• The National Health Authority under its Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is introducing a new system to measure and grade hospital performance. 

• The NHA is the apex body responsible for implementing AB-PMJAY.

• The new initiative will introduce the concept of ‘value-based care’, where payment will be outcome-based and providers will be rewarded according to the quality of the treatment delivered. 

• Under the new model, the providers will be rewarded for helping the patients improve their health, which consequently will reduce the effects of disease in the population in the long term.

The performance of AB PM-JAY empanelled hospitals will be measured based on five performance indicators. They are:

i) Beneficiary satisfaction

ii) Hospital re-admission rate

iii) The extent of out-of-pocket expenditure

iv) Confirmed grievances

v) Improvement in patient’s health-related quality of life.

• The performance of the hospitals based on the above indicators shall also be made available on a public dashboard that will help the beneficiaries make an informed decision. 

• As a result, the hospital’s performance will not only determine the hospital’s financial incentive but will also create a demand for quality treatment among PMJAY beneficiaries.

Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY)

• Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) which provides health coverage up to Rs 5 lakh per family per year to around identified 10.74 crore poor and vulnerable families identified based on Socio Economic Caste Census (SECC) data.

• The out-of-pocket expenditure for hospitalisation pushes millions of people into poverty every year. In order to address this and provide health cover of Rs 5 lakh per family per year for secondary and tertiary care hospitalisation to poor and vulnerable section of the population, AB-PMJAY was launched, subsuming the erstwhile Rashtriya Swasthya Bima Yojana, in September 2018. 

• The scheme aims to improve affordability, accessibility, and quality of care for the poor and vulnerable section of the population.

• Ayushman Bharat marks a paradigm shift to move from a sectoral and selective approach of health service delivery to a comprehensive range of health care services. Ayushman Bharat aims to holistically address health (covering prevention, promotion and ambulatory care), at primary, secondary and tertiary level by adopting a continuum of care approach.

• This health cover includes 3 days of pre-hospitalisation and 15 days of post-hospitalisation expenses. 

• There is no cap on family size, age or gender to ensure that all members of the beneficiary families are covered. Also, benefits are portable across the country.

• Services include approximately a range of procedures covering all the costs related to treatment, including but not limited to drugs, supplies, diagnostic services, physician’s fees, room charges, surgeon charges, OT and ICU charges, etc.

• AB-PMJAY is an entitlement-based scheme. Eligible beneficiaries can directly visit any empanelled public or private hospital to avail cashless treatment. 

• The beneficiaries will not be required to pay any charges for the hospitalisation expenses.

• Ayushman cards are issued to the beneficiaries to create awareness about the scheme.

• States/UTs have the flexibility to run their own health protection schemes in alliance with AB-PMJAY at their own cost. Accordingly, states/UTs have expanded the scheme coverage to 14.75 crore beneficiary families at their own cost.

• The funding of the scheme is shared between central and state governments. The ratio of central share to state share for all states, except northeast states and Himalayan states and Union Territories with legislature, is 60:40. For northeast states and Himalayan states, the ratio is 90:10. In the case of Union Territories without legislatures, the central contribution of premium is 100 per cent.

How is AB-PMJAY implemented?

• At the central level, National Health Authority (NHA) has been set up as an attached office to the ministry of health and family welfare for implementing AB-PMJAY.

• NHA is headed by a full time CEO in the rank of secretary to the government of India. An 11 member Governing Board (GB), headed by the minister for health has also been established as the decision making body of the NHA.

• State Health Agency (SHA) is the nodal agency responsible for implementation of AB-PMJAY in the state. In addition to the state level posts, District Implementation Units (DIUs) have also been set up to support the implementation in districts.

• National Health Authority (NHA) has launched the new version of Health Benefit Package (HBP) 2022 under the AB-PMJAY scheme. The new version has added 365 new procedures taking the total package count to 1,949. With HBP 2022, differential pricing is being introduced for the first time under the scheme based upon the type of city and level of care.

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