Utilisation pattern of health benefit packages under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana

INTRODUCTION

Ayushman Bharat or “Healthy India” is a national initiative launched as part of the National Health Policy 2017, in order to achieve the vision of Universal Health Coverage (UHC).¹ Ayushman Bharat comprises two interrelated components, which are the establishment of health and wellness centers and the Pradhan Mantri Jan Arogya Yojana. It is one significant step towards the achievement of Sustainable Development Goal-3 with target number 3.8, which aims “to achieve UHC including financial risk protection, access to quality essential health care services, and access to safe, effective, high quality, affordable, and essential medicines and vaccines for all.”²

Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is one of the most ambitious and life-changing schemes. AB-PMJAY is the pillar of Ayushman Bharat, which aims to provide healthcare coverage to over 10 crore poor and vulnerable families in India, providing up to INR 5 lakh per family per year for secondary and tertiary care hospitalization.³ The scheme envisages reducing out-of-pocket expenditure and catastrophic expenditure on health care through the participation of the private sector in addition to the existing network of public hospitals.⁴

One of the critical operational aspects for the successful implementation of AB-PMJAY is appropriate price setting. AB-PMJAY coverage is currently available for hospitalization involving 1949 surgical and medical procedures. The empaneled health care providers under AB-PMJAY are paid based on a case-bundled payment for the specific procedures performed. The payment is inclusive of any outpatient diagnostics before procedure, procedure cost, subsequent hospitalization, and medicines for 15 days following hospitalization.⁵

The present study aims to inform healthcare providers about the current utilization patterns of health benefit packages (HBPs), highlighting the need for focused logistical management on the most frequently utilized packages. Additionally, the findings of this study will assist the government in making data-driven decisions to add or remove packages within specific specialties based on their utilization rates and cost-benefit analysis.

MATERIAL AND METHODS

Study Area: King George’s Medical University (KGMU), Lucknow, Uttar Pradesh

Study Design: Cross-sectional study

Sample size: All 4,542 packages utilized by the beneficiaries from different medical and surgical departments in the year 2023 were taken as the sample size in the present study. The requisite data on the utilization of HBPs for 2023 was obtained from the Ayushman portal with prior permission from the nodal officer of AB-PMJAY at KGMU.

Sample technique

The Flowchart 1 illustrates the sampling technique used to select HBPs for analysis. Firstly, HBPs were categorized under two main departments, surgical and medical. From each department, the 10 most utilized specialties* were identified. Subsequently, from the top 2 most utilized specialties under each department, the top 2 most utilized HBPs# were selected for further study. This multi-step approach ensured high-impact package selection based on utilization data.

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Flowchart 1

Sampling technique for selection of health benefit packages. *Specialty: The medical and surgical departments are divided into branches that have advanced knowledge and skill in their particular subjects. ^#Health benefit package: These are packages with defined procedure and costs, which benefit Ayushman beneficiaries after availing them in an empaneled hospital.

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Data analysis: The data was analyzed using the SPSS software version 24.0. Descriptive statistics, including mean and standard deviation (SD) for continuous variables, and frequency, along with percentages for categorical variables, were calculated.

RESULTS

Table 1 shows that in 2023, the most utilized packages in the medical department were under the cardiology specialty (22.8%), followed by general medicines (6.7%). The most utilized packages in the surgical department in 2023, were under the orthopedics specialty (15.7%), followed by 9.2% of surgical oncology packages.

Table 2 shows that the most utilized HBPs under the cardiology specialty was percutaneous transluminal coronary angioplasty, inclusive of the diagnostic angiogram (80.5%). Under the radiotherapy specialty, external beam radiotherapy (Telecobalt/Strock LA) (25 Fractions) (Inclusive of Simulation & Planning Cost) was most utilized (18.5%). The most utilized package under the orthopedics specialty was total hip replacement cementless (15.7%). Under surgical oncology, the most utilized package was composite resection (Oral Cavity) + regional flap + neck dissection (13.6%)

Table 3 shows that from the total amount of INR 32,21,73,036 spent on health packages in the year 2023, around 40.7% was utilized by the cardiology specialty, followed by 3% by pulmonary and critical care medicine, and 2% by general medicine.

Among surgical departments, around 19.2% of the total cost was utilized by orthopedics, followed by 7.7% by surgical oncology, 5.6% by neurosurgery, 3.3% by general surgery, and 2.8% by Cardio thoracic and vascular surgery (CTVS).

Among the medical departments, the costliest package of INR 4,31,640 was utilized by the radiodiagnosis specialty, followed by INR 3,88,495 utilized under the cardiology specialty. Among surgical departments, the costliest package of INR 3,86,735 was utilized under the CTVS specialty, followed by INR 2,83,315 utilized under the orthopedics department.

Table 4 shows that in the cardiology specialty, percutaneous transluminal coronary angioplasty inclusive of diagnostic angiogram was the costliest package and its utilization was 80.5%, followed by Permanent Pacemaker Implantation - Single Chamber and its utilization was 13.3%. In radiotherapy, the Linear Accelerator, External Beam Radiotherapy 3D CRT (25 Fractions)(Inclusive of Simulation & Planning Cost) was the costliest package, and its utilization was 17.9%. In the orthopedics specialty, Primary-Total Knee Replacement was the costliest package, and its utilization was 7.9%, followed by total hip replacement, with 15.7% utilization. In the surgical oncology specialty, composite resection (Oral Cavity) + regional flap + neck dissection – comprehensive was the costliest, and its utilization was 13.6%.

DISCUSSION

The present study showed that the most utilized package was cardiology, with a utilization of about 40.7% of the total cost of all the packages. Among packages utilized, percutaneous transluminal coronary angioplasty, inclusive of diagnostic angiogram (80.5%), was the most utilized package under the cardiology specialty.

Under the surgical department, the orthopedics specialty was most utilized (15.7%), with 19.2% of cost, and it had second costliest package of INR 2,83,315. Only 0.9% of packages were utilized under the CTVS specialty, but it had the costliest package of INR 3,86,735.

A similar study conducted in a Multispecialty Tertiary Centre of North India, Mufti S et al⁶. (2024) revealed that around 4844 claims were settled in the initial two years (December 2018 to December 2020). It showed that the highest number of claims (43.33%) were availed under the general medicine category, and 37.45% were from medical oncology. It also showed that interventional cardiology packages were the costliest, similar to the present study. The result is similar to this study in cost-wise analysis.

A project conducted by the World Health Organization (WHO), National Health Authority in 2022⁷ analyzed the trends of utilization of packages in 6 states including Uttar Pradesh. It showed that in public hospitals in Uttar Pradesh, 14.8% of cardiology, 27% of medical oncology, 32.4% of nephrology, 34.5% of neurosurgery, 8.6% of orthopedics, and 28.1% of neurology packages were utilized. The percentage of package utilization in different specialties is almost similar to the current study; the minor difference is due to the period up to which the utilized packages were taken into consideration. The current study has considered packages utilized after COVID-19. It showed highest utilization of cardiology packages, whereas project conducted by WHO has taken packages utilized before 2021.

CONCLUSION

The study concluded that in the year 2023, among surgical departments, packages under the orthopedics specialty were most utilized, and among medical departments, packages under the cardiology specialty were most utilized. It was found that from the total amount of INR 32,21,73,036 spent on health packages in year 2023, among medical departments, most of the cost was utilized by the cardiology specialty but the costliest package was under the radiodiagnosis specialty. Likewise in surgical departments, most of the cost was utilized by the orthopedics specialty and costliest package was utilized under the CTVS specialty.