban areas, our success rate has been 50-60 per cent. The data entry process is going on and the database will be available to all healthcare providers and insurance companies that sign up.
Beneficiaries will get an identification card, which can be downloaded on the mobile through an app.
The private sector is very concerned about the pricing...
The basic principle of the scheme is to cover the vulnerable segment of society--people at the bottom 40 per cent of the population. We want maximum benefit to go to them rather than to the medical profession or to insurance agencies.
We understand that they have to be compensated or they may not participate but we don't want them to garner most of the benefits.
Secondly, Ayushman Bharat is a very disruptive scheme. We are expanding healthcare services for 500 million people. If it (this population) was a country, it would be the third-largest after China and India. In fact, the fourth largest would be US with its 300 million people.
It is a large market. We have to move cautiously so that our scheme remains sustainable and does not inflate costs.
India is a big country and has huge diversity in terms of costs, and for any national-level costing, we have to take the median. So we started with the existing database that we have on schemes running in various states, rates for RSPY, CGHS and ESI. Based on all these existing rates, a committee was set up under the Director General of Health Services (DGHS). ICMR's Dr Vinod Kaul and his team reviewed the prices and after extensive consultations across the country, provided feedback on those rates.
A total of 1,350 packages with prices have been announced.
For the first time in the country an agency has been set up for strategic purchase of services. We are driven by evidence and science (when we arrive at a pricing package). A large number of providers from tier-2 and 3 cities are willing to come at these rates.
Having said that, we have also formed a steering committee with Niti Aayog, Indian Medical Association and various healthcare providers to undertake a costing study in the next one year, The committee will provide feedback and inputs to our work, and further refine costs which can be applicable for the entire country.
What are the additional incentives offered in terms of pricing?
To meet the twin objectives of encouraging quality and opening healthcare facilities in lagging districts, additional benefits are being offered.
The criteria for empanelment of hospitals have been shared. Every private hospital has been invited and government ones are expected to be part of the provider network.
In addition to the prices announced, 10 per cent weightage has been given for NABH accreditation, additional 15 per cent for advanced NABH accreditation, 10 per cent for a teaching hospital. These incentives bring the package rates almost to be equivalent to the CGHS rates. States can offer another 10 per cent (of the announced package rate). In addition, hospitals will get 10 per cent more (of announced packaged rates) if they are in aspirational districts.
Government hospitals in remote areas and aspirational districts will be incentivised by the state government. In fact the National Health Authority will allow the government hospital to retain their earnings from the scheme, 75 per cent of which will go towards infrastructure upgradation and 25 per cent can be used for staff incentives.
How will the payout to providers take place?
Healthcare being a state subject, the programme will be administered by the states. State Health Authorities are being set up and they are free to choose two models -- they may outsource managing of funds to insurance companies for a premium, or they may create a trust, keep the money with themselves and make payments as the bills come in.
The earlier experience was that the Centre would delay giving out money or the states would subsume it for other schemes and finally the insurance companies would delay payments or even reject claims.
Keeping that in mind, it has been decided that state governments will open an escrow account, to which the Centre will transfer money to each state based on the population. The total share of the centre is 60 per cent, the rest will be put in by the state.
Payment will be staggered, and 45 per cent of the total premium (will be paid) upfront to the insurance companies so that they have capital. Six months later another 45 per cent will be released and the remaining10 per cent will be released at the end of the year.
The important provision that should warm the hearts of the private sector hospitals is that NHA has decreed that the insurance company/ state government administered Trust has to release money to the provider with 15 days (two weeks) otherwise one per cent of the amount will have to be paid as penal interest per week.
The issue of insurance companies rejecting payments has been addressed by the NHA decree. There will be no rejection of payments by insurance companies. They can only recommend a rejection but the state government will have to pay. The whole process will be closely monitored by NHA.
How is the patient flow expected in the system? Will the beneficiaries be refereed to tertiary care hospitals from Primary Health Centres?
At this point, the scheme begins with offering hospitalisation expenses up to Rs 500,000 each. The patient can go to any of the empanelled hospitals for treatment.
But later, as the scheme matures and its administration becomes more robust, it will follow the flow of patients from a general practitioner at the primary health centre, on to secondary care and finally to tertiary care centres for treatment.
Screening at primary and secondary care centers will also give better health outcomes and decrease the burden in terms of cost at the tertiary level.
However, at this initial phase of rollout, the IT systems are not geared to handle patient flow in this manner. Neither is a patient with a serious illness expected to go back to a PHC for referral. Some states with advanced healthcare systems, such as Karnataka, are opting for the referral system but NHA has not made it mandatory at this point.
What will NHA's role be?
Apart from funding, training, supervision, hand-holding, setting up standards and guidelines on lagging areas, implementing, the agency will also ensure that rules are followed and safeguard them through monitoring for fraud and corruption. There are seven verticals -- information technology, state coordination for medical packages, empanelment of hospitals, monitoring evaluation, for demand generation (connecting patients to the right empanelled hospitals so that care is available to them as per need), among others.
We will be working very closely with state health agencies.
All eyes are on him he prepares the framework for the massive rollout that spans India. Corporate healthcare players expect an announcement from the Ramparts on August 15. Bhushan and his team have been clocking long hours. Are they ready? Excerpts from an exclusive interview with GIna Krishnan:
It has been less than 100 days since you took on setting up Ayushman Bharat. At what level of preparedness is the scheme?
The cabinet has approved the funding.
It is true that we are working at a very fast pace. All the guidelines regarding the administrative verticals -- state coordination, benefit packages, hospital empanelment, IT support, demand and IEC, monitoring, etc -- are in place. Positions are being advertised.
One of the most important components is to get the software up and running. TCS (Tata Consultancy Services) has the mandate as of now. It should be ready by the end of July with the first module on hospital empanelment ready in a week. Field testing in some villages will also begin in July. The software will have a database of beneficiaries, empanelled healthcare providers, and state governments linked to the Ayushman Bharat site. The core software has modules on database of beneficiaries, hospital empanelment, transactions, grievances, etc.
MoUs with 23 states have been signed, and a few are expected in the next few weeks.
A lot has been done in terms of rolling out (the scheme) at the state level. States are at different levels of preparedness. Some already have ongoing schemes, so it is much easier for them to scale up. They just need to deepen what they are doing.
Others, such as Uttar Pradesh, Bihar and Madhya Pradesh, do not have any scheme -- no structure, expertise or experience. They are populous states, so we have to work hard at providing resources, establishing a programme management unit which can help the states service the scheme.
National portability for us is the most significant part of the scheme and a core feature. Healthcare will be available to a beneficiary in any part of the country, so states just need to add that and deepen what they are already doing.
Some states like Odisha do not want to join. Will they be independent providers of healthcare without joining into the National programme?
Since health is a state subject, states have to choose how to provide services to the people. If they decide not to join because of technical concerns about the scheme, we can address and solve those, but if they are not joining for political reasons, then we cannot comment.
It is true that Odisha is not yet joining the scheme, (but) we are still pursuing discussions with the state and haven't given up. We want all states to be part of the programme. When we talk about a national level scheme that covers 500 million people, we want all states to be part of it so that we can all together move towards the ultimate goal of Universal health coverage. We will continue to have a dialogue with Odisha. Delhi signed on last week, West Bengal is interested and Punjab too has indicated it will join in. We are hoping that sooner or later all 36 states will join. But by end July, we hope at least 28-30 will be a part of the scheme.
How was the enrolment done?
We don't call it enrolment because this is an entitlement-based scheme--it is identification or validation, because these people are already there and have been identified in the SECC database.
We have done this drive in rural areas of the 23 states and we have been able to identify and validate 80-85 per cent of the population in these states. In urban areas, our success rate has been 50-60 per cent. The data entry process is going on and the database will be available to all healthcare providers and insurance companies that sign up.
Beneficiaries will get an identification card, which can be downloaded on the mobile through an app.
The private sector is very concerned about the pricing...
The basic principle of the scheme is to cover the vulnerable segment of society--people at the bottom 40 per cent of the population. We want maximum benefit to go to them rather than to the medical profession or to insurance agencies.
We understand that they have to be compensated or they may not participate but we don't want them to garner most of the benefits.
Secondly, Ayushman Bharat is a very disruptive scheme. We are expanding healthcare services for 500 million people. If it (this population) was a country, it would be the third-largest after China and India. In fact, the fourth largest would be US with its 300 million people.
It is a large market. We have to move cautiously so that our scheme remains sustainable and does not inflate costs.
India is a big country and has huge diversity in terms of costs, and for any national-level costing, we have to take the median. So we started with the existing database that we have on schemes running in various states, rates for RSPY, CGHS and ESI. Based on all these existing rates, a committee was set up under the Director General of Health Services (DGHS). ICMR's Dr Vinod Kaul and his team reviewed the prices and after extensive consultations across the country, provided feedback on those rates.
A total of 1,350 packages with prices have been announced.
For the first time in the country an agency has been set up for strategic purchase of services. We are driven by evidence and science (when we arrive at a pricing package). A large number of providers from tier-2 and 3 cities are willing to come at these rates.
Having said that, we have also formed a steering committee with Niti Aayog, Indian Medical Association and various healthcare providers to undertake a costing study in the next one year, The committee will provide feedback and inputs to our work, and further refine costs which can be applicable for the entire country.
What are the additional incentives offered in terms of pricing?
To meet the twin objectives of encouraging quality and opening healthcare facilities in lagging districts, additional benefits are being offered.
The criteria for empanelment of hospitals have been shared. Every private hospital has been invited and government ones are expected to be part of the provider network.
In addition to the prices announced, 10 per cent weightage has been given for NABH accreditation, additional 15 per cent for advanced NABH accreditation, 10 per cent for a teaching hospital. These incentives bring the package rates almost to be equivalent to the CGHS rates. States can offer another 10 per cent (of the announced package rate). In addition, hospitals will get 10 per cent more (of announced packaged rates) if they are in aspirational districts.
Government hospitals in remote areas and aspirational districts will be incentivised by the state government. In fact the National Health Authority will allow the government hospital to retain their earnings from the scheme, 75 per cent of which will go towards infrastructure upgradation and 25 per cent can be used for staff incentives.
How will the payout to providers take place?
Healthcare being a state subject, the programme will be administered by the states. State Health Authorities are being set up and they are free to choose two models -- they may outsource managing of funds to insurance companies for a premium, or they may create a trust, keep the money with themselves and make payments as the bills come in.
The earlier experience was that the Centre would delay giving out money or the states would subsume it for other schemes and finally the insurance companies would delay payments or even reject claims.
Keeping that in mind, it has been decided that state governments will open an escrow account, to which the Centre will transfer money to each state based on the population. The total share of the centre is 60 per cent, the rest will be put in by the state.
Payment will be staggered, and 45 per cent of the total premium (will be paid) upfront to the insurance companies so that they have capital. Six months later another 45 per cent will be released and the remaining10 per cent will be released at the end of the year.
The important provision that should warm the hearts of the private sector hospitals is that NHA has decreed that the insurance company/ state government administered Trust has to release money to the provider with 15 days (two weeks) otherwise one per cent of the amount will have to be paid as penal interest per week.
The issue of insurance companies rejecting payments has been addressed by the NHA decree. There will be no rejection of payments by insurance companies. They can only recommend a rejection but the state government will have to pay. The whole process will be closely monitored by NHA.
How is the patient flow expected in the system? Will the beneficiaries be refereed to tertiary care hospitals from Primary Health Centres?
At this point, the scheme begins with offering hospitalisation expenses up to Rs 500,000 each. The patient can go to any of the empanelled hospitals for treatment.
But later, as the scheme matures and its administration becomes more robust, it will follow the flow of patients from a general practitioner at the primary health centre, on to secondary care and finally to tertiary care centres for treatment.
Screening at primary and secondary care centers will also give better health outcomes and decrease the burden in terms of cost at the tertiary level.
However, at this initial phase of rollout, the IT systems are not geared to handle patient flow in this manner. Neither is a patient with a serious illness expected to go back to a PHC for referral. Some states with advanced healthcare systems, such as Karnataka, are opting for the referral system but NHA has not made it mandatory at this point.
What will NHA's role be?
Apart from funding, training, supervision, hand-holding, setting up standards and guidelines on lagging areas, implementing, the agency will also ensure that rules are followed and safeguard them through monitoring for fraud and corruption. There are seven verticals -- information technology, state coordination for medical packages, empanelment of hospitals, monitoring evaluation, for demand generation (connecting patients to the right empanelled hospitals so that care is available to them as per need), among others.
We will be working very closely with state health agencies.
Ayushman Bharat Primer
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