The trust and insurance models of healthcare purchasing in the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana in India: early findings from case studies of two states
Abstract Background The Pradhan Mantri Jan Arogya Yojana (PMJAY), a publicly funded health insurance scheme for the poor in India, was launched in 2018. Early experiences of states with various purchasing arrangements can provide valuable insights for its future performance. We sought to understand...
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| Format: | Article |
| Language: | English |
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BMC
2022-08-01
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| Series: | BMC Health Services Research |
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| Online Access: | https://doi.org/10.1186/s12913-022-08407-2 |
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| author | Kheya Melo Furtado Arif Raza Devasheesh Mathur Nafisa Vaz Ruchira Agrawal Zubin Cyrus Shroff |
| author_facet | Kheya Melo Furtado Arif Raza Devasheesh Mathur Nafisa Vaz Ruchira Agrawal Zubin Cyrus Shroff |
| author_sort | Kheya Melo Furtado |
| collection | DOAJ |
| description | Abstract Background The Pradhan Mantri Jan Arogya Yojana (PMJAY), a publicly funded health insurance scheme for the poor in India, was launched in 2018. Early experiences of states with various purchasing arrangements can provide valuable insights for its future performance. We sought to understand the institutional agencies and performance of the trust and insurance models of purchasing with respect to; a) Provider contracting b) Claim management c) Implementation costs. Methods A mixed methods case study design was adopted. Two states, Uttar Pradesh (representing a trust model) and Jharkhand (representing the insurance model) were purposively selected. Data sources included document reviews, key informant interviews, quantitative scheme data from the provider empanelment and claims database, and primary data on costs. Descriptive statistics were reported for quantitative data, content analysis was used for thematic reporting of qualitative data. Results In both models, the state was the final authority on empanelment decisions, with no significant influence of the insurance company. Private hospitals constituted the majority of empanelled providers, with wide variations in district-wise distribution of bed capacities in both states. The urgency of completing empanelment in the early days of the scheme created the need for both states to re-review hospitals and de-empanel those not meeting requirements. Very few quality- accredited private hospitals were empaneled. The trust displayed more oversight of support agencies for claim management, longer processing times, a higher claim rejection rate and numbers of queries raised, as compared to the insurance model. Support agencies in both states faced challenges in assessing the clinical decisions of hospitals. Cost-effectiveness showed mixed results; the trust cost less than the insurance model per beneficiary enrolled, but more per claim generated. Conclusions Efforts are required to enable a better distribution and ensure quality of care in empanelled hospitals. The adoption of standard treatment guidelines is needed to support hospitals and implementing agencies in better claim management. The oversight of agencies through enforcement of contracts remains vital in both models. Assessing the comparative performance of trusts and insurance companies in more states at later stages of scheme implementation, would be further useful to determine their cost-effectiveness as purchasers. |
| first_indexed | 2024-04-11T21:46:49Z |
| format | Article |
| id | doaj.art-7b4102dac0bb488eb4832dc22d55850b |
| institution | Directory Open Access Journal |
| issn | 1472-6963 |
| language | English |
| last_indexed | 2024-04-11T21:46:49Z |
| publishDate | 2022-08-01 |
| publisher | BMC |
| record_format | Article |
| series | BMC Health Services Research |
| spelling | doaj.art-7b4102dac0bb488eb4832dc22d55850b2022-12-22T04:01:24ZengBMCBMC Health Services Research1472-69632022-08-0122111810.1186/s12913-022-08407-2The trust and insurance models of healthcare purchasing in the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana in India: early findings from case studies of two statesKheya Melo Furtado0Arif Raza1Devasheesh Mathur2Nafisa Vaz3Ruchira Agrawal4Zubin Cyrus Shroff5Goa Institute of ManagementGoa Institute of ManagementGoa Institute of ManagementGoa Institute of ManagementNational Health Authority, Ministry of Health and Family Welfare, Government of IndiaAlliance for Health Policy and Systems Research, World Health OrganizationAbstract Background The Pradhan Mantri Jan Arogya Yojana (PMJAY), a publicly funded health insurance scheme for the poor in India, was launched in 2018. Early experiences of states with various purchasing arrangements can provide valuable insights for its future performance. We sought to understand the institutional agencies and performance of the trust and insurance models of purchasing with respect to; a) Provider contracting b) Claim management c) Implementation costs. Methods A mixed methods case study design was adopted. Two states, Uttar Pradesh (representing a trust model) and Jharkhand (representing the insurance model) were purposively selected. Data sources included document reviews, key informant interviews, quantitative scheme data from the provider empanelment and claims database, and primary data on costs. Descriptive statistics were reported for quantitative data, content analysis was used for thematic reporting of qualitative data. Results In both models, the state was the final authority on empanelment decisions, with no significant influence of the insurance company. Private hospitals constituted the majority of empanelled providers, with wide variations in district-wise distribution of bed capacities in both states. The urgency of completing empanelment in the early days of the scheme created the need for both states to re-review hospitals and de-empanel those not meeting requirements. Very few quality- accredited private hospitals were empaneled. The trust displayed more oversight of support agencies for claim management, longer processing times, a higher claim rejection rate and numbers of queries raised, as compared to the insurance model. Support agencies in both states faced challenges in assessing the clinical decisions of hospitals. Cost-effectiveness showed mixed results; the trust cost less than the insurance model per beneficiary enrolled, but more per claim generated. Conclusions Efforts are required to enable a better distribution and ensure quality of care in empanelled hospitals. The adoption of standard treatment guidelines is needed to support hospitals and implementing agencies in better claim management. The oversight of agencies through enforcement of contracts remains vital in both models. Assessing the comparative performance of trusts and insurance companies in more states at later stages of scheme implementation, would be further useful to determine their cost-effectiveness as purchasers.https://doi.org/10.1186/s12913-022-08407-2Strategic purchasingProvider contractingClaim managementPurchasing modelHealth insuranceHealth financing |
| spellingShingle | Kheya Melo Furtado Arif Raza Devasheesh Mathur Nafisa Vaz Ruchira Agrawal Zubin Cyrus Shroff The trust and insurance models of healthcare purchasing in the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana in India: early findings from case studies of two states BMC Health Services Research Strategic purchasing Provider contracting Claim management Purchasing model Health insurance Health financing |
| title | The trust and insurance models of healthcare purchasing in the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana in India: early findings from case studies of two states |
| title_full | The trust and insurance models of healthcare purchasing in the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana in India: early findings from case studies of two states |
| title_fullStr | The trust and insurance models of healthcare purchasing in the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana in India: early findings from case studies of two states |
| title_full_unstemmed | The trust and insurance models of healthcare purchasing in the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana in India: early findings from case studies of two states |
| title_short | The trust and insurance models of healthcare purchasing in the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana in India: early findings from case studies of two states |
| title_sort | trust and insurance models of healthcare purchasing in the ayushman bharat pradhan mantri jan arogya yojana in india early findings from case studies of two states |
| topic | Strategic purchasing Provider contracting Claim management Purchasing model Health insurance Health financing |
| url | https://doi.org/10.1186/s12913-022-08407-2 |
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