A hospital-based descriptive study of Ayushman Bharat-Pradhan Mantri Jan-Arogya Yojana: an analysis of 4844 claims

INTRODUCTION

Ayushman Bharat Pradhan Mantri Jan Arogya Yojna was launched in September 2018 in India. The beneficiaries of the PM-JAY were identified by applying the ‘deprivation and occupational criteria’ to the socio-economic caste census 2011 (SECC-2011).¹ Although government health expenditure as a percentage of gross domestic product in India has improved from the dismal of 1.1% in 2014-15 to 1.35% in the year 2019-2020 it still remains among the lowest few in the world.^2,3 As per the latest national health accounts report out of pocket expenditure (OOPE) on healthcare was around 60.6% in 2015-16 which has declined to 47.1% in 2019-20.⁴ The Insurance Regulatory Development Authority of India also stated that around 70% people in India did not have any health insurance that put additional financial burden on family and pushed families into poverty or the poor became poorer.⁵ Kastor et al found OOPE is 3.5 times higher in private health care facilities.⁶

According to the findings of a study conducted among the urban poor population of Delhi, only 9.5% of RSBY beneficiaries utilized the schemes under the RSBY.⁷ To prevent the OOPE, Government of India introduced world’s largest social security scheme named National Health Protection Scheme which included the Pradhan Mantri Jan Arogya Yojana (PM-JAY). It is a government funded Health Insurance Scheme with centre to state contribution of 60:40 in most of the states and 90:10 for some, including Jammu and Kashmir. It provides a cover of Rs. 5 lakhs per family per year. There is no restriction on family size, age or gender with coverage of all pre-existing conditions. It covers up to 3 days of pre-hospitalization and 15 days post-hospitalization expenses such as diagnostics and medicines. Services included approximately 1,393 procedures initially.⁸

Currently, literature search did not reveal any hospital-based study of the AB-PMJAY, although field studies regarding awareness or utilization of the scheme have been conducted. Current study is expected to provide insight into the scheme by performing a descriptive analysis of the claims settled in the hospital.

Objective

To study and analyze settled claims of beneficiary patients of AB-PMJAY for: i) demographic characteristics and procedures/claims availed by them in a tertiary care, multi-specialty, teaching hospital, ii) perform a monetary analysis of the settled claims.

METHODS

Study design/study type/study place

It was a cross sectional, retrospective record study carried out at a tertiary care hospital of northern India covering initial two years from the launch of scheme (15^th December 2018 to 30^th December 2020). The hospital is a 1015 bedded multispecialty, teaching and research institute and a referral center for the union territory of Jammu and Kashmir.

Procedure

Anonymized data regarding all the 4844 AB-PMJAY claims was collected from the Transaction Management System portal maintained in the claim processing department of AB-PMJAY office. The data consisted of demographic characteristics of beneficiaries, diagnosis, procedure details and cost of claims. Data was cleaned and checked for any missing information.

Statistical analysis

Data analysis was performed by using excel-2016 and descriptive statistics of absolute counts, percentages, mean, mode, minimum and maximum were obtained.

Inclusion/exclusion criteria

Only settled claims were included in the data. Claims which were under process or had been rejected were not included.

RESULTS

Demographic analysis of claims

A total of 4844 claims were settled under PM-JAY from 15 December 2018 till 31 December 2020. In 3924 claims (81.00%) beneficiaries belonged to the age group of 15-64 years and 2961 (61.13%) were males.

Residential status of beneficiaries availing claims

In 4510 claims (93.10%) beneficiary patients belonged to the districts of Kashmir province, while only 301(6.21%) belonged to districts of Jammu province. The highest number of claims (1210=24.98%) were settled for Srinagar district. Approximately, 65% of patients belonged to rural areas. Table 1 reveals the district-wise distribution of beneficiaries in the settled claims.

Distribution of claims by specialties

2099 (43.33%) claims belonged to general medicine followed by 1814 (37.45%) to medical oncology. A comparatively much lesser number (244) claims belonged to general surgery, followed by cardiology, urology, neurosurgery, surgical oncology, CTVS, plastic surgery and others respectively (222, 125, 112, 98, 70 and 23 respectively). Fewer claims belonged to pediatric medicine (14), radiation oncology (9), orthopedics (6), pediatric surgery (4), obstetric and gynecology (3) and otorhinolaryngology (1).

Analysis of general medicine claims

Out of 2099 general medicine claims, (848=40.40%) were settled for hemodialysis followed by acute kidney injury (245=11.67%) and acute febrile illness (134=6.38%).

Analysis of medical oncology claims

Total number of claims settled for chemotherapy of various cancers were 1812, out of which 883 were for unlisted chemotherapy regimens.

Analysis of cardiology claims

A break up of the claims settled for interventional cardiology. Maximum number of claims were for percutaneous transluminal coronary angioplasty (PTCA) with placement of medicated stents (111=49.55% of I. cardiology claims), followed by Permanent pacemaker implantation, unspecified claims, right heart catheterization and ASD device closure respectively (49=21.88%, 10.27%, 7.59% and 4.46% of cardiology claims respectively).

Analysis of surgical claims

Among surgical claims maximum number (244) were settled for general surgery followed by urology (125), neurosurgery (112), surgical oncology (98), cardiothoracic-vascular surgery (70), plastic surgery (23).

Results of objective 2

A total of 4844 claims were settled during the period for a total amount of INR.71497764 (seven crore fourteen lac ninety-seven thousand seven hundred and sixty-four Indian rupees) (Table 8).

Out of these claims 3870 (79.89%) were for an amount ≤INR.20,000.

DISCUSSION

The study revealed that around 4844 claims were settled during initial two years from the start of implementation of AB-PMJAY in the hospital. Of these 80% of the claims, were for beneficiaries in the age group 15-64 years and in 61.13% claims, beneficiaries were male. Kaur et al in a study regarding Ayushman Bharat scheme found that 51.5% claims for all packages showed a male predominance, which is 9% lesser than our study.⁹ Devadasan et al studied two community health insurance schemes in India in 2006 and found that 59% and 75% of those hospitalized were male beneficiaries in ACCORD and SEWA respectively.¹⁰ Mirza also found a male preponderance (55.1% when he analyzed over 90,000 cases admitted in All India Institute of Medical Sciences.¹¹

In 65% claims, beneficiaries were rural. Chauhan et al also observed that 60% patients belonged to rural areas.¹² In our study we found that although maximum number of patients belonged to Srinagar which is within 30 km radius but patients from districts which were 50 km away from the hospital also availed the services; which is understandable as SKIMS is the apex referral hospital of Kashmir. In contrast, Devadasan et al from a study conducted among RSBY enrolled households in Patan of Gujrat found that hospitalizations among beneficiaries living greater than 30 km away from towns were significantly lower.¹⁰ We observed that out of ten districts majority of beneficiaries belonged to the four, namely, Srinagar, Baramulla, Anantnag and Ganderbal of Kashmir province. Only few beneficiary patients from various districts of Jammu province availed the benefit of AB-PMJAY from SKIMS, the probable reason being difficult road connectivity, due to which their referral destination is neighbouring states of the Northern plains of India. In comparison to our study, Kastor et al who based his OOPE study on NSSO survey data of 2014, concluded that out of the total sampled population- 48.5% were females, 7.9% were aged 60 and above, and 30% were residing in urban areas.⁶

We observed that a major proportion of the claims were settled for procedures under non-communicable disease like chemotherapy for cancer, dialysis for chronic kidney disease, angioplasties and stents for blocked coronaries. It is now a known fact that non-communicable disease is as much a disease of the poor as it is of the rich, and its impact is felt more on the low-income groups leading to their further impoverishment. NCD burden in rural India has increased over the years as observed by Ross et al, when they studied NCDs among adults of age 35-70 years.¹³ AB-PMJAY has taken care of heavy OOPE incurred on non-communicable disease by the poor, such as, chemotherapy for cancers, coronary angioplasties for occluded coronaries in ischemic heart disease. Procedures of coronary stenting and pacemaker implantation were most frequent claims in cardiology with very high value of package cost which would otherwise be beyond reach of the lower socio-economic strata.^14-16 Based on the global burden of disease PFHI has released a report in which cardiovascular disease is a leading cause of death in all age groups above 15 years.¹⁷

Specialty wise, majority of the claims were availed under general medicine category (43.33% of all claims), followed by chemotherapy in cancer patients under the specialty of medical oncology (37.45% of all claims). Majority of the claims under medical oncology specialty were settled for unlisted (unspecified) procedure; the reason being that in the first year of AB-PMJAY implementation, health benefit package 1.0 was operational which grouped many chemotherapies under unspecified category. Beyond unspecified packages most frequent claims were settled for breast cancer being the most common cancer among women in the region.¹⁸ Procedures of hemodialysis (HD), followed by acute kidney injury (AKI) were most frequent claims under the general medicine category (40.40% and 11.67% of general medicine claims respectively) which is expected, keeping in view the increasing global burden of ESRD and AKI and corresponding disease load in our hospital.¹⁹ HD is the most common kidney replacement therapy in ESRD, which poor patients were not able to continue previously due to financial constraints, and now AB-PMJAY has made it more affordable.^20,21

Among surgical claims, benefit under general surgery was availed in majority (244 of total claims), followed by urology (125) neurosurgery (112), surgical oncology (98) and CTVS (70). Earlier studies regarding publicly financed insurance schemes in India have revealed comparable or contrasting observations. Utilization of claims in a particular hospital setting depends upon the broad or super-specialty departments available therein. Patel et al in a utilization survey of RSBY beneficiaries observed that 50% patients utilized packages in general medicine, 25% in general surgery, 11.1% in neurosurgery.²² Prinja et al revealed that, in contrast to secondary care, state sponsored health insurance schemes catered mainly to tertiary care needs for injuries (21-27%), oncology (6-17%) and cardiovascular/respiratory/nephrology conditions (9-10%). They also concluded that RSBY scheme was used predominantly for medical as compared to surgical procedures.²³

On the other hand, Devdasan et al found that that among 520 hospitalized, RSBY beneficiary patients, common reasons for admissions were pregnancy related (96), hysterectomies (58), injuries (53) and cardiovascular related disease.¹⁰

Patil et al conducted a survey in Mumbai on surgical procedures availed by beneficiaries of employees insurance scheme. They found that cataract (22.8%), caesareans (3.8%), surgeries for fractures (3.27%) and hernia (2.86%) were the commonest surgeries. 44.2% of surgeries belonged to the essential surgeries.²⁴ In our hospital no obstetric surgery was claimed under AB-PMJAY due to the fact that pregnancy related cases were covered under Janani Swathya Surakhsha Karyakaram (JSSK). Also, an inpatient ophthalmology department does not exist in the hospital.

Total value of settled claims was INR.71497764.00 out of which approximately four-fifth (3870=79.89%) were for less than INR 20,000 range. These were mostly medical packages, majority of which are priced around INR 2000. Only some packages for cancer treatment are above INR 20,000 range, while most are much lower. On the other hand, most of the surgical packages are costlier especially, CTVS claims. Interventional cardiology packages are the costliest. Descriptive stats for claim values like minimum, maximum, mean and mode were calculated. Interquartile range was calculated where outliers were found or distribution was outside normal. It was observed that 105 claims (2.17%) belonging to CTVS, cardiology and medical oncology were valued at ≥INR 1lac and accounted for INR.15994481 (22.37%). Of these 44 belonged to cardiology and accounted for INR.7524401 (10.52% of total claim amount). Infact, 4 claims in cardiology were for INR 4 lac and above. 37 claims belonged to CTVS and accounted for INR 5579500 (7.80% of total claim amount). 24 claims (0.51%) belonged to medical oncology and accounted for INR.2890580 (4.04% of total claim amount). It is worthwhile to mention that RSBY had a cap of 30,000 on sum insured and many surgical procedures especially CTVS, neurosurgery etc. would incur OOP expenses from the patients. Sriram et al have conveyed through their study that poor people enrolled in public health insurance programs for the poor would still incur OOPE for inpatient care.²⁵

The higher package costs in AB-PMJAY is hoped to reduce the OOPE, however evidence needs to be gathered on the subject. A systematic review conducted by Reshmi et al on Impact of public-funded health insurances in India on health care utilization and financial risk protection opined that there were conflicting studies on the effect of PFHIs on OOPE and CHE, however they concluded that there was a lack of studies yet on AB-PMJAY and it was immature to comment on its impact.²⁶

Limitation of this study is that it was a uni-centric study so comparison could not be done.

CONCLUSION

The study provides an insight into the frequency of various claims, their costs, disease /procedural burden of beneficiary patients of AB-PMJAY. It is limited to a single center but can be expanded into a multicentric one. It will provide policy feedback and help in future planning and implementation of the scheme.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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