UP, MP, Bihar send most patients out for treatment under PM-JAY

Uttar Pradesh (UP), Madhya Pradesh (MP) and Bihar are among the states that send maximum patients out to other states for treatment under the Pradhan Mantri Jan Arogya Yojana (PM-JAY), popularly referred to as the Ayushman Bharat scheme.

This is revealed in an analysis carried out by the National Health Authority (NHA) on the portability feature of the scheme availed by 81,254 patients. PM-JAY has an option of portability, which enables eligible beneficiaries to access the scheme’s services in any empanelled hospital across the country, irrespective of their state of residence.

PM-JAY provides every poor family with an annual cashless health insurance cover of ₹5 lakh.

“Also, an additional telephonic survey of 938 beneficiaries revealed that up to 70 per cent of patients have reported that they sought portability due to lack of required facilities in home states, whereas 20 per cent informed that they were referred to other states, which suggests unavailability of manpower and infrastructure. Also, one-third of the portable patients had no access to follow-up care,” said an NHA official.

While MP and UP contribute nearly half of portability cases by volume and value, most of these cases are received by Gujarat and the National Health Care Providers (NHCP), which are hospitals like PGI Chandigarh, the All India Institute of Medical Sciences, Ram Manohar Lohia Hospital and Safdarjung Hospital among public entities. The private hospitals falling under this category are all Gujarat-based, namely the UN Mehta Institute of Cardiology Research Centre, Dhiraj Hospital, The Gujarat Cancer Research Institute and Haria LG Rotary Hospital.

“Most patients approach the NHCPs for tertiary level procedures like cardio-thoracic, vascular and neurosurgery as also for cancer care – medical oncology and paediatric cancer, interventional neuroradiology, burns management and poly-trauma,” the official said.

States with common borders

In MP, for instance, up to 10 per cent of all claims are sent outside the state. MP has sent at least 11,765 patients to Gujarat, while UP has sent 4,288 patients to Uttarakhand, and 3,572 patients to Maharashtra. Bihar, in turn, has sent 3,258 patients to UP. “Most portable cases are between states with common borders,” explained the official.

Most patients are travelling from UP’s Bijnor and Saharanpur; MP’s Ratlam, Dhar, Mandsaur and Jhabua; Jharkhand’s Garhwa districts; and the union territories of Dadra & Nagar Haveli to NHCPs; Ahmedabad, Vadodara and Valsad in Gujarat; Dehradun in Uttarakhand; Varanasi in UP; and Nagpur and Mumbai in Maharashtra.

The average treatment amount under portability is ₹24,103, almost double the average national amount of ₹13,499. In case of treatment under NHCPs, this amount increases to ₹39,028 per patient.

As of December 20, 2019, PM-JAY had covered a total volume of 70 lakh claims, for a total treatment value of ₹10,000 crore, and portable cases account of nearly 1 per cent of all PM-JAY claims with claims raised worth ₹135 crore.

“While the volume of portable cases account for a relatively low percentage, this share has increased from 0.1 per cent in October 2018 to 1.2 per cent in November 2019,” the official said.

However, portability may not always be a smooth journey for patients: while about 15 per cent of patients registered could not be converted to pre-authorisations, about 20 per cent of pre-authorisations raised under portability did not lead to initiation of claims. “This suggests challenges in processing of portable claims prior to initiation of the payment cycle that need to be addressed,” said the official.

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