Ayushman Bharat expansion to benefit elderly; experts raise key concerns

With rising number of patients, healthcare providers call for timely payments

The industry has welcomed the Centre’s move to expand coverage under the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) to all citizens aged 70 and above.

 

However, it has pointed out that sustainability of the scheme hinges on ensuring adequate reimbursement rates and timely payments to hospitals.

 

Calling the expansion a timely step towards ensuring care for the elderly, Probal Ghosal, chairman, director and co-founder, Ujala Cygnus Healthcare Services, said the inclusion of senior citizens means that many can now seek treatment they may have delayed or avoided due to financial constraints.

 

The scheme provides cashless and paperless benefit cover of Rs 5 lakh per annum per family on a floater basis in empanelled hospitals across India. The scheme expansion is expected to cover around 60 million senior citizens coming from 45 million families. 

 

 

Experts believe that expanding the beneficiary base by a significant margin could present both opportunities and challenges, particularly regarding the viability of the scheme for smaller and medium-sized hospitals. 

 

“Such institutes often operate on tight margins and the added pressure of accommodating a larger patient base could potentially strain their resources,” an industry insider said.  

 

Several private hospital associations have, in the past, complained of lower rates and delays in reimbursement related to procedures performed under the scheme.

 

Recently, the Private Hospital and Nursing Home Association (PHANA), Punjab, and state chapter of the Indian Medical Association (IMA) had announced suspension of all treatment under the scheme in state’s empanelled private hospitals.

 

This is over unresolved payments worth Rs 600 crore pending for six months. 

 

Similarly, the Haryana state chapter of IMA had also resolved an issue involving around Rs 133 crore in pending payments with the state government in July this year. 

 

According to National Health Authority (NHA) data, more than 30,000 hospitals and health centres are currently empanelled under the Ayushman Bharat scheme, of which 13,582 are private. 

 

Commenting on these challenges, Harsh Mahajan, Chair- Ficci Health Services Committee and founder and chief radiologist, Mahajan Imaging and Labs, said urgent steps are needed to address existing issues like low reimbursement rates and delayed payments to hospitals. 

 

“To support smaller hospitals, the government could consider special provisions, like low-interest loans or land allocations, to expand infrastructure quickly. Revising reimbursement rates based on scientific costing will also make it feasible for these hospitals to operate sustainably,” he added.

 

Ghosal added that a balanced approach that combines thoughtful policy adjustments and open communication with healthcare providers can ensure the scheme’s sustainability.

 

“Regular interaction with stakeholders is crucial; through these dialogues, feedback can be used constructively to streamline processes and eliminate operational challenges,” he said.  

 

Expanded coverage for senior citizens 

The  Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana will include all citizens aged 70 and above, benefiting an estimated 60 mn seniors from 45 mn families. It will give a cashless, paperless cover of Rs 5 lakh annually

 

Crux of matter 

  - Experts warn expansion may strain resources for smaller hospitals, which operate on tight margins and face challenges with low reimbursement rates and delays in payments

  - Private hospitals in Punjab have previously suspended services under AB-PMJAY due to pending payments, with unresolved amounts reaching up to Rs 600 crore in some cases

  - Industry leaders advocate for policy support, including low-interest loans and scientific-based reimbursement rate revisions