What does Ayushman Bharat’s new system to grade hospitals mean? Praveen Rao explains

NewsMeter spoke to Praveen Rao, a digital transformation expert and public sector advisor with experience in strategic consulting in health and e-governance.

By Newsmeter Network  Published on  19 Jan 2023 2:30 AM GMT
What does Ayushman Bharat’s new system to grade hospitals mean? Praveen Rao explains

Hyderabad: The National Health Authority has introduced a new system to measure and grade the performance of hospitals empaneled in Ayushman Bharat Pradhan Mantri Jan Arogya Yojana. But the question is: Are the healthcare systems ready for it?

The objective of the government is to shift the focus to patient-centric care and incentivise it. Are the hospitals in sync with the system and will they not exploit the insurance model?

NewsMeter spoke to Praveen Rao, a digital transformation expert and public sector advisor with experience in strategic consulting in health and e-governance.

NewsMeter: What and in which way will grading hospitals help under the Ayushman Bharat scheme work ?

Praveen Rao: On the recommendation of the National Health Policy 2017, Ayushman Bharat was launched by the Government of India to achieve the vision of Universal Health Coverage (UHC). Ayushman Bharat endorses an extended approach of care comprising two inter-related components which are:

· Pradhan Mantri Jan Arogya Yojana (PM-JAY)

· Health and Wellness Centres (HWCs)

The National Health Authority (NHA) has upgraded to a new system which grades the performance of the registered and empaneled hospital under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) scheme.

This upgrade will help the system move from a volume-based to a value-based healthcare delivery system.

As per the NHA, after the implementation of value-based care, the achievement of registered/empaneled hospitals will be counted on various indicators:

· Improvement in patient’s health-related quality of life

· Hospital readmission rate

· Beneficiary satisfaction

· The extent of out-of-pocket expenditure

· Confirmed grievances

The overall objective is to attain high-quality health and satisfaction from all the services covered under the scheme.

This new grading system will provide a win for all contributors, from healthcare service providers to patients, suppliers, etc.

NM: What is outcome-based care and how can a hospital plan its roadmap?

PR: The outcome-based care or value-based care comprehensively works on a result-based approach.

NHA is investing heavily under the Ayushman Bharat scheme by creating digital records, giving financial incentives, and encouraging many digital software companies to come forward and join ABDM to provide patient-centric healthcare.

Of all hospitals which are empaneled, a majority of them have dedicated Ayushman Bharat units in their hospitals. In case they don’t have, they must start on an immediate basis.

Secondly, it’s a scheme with the intention to ease citizens’ life during any crisis therefore, it’s very important that the staff and manpower of the hospital be properly trained.

Moreover, it is also expected that hospitals should not consider this scheme as an income source. Private hospitals are benefitting most from government insurance schemes which have become a mode of income for them.

NM: How will these steps taken by the government ensure that health is affordable and not exploited?

PR: On a lighter note, in any movie, there will always be a villain. According to an article, since its inception in 2018, more than 18,000 fraudulent hospital transactions have been detected in the insurance arm of Ayushman Bharat.

I believe this number will be far higher than what we are seeing. As per the statement by Dr. Bharati Pravin Pawar in the Parliament last session, “Ayushman Bharat–Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is governed on a zero-tolerance approach to any kind of fraud.”

Among practices deemed fraudulent under the scheme are suspect or non-genuine medical treatment claims, impersonation, and upcoding of treatment packages or procedures. (Upcoding is when a healthcare provider submits insurance claims for more serious and expensive procedures than were actually performed.)

Dr. Pawar said, “National Health Authority—the implementing agency of AB-PMJAY—has issued a comprehensive set of anti-fraud guidelines. Anti-fraud advisories are issued to states/UTs. National Anti-Fraud Unit (NAFU) is created at NHA for overall monitoring and implementation of anti-fraud framework supported by State Anti-Fraud Units (SAFUs) at the state level.”

Schemes like Ayushmaan Bharat and Arogyashri is using Artificial Intelligence and machine learning-based comprehensive fraud analytics solution to detect fraud proactively, develop algorithms that can be used on [a] large volume of data to identify suspect transactions and entities, and risk scoring of hospitals and claims.”

NM: What is value-based care and how will the patient and health service provider be able to identify it?

PR: The NHA has planned to move to 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, providers will be rewarded for helping patients improve their health, which consequently will reduce the effects of disease in the population in the long term.

In the case of patients with fewer claims, it can help in controlling the premium and helps in their investments.

The health service provider must be more cautious as their payments will depend on the quality of the treatment given to the patient.

NM: From a volume-based healthcare system to a value-based healthcare system, the Ayushman Bharat scheme envisions a transformation in care but how will private and public healthcare providers synergize in it?

PR: The initiative taken to move from a volume-based healthcare system to a value-based healthcare system is a significant step and it will help an incremental gain in overall health management. On the other side, it will be tough for private healthcare agencies to digest this as many of them or a majority of them are treating this scheme as their source of income.

The synergy is only possible when hospitals and other service providers treat this scheme for mankind. As per the current situation and the available data, healthcare agencies are yet to be in sync with the scheme.

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