As the country’s cashless health insurance scheme — Pradhan Mantri Jan Arogya Yojana (PM-JAY), popularly referred to as Ayushman Bharat — completes 150 days, PM-JAY CEO Indu Bhushan spoke to Businessline on the scheme's performance and the challenges ahead. Excerpts:

What are your reflections on the journey, and what challenges lie ahead?

The scheme has had a good start, as close to 12 lakh patients have benefitted. We have issued 1.55 crore cards. A large number of people access it to look at eligibility and every five to six seconds someone is provided benefit of the transaction management system.

Now, the focus is on reaching the last mile. Of the bottom 40 per cent target group, the bottom-most 5-10 per cent people are more disadvantaged and within families women and children may not be getting the benefit. We need to start working on mainstreaming standard treatment protocols, medical audits, work with hospitals to ensure that quality services are being given.

There are three models in place — trust, insurance, hybrid — for the scheme. In the insurance model, for example, giving ₹1,500 crore to an insurance agency could be problematic for the fear that insurance companies are the ones that benefit out of the scheme...

We are not giving away money, but money is being used to pay the hospital. We have capped the maximum claim ratio at 85 per cent. Beyond that the insurance companies have to give the money back to the government. None of the insurance companies will make a windfall gain.

For example, government pays ₹100 in premium and the total claim during policy period by hospitals is ₹60, potentially insurance company is making a profit of ₹40, but they can't keep that ₹40. They have to return ₹25 to the government and maximum they can keep is ₹15. We want to avoid windfall gains for insurance companies. It does not work like that in private insurance. Also, insurance companies are not assured of their 15 per cent profit as claim ratio can over run 100 per cent of premium paid, and insurance companies can lose money.

In Budget you have not got the amount you demanded. You will get it at later stage is the impression. Will this affect the uptake?

We will give the States all the money that they need. We have already released large amount of money, but I cannot share the numbers and we have told them that whatever is due from our side, we will pay. There is no crunch. Bihar, for example, was given more than sufficient resources and we have asked the money back from them as they are not being able to spend it.

Kerala and West Bengal are disgruntled that even as the scheme is co-branded along with existing State schemes it is not publicised in the letter issued by the Prime Minister. How do you handle politics over branding?

Co-branding has been agreed upon with all States through MoUs, which is clear that we will have Ayushman Bharat and their own scheme together. The PM’s letter, however, only talks about the scheme (central). We have not customised the letter for the State, except for the language, may be we could have done so.

You are keeping the private sector at bay because of your costs. Can you explain the methodology for determining package rates, as currently different States are using different package rates?

Different kind of hospitals have different rates. From government-run to missionary and private hospitals, it varies. Hospitals in metros will have a different costing structure as compared to outside metros. It is a complicated exercise and we need a lot of data. We are working with the Department of Health Research by establishing 24 different expert committees to work on costing. DHR has done a lot of work on determining costs for 200 packages and it is in progress.

If you look at it from a micro perspective, the scheme is great, but on a macro level there are debates, issues and criticisms...

There was this man from Jamshedpur living with a three kg tumour near his ear for 23 years. He did not have the money to get treated. He got to know about the scheme and the tumour was removed. This scheme is helpful as even in public hospitals things are not free, you still have to pay or some services are not directly available, and the scheme mechanism covers everything.