National health insurance claims analysis shows gaps in medical infrastructure

An analysis of utilisation patterns of the Pradhan Mantri Jan Arogya Yojana - the government's flagship health insurance scheme - shows wide variation in average claims among different states.

States with already functioning secondary/tertiary care programmes, such as Tamil Nadu, Andhra Pradesh and Maharashtra, show 2-2.5 times the average spend per patient compared to traditional health laggards like Uttar Pradesh and Jharkhand, reported Indian Express.

PMJAY data till 9 July shows that of the total INR34.83bn ($486m) paid out to settle claims so far, the highest share was of Gujarat, with INR7.48bn for 437,774 hospitalisation cases. Chhattisgarh came second with INR4.5bn in claims and 569,456 hospitalisation cases, and Tamil Nadu third with INR4.4bn in claims and 207,906 hospitalisation cases.

However, a look at the average claim size shows that Andhra Pradesh tops the list at INR28,709, followed by Maharashtra at INR25,333, and Karnataka at INR25,075. On the other hand, the average claim size in Uttar Pradesh, with a total of INR1.5bn claimed so far for 119,512 hospitalisation cases, was INR12,195.

Reasons for divergence

A senior officer of the National Health Authority, commenting on the large divergence in the average claim size, said, “States like Andhra Pradesh and Tamil Nadu which have a robust public health system seem to spend more on tertiary care. The same is the case for Maharashtra, where three-quarters of the hospitals empanelled are in the private sector.

However in states such as Uttar Pradesh and Bihar, more money is being spent on secondary care procedures. This is a symptom essentially of the lack of capacity and infrastructure. The government needs to spend more in these states on infrastructure; we also need the private sector to invest in these states,” said the officer, who did not want to be named.

In states which have capacity, the PMJAY seems to be moving towards subsidising catastrophic health spends, as it was intended to, while in the less well-endowed states, it is meeting more basic health needs. Launched in September last year, the PMJAY provides annual healthcare cover of INR500,000 per family to 107.4m poor households or around 500m people.

When states signed a memorandum of understanding with the central government to adopt the PMJAY, their existing medical insurance schemes — such as Arogyashri in case of Andhra Pradesh — were subsumed into the central scheme. Two states that are yet to adopt the PMJAY are Odisha and Telangana. West Bengal became a part of the scheme but has since withdrawn from it.

Source: Asia Insurance Review