The National Health Authority (NHA) has overhauled the existing health benefits packages of the AB-PMJAY, which includes revising their costs to remove any aberrations and discontinuation of around 554 packages, officials said on Thursday.
The NHA is the apex body responsible for the implementation of the Centre's flagship health insurance scheme Ayushman Bharat-Pradhan Mantri Jan Arogya Yojna (AB-PMJAY).
The officials said as many as 237 new packages have been introduced in the scheme.
The governing board of the NHA decided to undertake an exercise to remove the aberrations and anomalies in the existing health benefit packages to further strengthen its delivery, they said.
Rates of 270 packages including bypass surgery, temporary pacemaker implantation, knee replacement, breast cancer treatment, stone removal from kidney among others have been increased while prices of around 60 packages including dialysis and cataract surgeries have been reduced, an official said.
There is no change in the rates of 469 packages, he added.
Besides, there has been an introduction of 237 new packages and adoption of 43 stratified packages, the official said.
"Without compromising the range of treatment covered under PM-JAY, 554 packages will be discontinued, and there is a reduction in the rate of 57 packages. Overall, a conscious attempt has been made to keep the price of abuse prone packages at the minimum level to minimise incentives for abuse," a senior official said.
"We are confident that with the revision in the health benefit packages of Ayushman Bharat PM-JAY, many new private hospitals will get empanelled with the scheme. This will help improve the access to good quality healthcare, and lakhs of vulnerable families will receive free treatment," Union Health Minister Harsh Vardhan said.
Currently, the PM-JAY has 1,393 treatment packages out of which 1,083 are surgical, 309 medical and 1 unspecified package.
According to NHA officials, since the launch of the scheme which completed one year on September 23, it had been receiving feedback on its various aspects including existing HBP and their rates.
The governing board of the NHA took a serious note of that and decided to undertake an exercise to remove the aberrations and anomalies in the HBP. A vigorous and scientific procedure was followed, the official said.
The NHA, along with the Department of Health Research (DHR), the Indian Council of Medical Research (ICMR) and the Tata Memorial Hospital, consulted specialist committees, which helped remove the inconsistencies in the nomenclature and pricing for their respective specialties, an official statement said.
"In the spirit of cooperative federalism, before finalising the changes, feedback was also taken from the states and the Union Territories. Their feedback was examined by the review committee," Dr Indu Bhushan, CEO of NHA, said.
The states and the UTs which are using insurance model or a combination of trust and insurance model shall have autonomy to either continue using existing package master till their current contract period ends or shift to the new version after making suitable amendments in their contract, he said.
The revised oncology packages will revamp cancer care for the beneficiaries and are aligned to reflect the current best practices in the country, Vardhan said.
"These revised rates are expected to further augment cancer care in the country, along with drastic reduction in the catastrophic expenses associated with it. Oncology packages have been split, to include multiple regimens of surgical and medical oncology, complemented by radiotherapy regimens," he said.
The NHA officials said a conscious attempt has been made to standardise the nomenclature and definitions of the packages.
The NHA, in collaboration with the World Health Organization (WHO), has initiated the process of aligning the HBP with International Classification of Health Interventions (ICHI) and the International Classification of Diseases (ICD) coding of the WHO, they said.
When completed, India may become the first country to use ICHI in its HBP list, Bhushan said.
Several innovative concepts were used by the NHA while revising the packages such as cross specialty packages, stratified packages and add-on packages which will enhance the ease of selecting the right package for the empanelled hospital, he said.
To ensure that the hospitals do not overcharge, and rates do not vary across hospitals, empanelled healthcare providers (EHCP) are paid based on specified package rates, Bhushan said.
A package consists of all the costs associated with the treatment, including pre and post hospitalisation expenses. The specified surgical packages are paid as bundled care, where a single all-inclusive payment is payable to the EHCP by insurer/SHA.
The treatment packages are very comprehensive, covering treatment for nearly 24 specialities that include super speciality care like oncology, neurosurgery and cardio-thoracic and vascular surgery, etc.
The AB-PMJAY which completed one year on September 23 aims to cover over 10 crore poor and vulnerable families (approximately 50 crore beneficiaries), providing a coverage of up to Rs 5 lakh per family per year for secondary and tertiary hospitalisation.
As many as 32 states and Union Territories have already implemented the scheme. Delhi, Odisha, Telangana, and West Bengal are yet to join the scheme.
Since the launch of the PMJAY, 46.5 lakh hospital treatments amounting to claims worth Rs 7,490 crores have been provided. Fifty-three per cent of the treatments were provided in private hospitals, while 60 per cent were for tertiary care.
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