Most Ayushman Bharat Claims Made in Private Hospitals, Says Govt Report

Significantly more people utilised benefits under the Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) at private hospitals than in government hospitals, according to a report published by the National Health Authority (NHA). Out of the 49 lakh beneficiaries who utilised the benefits under the scheme, 33 lakh, that is, 63% of the claims were made in private hospitals, while the remaining 37% were made in public hospitals. Benefits worth Rs 3,767 crore, that is, 75% of the total cost of packages claimed by beneficiaries of the scheme, were utilised in private hospitals, while for government hospitals, this amount was Rs 1,237 crore (25%).

The report pointed out that as on August 31, 2019, 15,968 hospitals are empanelled under the AB PM-JAY, out of which 7,446 (46.63%) are public hospitals and 8,522 (53.37%) are private hospitals, including not-for-profit entities. The number of private hospitals is higher, it was seen in the report that a much higher proportion of beneficiaries opted for treatments in private hospitals compared to public hospitals in most of the 32 states and union territories where the scheme has been implemented.

According to the report, large private hospitals that have more than 100 beds and medical colleges which primarily provide tertiary care, accounted for more than 60% of claims from private hospitals. Smaller hospitals with high number of claims primarily catered to day care procedures such as haemodialysis, cataract and chemotherapy for palliative care.

In most of the states, the number of claims made in private hospitals was much higher than the number of claims made in public hospitals. The proportion of claims made in private hospitals was the highest in Jharkhand, where out of 2,53,832 cases, 2,21,741 (87.36%) claims were made in private hospitals. Benefits worth Rs 238 crore were availed in the state out of which, benefits worth Rs 219.14 (92.22%) crore were utilised in private hospitals. 

Other states with very high proportions of claims made in private hospitals were Gujarat (80.53%), Maharashtra (78.54%), Andhra Pradesh (77.12%), Uttar Pradesh (76.1%), Chhattisgarh (75.69%), and Haryana (71.99). The report pointed out that the trend of higher number of claims in private hospitals is seen for all the states and union territories except a few like Kerala, Karnataka, Assam, Madhya Pradesh, and Bihar.

The proportion of claims made in public hospitals was the highest in Tripura (99.83%). Claims made in public hospitals made up for 96.88% of the total cost of benefits claimed in the state. Tripura was followed by Mizoram (96.32%), Himachal Pradesh (87.98%), Kerala (77.51%), and Bihar (75.56%).

There were also states in which even though the proportion of benefits claimed in public hospitals were significantly higher than in private hospitals, the claims made in private hospitals constituted the major chunk of the total cost of the benefits availed in these states. The biggest example of this was Karnataka, where 69.43% of the claims were made in public hospitals, while 30.57% were made in private hospitals. However, the claims made in public hospitals made up only 21% of the total cost of benefits made in the state. The other states that exhibited a similar pattern were Madhya Pradesh and Punjab.

The report said, “In-depth analysis of top utilised private hospitals shall be conducted with inputs from state authorities. This will be coupled with medical audits to ascertain the authenticity of the claims for the hospitals that are flagged amongst high utilisation without plausible explanation.”

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