AYUSHMAN BHARAT: A GAME CHANGER

It is unfortunate that no scientific study has been done till date to compute actual costing of delivering variety of medical procedures under different settings. It will be appropriate that Ministry of Health and Family Welfare (MOHFW) should endeavor on urgent basis to ascertain the actual costs to private hospitals in rendering services to beneficiaries under NHPS. Government may institute an independent agency with representatives from IIM, cost accountants from professional consulting companies, major hospitals and insurance companies to carry out a costing study…..
By Dr Girdhar J Gyani

Preamble: Government of India in its budget proposals for year 2018-19 has come out with some of the land mark initiatives. These include National Health Protection Scheme (NHPS) and opening up of 1.5 lakh health and wellness centres. Looking at sheer size and quantum of work load, it would be imperative that resources available with public and private sector are pooled, utilized and managed to achieve the desired goals; under the overall gambit of universal health coverage (UHC).
Health and Wellness Centre: The government has announced to launch 1.5 lakh Health & Wellness Centres (HWC) to bring promotional, preventive and primary health care system closer to the homes of people. These centres will provide comprehensive health care, including for non-communicable diseases and maternal and child health services. These centres will also provide free essential drugs and diagnostic services. The Budget allocation for this flagship programme is Rs 1200 crore. Contribution of private sector through CSR and philanthropic institutions in adopting these centres is also envisaged.
Considering that we have about 1.5 lakh sub-centres available, it will be in fitness of things that these sub-centres are upgraded into HWCs which are closest to the community. The first point of referral for such HWCs in normal course would be nearby existing PHC/ CHC to provide the package of comprehensive primary health care. It will have further linkages with the district hospitals and tertiary care teaching hospitals. For sub-center to be an effective in the new role of HWC, re-engineering of existing structure and resources will be required to enable it to provide comprehensive primary care including; Maternal Health Care Services, Neonatal and Infant Health Care Services, Management of Communicable and Non-Communicable Diseases along with necessary diagnostic services etc.
Reference to the Health & Wellness Centers was made in the the national health policy released on 15th March 2017. Few states including Haryana, Punjab and J&K are known to have initiated converting some of their sub-centers in to HWCs. Haryana & Punjab governments have planned to train community health officers, who would manage these centers, with specialist doctor from nearby PHC or CHC visiting HWCs on regular basis.
Role of Private Sector: Private sector has huge opportunity by adopting few sub-centers as HWCs. AHPI has proposed to the government that its member hospitals will be willing to manage some of the HWCs within the same budget, which government provide for existing sub-center. The manpower would be fully deployed by the private sector provider, with provision of specialist doctor visiting on need basis from main hospital or consulting through telemedicine as appropriate. Entry of private sector in a way will also generate healthy competition as well as cooperation between public and private sector. Some of the additional suggestions for effective functioning of proposed HWCs are appended below:
1- Maintenance of electronic family file for every house in the community should become integral part of proposed HWCs, so that community statistics is adequately monitored and whenever required corrective steps could be taken. There should be a separate division/agency to conduct community surveys to keep track of life style diseases, infections, immunization and other illnesses and advice people on life style changes which are required.
2- Maternity and child welfare schemes are very important. Birth and death registers and wedding registers are important. Support will be required for early diagnosis of pregnancy and managing the expectant mothers throughout their difficult times.
3- Creating specialty clinics in some of the most underserved areas of the country as per local requirements for specific disease/epidemic control, wheredoctors could visit these centres on a periodic basis engaging in both treatment andpreventive care.
4- There is a requirement for leveraging technology. Telemedicine services can be effectively utilized to connect remote areas withTaluk& District Hospitals, in view of the scarcity of qualified doctors. With good penetration of mobiles in the country, this should be easily possible. There is a requirement for having paramedical staff to provide primary care in rural areas as there is a huge gap in the availability of doctors/nursing staff. More healthcare workers should be given training and certification to treat minor illnesses.
5- Use Technology to drive positive healthcare outcomes – App based Remote Monitoring Technologies for creating awareness and improving treatment/management of chronic conditions (home health care)wherever frontline healthcare workers are involved, use digital connect to transform them into “knowledge supervisors”. This, by way of imparting “Skill training” through an innovate combination of smart phones and web based technologies to train the healthcare workers in areas. We can bring the entire radio imaging (besides ultrasound) on to an electronic/cloud based platform.
6- It will need emphasis on clean model environment in a health & wellness centre in line with Prime Minister’s ‘Clean India Campaign’. Supply of clean water, 24X7 electricity, clean linen and good clean examination room for patients should be basic elements. It will also require all round maintenance of facility along with un-interrupted Wi-Fi connection.
7- Government should progressively aim at adequate space around HWC (10-acre campus) so that staff could be provided with living quarters to look after emergencies.
National Health Protection Scheme: This is flagship programme under AYUSHMAN BHARAT, which will cover over 10 crore poor and vulnerable families (approximately 50 crore beneficiaries) providing coverage upto Rs5 lakh per family per year for secondary and tertiary care hospitalization. This will be the world’s largest government funded health care programme. Adequate funds will be provided for smooth implementation of this programme.
If there were adequate public sector hospitals, then scheme could have been delivered through network of CHCs, District Hospitals and government teaching hospitals. But considering that about 60% IPD beds are with the private sector, it is inevitable that private sector will havean important role in NHPS. The scheme however should ensureself-sustenance of hospitals. We have experience of operating central government insurance schemes like CGHS, ECHS, ESIC, RSBY etc. Similarly there are state government sponsored schemes in states like; AP, TELANGANA, TN, MH, GJ, RAJ, KARNATAKA etc. There are enough success/failure lessons from these schemes, which could be made use of in designing near perfect model to deliver NHPS. Some of the suggestions are appended below;

1-REFERRAL MECHANISM: NHPS’ success will critically depend on strengthening of 1.5 lakh Health and Wellness Centres, which will not only help in lowering incidence but also serve as a strong Gate Keeper to appropriately channelize referrals for secondary and tertiary procedures. Government may consider putting together a ‘negative list’ of procedures that should strictly be treated only in the public hospitals

2- EMPANELMENT OF HOSPITALS: World over, quality and patient safety in healthcare is driven either through regulation or by PAYERS. NHPS being government run insurance scheme, it should be imperative that Patient Safety must be key consideration while empanelling of hospitals. NHPS as a rule should not empanel any hospital unless it has been verified based on established minimum criteria on quality/patient safety. Some of state run insurance schemes have made Entry Level NABH certificate as minimum criteria for empanelment. We have about 650-hospitals accredited by NABH. Then there are 700-hospitals which are certified under entry level standard by NABH. To begin with this number (650+700) can become critical mass of empaneled hospitals. In case there is need to rope in more hospitals, these can be provisionally empaneled based on defined structural criteria (in terms of number of beds/specialties etc.) as decided by MOHFW, with condition that they will obtain at least entry level certification by NABH within 1-year. In time to come, we may implement ‘pay for performance’ model where reimbursement is linked to clinical & managerial outcomes.

3- FIXING OF RATES: It is unfortunate that no scientific study has been done till date to compute actual costing of delivering variety of medical procedures under different settings. It will be appropriate that MOHFW should endeavor on urgent basis to ascertain the actual costs to private hospitals in rendering services to beneficiaries under NHPS. Government may institute an independent agency with representatives from IIM, cost accountants from professional consulting companies, major hospitals and insurance companies to carry out a costing study, which may find out the cost of delivering healthcare in a model hospital. By using appropriate factor, these costs could be computed for various settings/categories of hospitals based on geographical location, size, level of specialty, status of accreditation etc. Scheme may also decide what procedures should be referred to which category of hospitals to ensure safety as well as optimum and cost effective utilization of the hospital network. Over and above patients can be given option for co-payment in case they want to upgrade the level of care – for example pay extra out of pocket for private room or extra for FDA implants as required. The rates fixed once, should be subjected to periodic revision. As incentive for quality, the rates for full NABH accreditation could be fixed at 15% higher than rest.
4- ON-LINE PAYMENT/TRACKING: The NHPS system should be digitized, where hospitals can submit bills ON-LINE and even the payment should be made ON-LINE. The payment should be reimbursed in time bound manner. For example, 50% money could be transferred within 10-days of submission of bills. Balance 50% could be transferred within next 20-days. In case of delay, there should be provision to pay interest; this aspect is important as present schemes have failed largely on this account that payments are delayed for months. State government schemes like in TN, TELANGANA and AP have transparent and efficient system of digital tracking of patients and treatment line, which can be studied and adopted for NHPS. AROGYA MITRA is good concept as has been in practice in TN-CM scheme.

5- Grievance Redressal: It is important that NHPS has built-in grievance redressal mechanism, which can listen grievances from beneficiaries as well as from empaneled hospitals. While beneficiaries will have grievances from treating hospitals, the empaneled hospitals will have grievances mainly on account of delay in payment and some time the un-accounted deductions from the submitted bills. Both are important to be addressed for long term success of scheme.
6- Patient Verification:The scheme as we know is for those, who are part of SECC (Socio Economic Caste Census) list and has an Aadhaar number, as enrolled. This would eliminate all malpractices/inefficiencies observed on ground during enrolment. Further, the enrolled members should be on a name basis rather than generic family name of 1+4. This would avoid impersonation and frauds on the ground. In case one is part of SECC list but does not have Aadhaar, provide clear guideline for alternative ways of identification to avoid any issues with reimbursements later.
7- Scheme Regulator: NHPS may designate an independent Quality regulator, who would lay out clear guidelines with respect to re-use of single use device, use of generic medicines etc. applicable for all empanelled providers under the scheme so as to enable delivery of quality services at an affordable cost. An appropriate medical audit system to be in place

CONCLUSION: It is first time since independence that government has come with bold initiative with focus on healthcare. As mentioned above NHPS is going to be world’s largest UHC scheme. All efforts therefore must be channelized to make it happen. Once we succeed, it will revolutionaries the complete health delivery systems in the country. World is keenly awaiting to see how such a mega scheme is rolled and sustained. It is going to be boon for BPL families to mitigate serious illness cases. It will also give boost to healthcare industry, which is passing through anxious moments due to sustainability issues. All in all it should be exciting journey which hopefully will open up road to happy and healthy India.

(The author is Director General, Association of Healthcare Providers India)