PMJAY Affected by Lockdowns | 11 Aug 2020

Why in News

According to the “Pradhan Mantri Jan Arogya Yojana (PMJAY) Policy Brief (8): PMJAY Under Lockdown: Evidence on Utilization Trends’’, the nationwide lockdown has had a significant negative impact on inpatient care utilisation under the scheme.

  • The analysis covers 22 weeks of data, from 1st January to 2nd June 2020. The national lockdown started on 25th March and was significantly relaxed as of 1st June.
  • The analysis is based on claims data drawn from the PMJAY Transaction Management System (TMS) and the main indicator of claim volumes (utilization) is non-rejected pre-authorisation requests.

Pradhan Mantri Jan Arogya Yojana

  • It offers a sum insured of Rs. 5 lakh per family for secondary care (which doesn’t involve a super-specialist) as well as tertiary care (which involves a super-specialist).
  • It is an entitlement-based scheme that targets the beneficiaries as identified by the latest Socio-Economic Caste Census (SECC) data.
    • Once identified by the database, the beneficiary is considered insured and can walk into any empanelled hospital.
  • The insurance cost is shared by the centre and the state mostly in the ratio of 60:40.
  • Packaged rates are the rates which include everything so that each product or service is not charged for separately.
    • These rates also mention the number of average days of hospitalization for a medical procedure and supporting documents that are needed.
    • These are flexible but the hospitals can’t charge the beneficiary more once fixed.
  • The National Health Authority (NHA) has been constituted as an autonomous entity under the Society Registration Act, 1860 for effective implementation of PMJAY in alliance with state governments.
  • The State Health Agency (SHA) is the apex body of the State Government responsible for the implementation of PMJAY in a State.

Key Points

  • Demographic groups, women, younger and older populations (under 20 and over 60) reduced their utilisation by more than men, young adults or the middle-aged.
  • Among procedures, planned surgeries such as cataract operations and joint replacements suffered a decline of over 90%, while hemodialysis (also known as dialysis which is a process of purifying the blood) declined by only 20%.
  • Overall, average weekly claim volumes in 10 weeks of lockdown were 51% lower than the weekly average observed during the 12 weeks prior to the lockdown.
    • The steepest decline (over 75%) was registered in Assam, followed by Maharashtra and Bihar, while much smaller declines (about 25% or less) were observed in Uttarakhand, Punjab and Kerala.
  • There was a small but perceptible shift in PMJAY utilisation from the public to private hospitals.
  • Significant declines were noticed in admissions for child delivery and oncology (study and treatment of tumours).
    • The utilisation of neo-natal packages declined by 24%.
    • There was a slight shift from public to private hospitals for neonatal care and the largest declines have been observed in the public sector in Tamil Nadu and Madhya Pradesh.
    • The 64% decline in oncology volumes across India was concentrated in a few States.
    • In the public sector, which plays a smaller role in oncology care under PMJAY, there was a 90% decline in claims in Maharashtra and a 65% decline in Tamil Nadu.
  • While access to medical facilities was one of the few exceptions to stay-at-home orders during the lockdown, care-seeking behaviours and healthcare provision were nevertheless significantly affected, due to the following reasons:
    • On the Supply Side:
      • Hospitals may be preoccupied with Covid-19 preparations or caseloads, resulting in fewer resources for non-Covid-19 cases.
      • This may be particularly relevant in public hospitals, which have been the primary focus of the policy response and could extend to activities such as submitting pre-authorisation requests or claims documents as required under PMJAY.
      • Private hospitals may reduce services out of fear among health workers that they will become infected.
    • On the Demand Side:
      • PMJAY beneficiaries might delay or forego treatment due to fear of infection at a hospital.
      • They may not be able to reach hospitals due to public transport shutdowns and mobility constraints.
      • The economic crisis may affect financial considerations related to seeking care.
  • Health experts have highlighted that ensuring the least possible impact on key health programmes will be an ongoing challenge which needs continued close monitoring.

Source: TH