Professional Documents
Culture Documents
Protection Mission
Providing Universal Health Coverage to 500 million people
www.pwc.in
Executive summary
Contents
around 1.25% of the GDP and an underperforming public healthcare ecosystem.
It is extremely worrying that nearly 55–60 million Indians are pushed into poverty
every year because they are unfortunately compelled to shell out half of their annual
household expenditure to meet medical needs, especially for hospitalisation. Even
after 70 years of independence, there is no real health insurance scheme for 80% of
the Indian population.
One of the major policy initiatives of the government has been the announcement
UHC and past
learnings 3 of the Ayushman Bharat – National Health Protection Mission (AB-NHPM) for the
vulnerable section of the Indian population which, if implemented effectively, will
help the nation move closer to the Sustainable Development Goal of ‘Universal
Health Coverage’.
It is expected that the scheme will have a far-reaching impact on the entire Indian
healthcare and insurance landscape. The scheme envisages the adoption of standard
treatment guidelines and defined package rates for surgical procedures, and the
Putting in the
building blocks 13 widespread use of IT and data analytics to monitor scheme implementation and
manage fraudulent claims. All these measures taken together will help in regulating
the hitherto unregulated hospital and healthcare sector and in making the health
insurance sector a sustainable one. The scheme will help in generating large
volumes of data which may be used later for designing better and targeted health
programmes. This will assist in effective medical management; in studying the
impact of including or excluding specific diseases, populations or coverages; and in
optimising cost and improving efficiencies.
Imperatives for
success 21 The scheme will also help in enriching the database of hospitals registered with the
Registry of Hospitals in Network of Insurance (ROHINI) System and the human
capital captured under the National Health Resource Repository (NHRR) project.
This can later be used innovatively for improvement of access to and quality of
healthcare services in the country. The scheme will have a multiplier impact on the
healthcare and allied sectors like pharmaceutical, diagnostics and medical devices
and the overall Indian economy by way of employment generation.
The execution of the scheme, however, will be a big challenge since it would involve
identifying and focusing on the right critical success factors, allocating the optimum
budgetary support, incentivising all stakeholders appropriately (e.g. insurance
companies, third-party administrators, healthcare providers) and acting speedily to
cover all the beneficiaries.
In the long run, AB-NHPM should envision strengthening of primary care, inclusion
of out-patient treatment and a public healthcare delivery system, and expanding
the scope of coverage to the entire population in order to make the government’s
transition from provider to payer a successful one and achieve Universal Health
Coverage in the true sense.
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UHC and past
Section 1 learnings
UHC is a dynamic process that should be responsive to constantly changing demographic, epidemiological and technological trends.
The changing nature of health systems has significant implications for UHC monitoring.
Extent to which
population is Services: Which
not covered services are
covered?
Adapted from Tracking Universal Health Coverage: First Global Monitoring Report: WHO and World Bank
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UHC extends beyond curative care and has direct
implications on health outcomes
Community and
Unintended
pregnancies averted 400
cross-sectoral due to use of modern million
services contraceptive methods: (2016–2030)
Birth, newborns Early and later childhood Young adults Older adults
infections averted: 21 (2016–2030)
and infancy and adolescence
Additional people with
access to clean water in
2030 (above 2015 baseline): 226 million
Additional number
of people accessing
treatment for depression: 94 million
WHO modelled projections for 67 low- and
Source: PwC research and WHO report on ‘Together on the road to middle-income countries (2016–2030)
universal health coverage: A call to action’
Ayushman Bharat – National Health Protection Mission 5
Government-sponsored insurance schemes
are critical for UHC
Government-sponsored
Limited private insurance group insurance schemes
andextremely high OOPE
Primary
Payment mechanism
Supplemental insurance
No. of government
Reforms underway to complement public
insurance schemes
insurance scheme
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While multiple government-sponsored insurance
schemes exist in India….
Rajasthan Bhamashah Swasthya Bima Yojana, State Insurance and Provident Fund
Department, Rajasthan Chief Minister’s Relief Fund
Madhya Pradesh MP Swasthya Suraksha Yojana
Arunachal Pradesh Arunachal Pradesh Chief Minister Universal Health Insurance Scheme
(APCMUHIS)
Assam Atal Amrit Abhyan, Assam Aarogya Nidhi, Sneha Sparsha
Andhra Pradesh Arogya Raksha Health Scheme, Dr. NTR Vaidya Seva Scheme
Number of
policies issued: 13 million Average amount
per claim: 25,000 INR Claim settlement: 40% cashless,
47% reimbursement and
Lives covered ~450 million Number of claims: 110 million via both cashless and
13% reimbursement
Despite the increase in annual growth, more than 80% of the population still does not have
any significant health insurance coverage.
22% 24%
13% 15%
4375
3590
2880
2162
Number of Lives covered under health insurance (in lakhs) Annual growth rate
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More than two-thirds of healthcare
spend is out-of-pocket expenditure
4%
7%
67%
More than 2/3rd of Private health insurance Health insurance It is imperative for any
expenditure on healthcare accounts for <5% of total covers mostly UHC scheme to cover OPD/
is out of pocket healthcare financing in-patient treatment medicines/diagnostics
Population coverage A majority of these schemes are targeted at below Minimal inclusion of above poverty
poverty population population in government schemes
Usually covers only-in-patient expenses and don’t Mostly excludes OPD, diagnostic and
Spectrum
cover wellness and rehabilitative care pharmaceutical expenses
Pricing of packages
Highly skewed No standardised package
Treatment protocols
Subjective medical decisions No defined clinical protocols
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AB-NHPM is now poised to become the world’s
largest sponsored health insurance scheme
Budgetary announcement
Population
coverage
In-patient
coverage
Diagnostics
Pharmaceuticals
Out-patient
coverage
Wellness
Rehabilitation
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Putting in the
Section 2 building blocks
Analyse the fiscal space Design and implement Fortify payment Widening of population
the UHC scheme mechanisms coverage, OPD, drugs
and diagnostics; progress
Define: Target towards preventive and
population and Introduce disease
coding and EMR rehabilitative care
service coverage
Consider: Public vs
Identify additional
private, contributory Reduce fraud
sources of funding Monitor the health
vs non-contributory,
mandatory vs non- outcomes
mandatory nature Introduce standard
of scheme treatment protocols
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AB-NHPM promises to bring about a tectonic shift in the
healthcare ecosystem
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Enrichment of ROHINI system and NHRR creation
Enriching the ROHINI system Improved user experience Better fraud management at
through large-scale empanelment by enabling choice of best provider level due to generation
and registration of hospitals suited provider of unique IDs for each hospital
and improving claim efficiencies
…by removing inefficiencies like This will help in leveraging private It will also address the issue of
non-reporting, under-reporting and sector health infrastructure in unavailability of private sector
delays in transmission of public service delivery. health resource data, health
health data. infrastructure, equipment and other
important data points.
ortunitie
pp
s
O
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This will positively impact the current
healthcare ecosystem
Institutional structures • Identifying and setting of State • Operations support in • Capacity building of officers at
Health Agency (SHA) and District stabilising and issue resolution regular intervals
Implementation Units (DIUs) • Scale up implementation • Strengthening of SHAs and
• Building contracts with insurance across states institutional structures
companies/implementation
support agency
Identification and • Updating Socio-Economic Caste • Linkage for approval to Monitor training of all stakeholders involved in
verification of beneficiaries Census (SECC) list insurance company beneficiary identification
• Creating multiple service location • Issuance of e-card
• Develop unique list of beneficiaries
Hospital empanelment • Setting of State and District • Appointment of nodal officer • Hospital quality strengthening (nudging
Empanelment Committee for administrative and towards entry-level National Accreditation
• Online empanelment of hospitals via medical purposes Board of Hospitals [NABH] or higher)
PMRSSM interface (registration and • Hospital transactions for • Evolve hospital rating system for further usage
application, tracking, follow-up, etc.) treatment procedures
• Signing of contracts
Information technology Deployment of requisite hardware, • Assess Information Technology • Monitor deployment of IT hardware, software
software, allied infrastructure and IT team (IT) team for readiness and allied infrastructure at empanelled
across states • Track readiness of state’s IT hospitals
platform for scheme and it’s • Monitor and reporting of deployment of kiosks
integration with central software • Develop standard operating
procedures (SOPs)
IEC and capacity building • SOPs need to be defined for all Strengthening of SOPs and • Ongoing capacity building and Institutional
key processes guidance documents and strengthening
• Development of Information, Education implementation of IEC campaign • Incorporation of DRGs, disease coding and
and Communications (IEC) strategy electronic medical reports (EMRs)
and guidelines
• Develop and devise training
methodologies
Identification of critical success factors, their seamless execution and evolution over the course of implementation will be the
pillar for effective implementation.
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Right pricing strategy
li ne low empanelment)
Trend
Difference between market price and NHPS price is higher for costly procedures,
thereby limiting the availability of these procedures. It is imperative to follow the
right pricing strategy for the scheme to make maximum impact.
Difference between market price and NHPS price is higher for costly procedures and this might limit the availability of these
procedures. Hence, it is imperative to follow the right pricing strategy for the scheme to make maximum impact.
RSBY AB-NHPM
Premiums should be appropriately benchmarked to insurers so that they can be engaged constructively.
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Right budgetary considerations
45 40 45
40
Claims cost (crore INR)
Thousands
Hundreds
Premium per family (INR)
40 40
35 33 35
30 30 30
23 24
25 25
23 19
20 16 20
15 15
13
10 8 10
5
5 3 2 5
2 1
- -
Current Estimate Case 1 Case 2 Case 3
Public hospitals claims Private hospitals claims Total scheme cost* Premium per famly
Reduction in private cost due to introduction of package rates NA 50% 20% 20%
Source: PwC simulation based on NSSO report * Assuming 15% administrative expenses
Inefficiencies
Duplication of
in scheme Poor beneficiary Dual premium for
beneficiaries across Insurance frauds
management and targeting same services
multiple schemes
roll-out
Sarva Swasthya Mission Jharkhand Entire population of Jharkhand Family pays the premium: Public and private hospitals coverage:
• BPL (>25,000 INR),offered • 20 INR per family up to 30,000 INR
Health security by affordable member and 170 INR as
pricing of standardised services subsidy Private hospitals coverage: up to
• Total premium: 190 INR 30,000 INR
Chief Minister’s Tamil Nadu 1. Families (residents of state) with Government of Tamil Nadu Based on ailment/procedure:
Comprehensive Health income less than 72,000 INR per pays the entire premium 1,00,000 INR or 2,00,000 INR per
Insurance Scheme annum family per year and grants for
2. Sri Lankan refugees follow-up treatment
3. Orphans
4. Migrants on fulfilment of
certain conditions
Mukhyamantri Amrutum Gujarat 1. BPL (part of district BPL list) – Government of Gujarat 2 lakh INR/family for tertiary
and Vatsalya Yojana for Amrutum pays the entire premium medical cover and 300 INR
2. Families with income of 1.5 lakh transportation charges
INR and below – for Vatsalya
Existing schemes have seen a significant rise in financial costs due to systemic inefficiencies and fraudulent behavior
across stockholders.
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Right infrastructure
1.6
Average length of stay (ALOS) 3 days
*F
rom new population which comes under
coverage for the first time, and also from
increased demand from previously covered
population due to higher coverage
13.5 13.5
Right infrastructure strategy required to meet new bed capacity demand from AB-NHPM
State health
agency (SHA)
district
implementing
units (DIUs)
Key functions Policy Contracting and Verification, Fraud and Adaptation Capacity Monitoring
support and coordination validation and abuse control of treatment building and reporting
implementation with insurance/ issuance of and its protocols and initiatives and of periodic
trusts e-card monitoring package price IEC activities implementation
revision status
Operational Operations and Monitoring IT and data Medical Capacity Grievance Finance and
framework admin. officers and evaluation managers and quality building and redressal accounts
officers managers Information mechanism officers
Education manager
Communication
(IEC) managers
Appropriate institutional mechanisms would be needed for strategic implementation support and programme management.
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Right leakage management
PMRSSM will create a need for various system analytics for risk mitigation in implementation/operations.
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Right monitoring dashboards (illustrative)
Claims 10
Qualified staff
absent
20 15
Fraud
15 17
10
Complaint
23 32
28
35 12
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Acknowledgements
Healthcare team Publishing and Online Media
Krishnakumar Sankarnarayan, Executive Director, PwC Dion D’Souza
Dr. Preet Matani, Director, PwC
Ashish Rampuria, Principal Consultant, PwC
Dr. Ashwani Aggarwal, Principal Consultant, PwC
Corporate Communications
Harshpal Singh
Dr. Chesta Sharma, Principal Consultant, PwC
Dr. Puneet Biblani, Principal Consultant, PwC
Dr. Nandini Pattnaik, Consultant, PwC
Contacts
Neerja Bhatia (Ms) Dr Rana Mehta
Executive Director Partner and Leader, Healthcare
Confederation of Indian Industry (CII) PwC India
The Mantosh Sondhi Center 7th Floor, Building No.8, Tower C,
23 Institutional Area, Lodhi Road DLF Cyber City, Gurugram,
New Delhi 110003, India Haryana 122002
Tel : +91 11 24629994 / 45771000 Mobile : +91 9910511577
Fax : + 91 11 24626149 Email: rana.mehta@pwc.com
Email: neerja.bhattia@cii.in
HS/July2018-13900