The National Health Authority (NHA) has overhauled the existing health benefit packages of the AB-PMJAY, which includes revising their costs to remove any aberrations and discontinuation of around 554 packages.

The NHA is the apex body responsible for the implementation of the Centre’s flagship health insurance scheme Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY).

Officials said as many as 237 new packages have been introduced in the scheme.

The NHA’s governing board decided to undertake an exercise to remove the aberrations and anomalies in the existing health benefit packages (HBP) to further strengthen its delivery, they said.

The 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. Besides, there has been an introduction of 237 new packages and adoption of 43 stratified packages, he said.

“Without compromising the range of treatment covered under PMJAY, 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,” he said.

Union Health Minister Harsh Vardhan added: “We are confident that with the revision in the health benefit packages of AB-PMJAY, many new private hospitals will get empanelled with the scheme. This will help improve access to quality health care, and lakhs of vulnerable families will receive free treatment.”

Currently, the PMJAY has 1,393 treatment packages out of which 1,083 are surgical, 309 medical and one unspecified package.

According to NHA officials, since the launch of the scheme on September 23, 2018, it had been receiving feedback on its various aspects including existing packages and their rates.

The governing board took a serious note of that and decided to undertake an exercise to remove the aberrations and anomalies in the packages. A vigorous and scientific procedure was followed, the official said.

The NHA, along with the Department of Health Research, the Indian Council of Medical Research and the Tata Memorial Hospital, consulted specialist committees, which helped remove the inconsistencies in the nomenclature and pricing for their respective specialties.

“In the spirit of cooperative federalism, before finalising the changes, feedback was taken from states and Union territories. Their feedback was examined by the review committee,” said NHA CEO Dr Indu Bhushan.

States and UTs that 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, in collaboration with the World Health Organisation (WHO), has initiated the process of aligning HBPs 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 more than 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 UTs have already implemented the scheme. Delhi, Odisha, Telangana and West Bengal are yet to join.

Since the launch, 46.5 lakh hospital treatments amounting to claims worth Rs 7,490 crore have been provided. As much as 53 per cent of the treatments were provided in private hospitals, while 60 per cent were for tertiary care.