|Year : 2021 | Volume
| Issue : 2 | Page : 63-68
Trends in cardiac care utilization under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana, India
Parul Naib1, Pulkit Kumar2, Sudha Chandrashekar3, Owen Smith4, Sheena Chhabra1
1 Delhi University, New Delhi, India
2 Tata Institute of Social Sciences, Mumbai, Maharashtra, India
3 London School of Hygiene and Tropical Medicine, London, England
4 Harvard University, Cambridge, Massachusetts, USA
|Date of Submission||01-Feb-2021|
|Date of Decision||31-Mar-2021|
|Date of Acceptance||10-Nov-2021|
|Date of Web Publication||14-Dec-2021|
Prof. Pulkit Kumar
L-526 Sarita Vihar, New Delhi
Source of Support: None, Conflict of Interest: None
Background: Ayushman Bharat, the flagship scheme of the Government of India, was launched in September 2018 to achieve the vision of universal health coverage in India. Objectives: One of the important components of Ayushman Bharat is the Pradhan Mantri Jan Arogya Yojna (PM-JAY) that provides a benefit cover of INR 5 lakhs per family per year for secondary and tertiary care hospitalization. Methods: The present study explores key trends in the utilization of cardiac care packages under the Ayushman Bharat AB PM-JAY. This would have an implication in making cardiac care more accessible by bridging the existing gaps in cardiac care delivery under PM-JAY. All cardiac claims under PM-JAY were analyzed for a period of 17 months (from the inception of the scheme in September 2018 to February 2020). Results: The analysis shows that claims from cardiac (cardiology as well as cardiothoracic and vascular surgery) specialty accounted for 5% of the total PM-JAY claim volume, however, it shares in the total claim volume. It was significantly higher at 26% indicating that a very high proportion of the scheme was utilized to provide free cardiac care to beneficiaries coming from the poorest segment of the population. Conclusion: The analysis also indicates significant variation in the supply of the cardiac facilities and the need to further develop health infrastructure for cardiac care, particularly in certain states where the supply is found to be inadequate.
Keywords: Cardiac care, cardiology, cardiovascular diseases, universal health coverage
|How to cite this article:|
Naib P, Kumar P, Chandrashekar S, Smith O, Chhabra S. Trends in cardiac care utilization under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana, India. Ann Clin Cardiol 2021;3:63-8
|How to cite this URL:|
Naib P, Kumar P, Chandrashekar S, Smith O, Chhabra S. Trends in cardiac care utilization under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana, India. Ann Clin Cardiol [serial online] 2021 [cited 2022 Jul 2];3:63-8. Available from: http://www.onlineacc.org/text.asp?2021/3/2/63/336219
| Introduction|| |
Cardiovascular diseases (CVDs) are the leading cause of mortality at a global level (31%) as well as in India (27%). Above this, 78% of all noncommunicable disease (NCD) deaths and 85% of premature adult NCD deaths occur in low- and middle-income countries.
Looking at the Indian experience, there has been a steady epidemiological transition from communicable diseases to NCDs. Between 1990 and 2017, the NCD burden has increased by 62% from 166 million cases to 269 million cases. During the same period, deaths due to CVDs increased by 90%, with more than half of these deaths being premature (population less than 70 years of age). At least 80% of premature deaths due to CVD are preventable. CVDs cases can be prevented by promoting awareness among the people about behavioral risk factors such as heavy smoking, unhealthy food diet, excessive obesity, physical inactivity, and consuming alcohol.
Recent studies from India show that individuals with lower levels of income or education are at higher risk of coronary heart disease (CHD), suggesting that for some population groups in South Asia, prevalence is following the pattern seen with advanced epidemics in developed countries – the highest prevalence is shifting from the more affluent to the less affluent., This is quite concerning since CVDs not only have an impact on the health of the affected person but could potentially entrench the entire family below the poverty line due to various reasons, including:
- Loss of productivity due to illness and premature mortalities
- Expenditures on health creating opportunity costs for other priorities such as education and Effect of household poverty on the education of children.
The poorest people in low- and middle-income countries are affected most. At the household level, sufficient evidence is emerging to prove that CVDs and other noncommunicable diseases contribute to poverty due to catastrophic health spending and high out-of-pocket expenditure.
In South Asia Region (SAR), individuals with lower socioeconomic status are developing a higher burden of CHD. One of the reasons for this could be the fact that a higher proportion of the poor use tobacco products. Looking at the impact of CVDs, the article aims to analyze the utilization of cardiac care under Pradhan Mantri Jan Arogya Yojna (PM-JAY) that will help to improve scheme performance by identifying and bridging the existing gaps in cardiac care delivery and would eventually reduce the catastrophic health expenditure due to CVDs.
For this study, aggregated PM-JAY claims data from the inception of the scheme in September 2018 to February 2020 have been considered for all states/union territories (UTs) which are implementing the PM-JAY. The period considered for analysis is from the date scheme which was rolled out in respective states/UTs to February 29, 2020. Due to the phased launch across states, data for Karnataka are considered for 15 months, for Kerala 11 months, for Punjab 7 months, and for other states, data are considered for 17 months. Claims data at the transaction level of Rajasthan and Goa were not available in the NHA database therefore excluded from the analysis. Telangana, Odisha, Delhi, and West Bengal are not implementing PM-JAY hence excluded from the study.
| Results|| |
Variation in the utilization patterns of cardiac care is observed across states and patients' demographics in terms of claim volume and value.
Overall utilization: Claim volume versus value
Out of the total claims submitted (~96 lakhs) for the period under consideration, the contribution of cardiac claims was 5% (~4.8 lakhs) in volume. However, this meager percentage of 5% volume amounted to 26% (INR 3225 crore) of the total financial outgo of the scheme. This seems to be indicative of the high average cost of cardiac care, translated to approximately INR 69,000 per claim against the national average of INR 11,000 per claim for all treatments combined. It could be assumed that in the absence of PM-JAY, these expenses would be borne by the poor families themselves, given the limited coverage of erstwhile Rashtriya Swasthya Bima Yojana which had an assured amount of only INR 30,000 per eligible family per year. Thus, PM-JAY with INR 5 lakh cover per eligible family provides a much wider safety net to prevent catastrophic expenditure arising from secondary and tertiary care for the poorest 40% of India's population.
Utilization across states
Cardiac package wise
Of the total 130 cardiac packages covered under PM-JAY, the top 5 cardiac packages accounted for 70% of the total utilization of cardiac claims. Among these cardiac packages, percutaneous transluminal coronary angioplasty (PTCA)-single stent (medicated, inclusive of diagnostic angiogram) accounted for the highest utilization (34%) followed by PTCA-double stent (20%), coronary artery bypass grafting (CABG) (9%), management of acute myocardial infarction (MI) (4%), and mitral valve replacement (3%).
Similarly, in terms of claim value, top 5 cardiac packages accounted for 82% of total utilization with PTCA-single stent (medicated, inclusive of diagnostic angiogram) accounted for the highest utilization (32%) followed by PTCA-double stent (24%), CABG (13%), mitral valve replacement CABG (9%), and management of acute MI (4%).
Based on active cardiac hospitals: [Map on a separate sheet as [Figure 1]]
Active cardiac hospitals are the PM-JAY empaneled hospitals that registered at least one cardiac claim during the period analyzed. Tamil Nadu has the highest number of active cardiac hospitals (527) followed by Maharashtra (210). A huge disparity in the distribution of active cardiac hospitals can be observed as half of the active hospitals empaneled with cardiac care are concentrated in four South Indian states as shown in [Figure 1]. States with prior public health insurance experience (Gujarat, Karnataka, Maharashtra, Tamil Nadu, and Andhra Pradesh) have a higher number of active cardiac hospitals compared to the states with no prior experience in state health insurance before adopting PM-JAY [Figure 1].
Based on claim utilization [Map on a separate sheet as [Figure 2]]
Higher utilization of cardiac care packages is observed across states with prior state-funded health insurance experience such as Gujarat, Karnataka, Maharashtra, Tamil Nadu, Andhra Pradesh, and Kerala [Figure 2].
Based on average claim value wise
Significant disparities in the average cardiac claim value are observed across states that range from INR 41,597 to INR 94,529 across states. This may be indicative of higher utilization of high-end packages (PTCA-single stent, PTCA-double stent, CABG, etc.) in certain states and variations in cardiac package rates across few states. Further research needs to be done to understand the high utilization of stent-related packages in certain states and how few states were able to achieve a lower cost of high-end packages.
Based on hospital type (public and private hospital)
Overall, 64% of claims are from private hospitals, while in terms of cardiac claims, the share of private hospitals increases to 79%. This may be indicative of greater access to quality cardiac facilities, specialists, and medical personnel in private hospitals closer to the home of the beneficiary, as compared to public hospitals. This trend of higher utilization in private hospitals as compared to the public is also seen across all states except for Himachal Pradesh, Kerala, Jammu and Kashmir, Bihar, and Chandigarh where the trend is reversed, and cardiac claim volume is higher in public hospitals.
Based on portability
Portability is one of the important features of PM-JAY, it allows beneficiaries to avail treatment outside their home state in any PM-JAY empaneled hospital in a cashless manner. While seeking treatment in other states/UTs, no empaneled hospital can deny services based on the beneficiary's home state. Roughly 1.8% of all Cardiac claims originated from hospitals outside of the beneficiary state, almost double that of the national portability average for all claims. This indicates a higher proportion of people need to travel to other states to avail quality cardiac care as compared to other treatments.
Looking at the patient origination states, about 75% of cardiac portable cases were for beneficiaries from four states: Madhya Pradesh (40%), UP (15%), Bihar (13%), and Punjab (8%). This could be attributed to a lack of quality cardiac care infrastructure and skilled medical personnel in these states or migrant workers who may be living in other states and needs to be explored further. Of the patients seeking cardiac care outside their home state, the majority traveled to Gujarat followed by Maharashtra.
Utilization by beneficiary attributes [chart on a separate sheet as [Figure 3]]
At an overall utilization of all packages, males seem to have a higher share (58%) compared to females (42%). When it comes to cardiac care, this differential becomes manifold and the share of males increases to 70% in comparison to 30% of females.
Claims distribution based on age shows that 50% of the cardiac claim volume is contributed by those aged between 41 and 60 years and 30% from those aged between 51 and 60 years. The male-to-female ratio for all claims indicated male predominance in all the age groups except for the age group of 21–30 years. It is observed that cardiac care utilization is almost equal for both genders in younger age groups. However, as the age increases, the share of females seeking cardiac care reduces as compared to males.
| Discussion|| |
Disparities in providing cardiac care utilization were observed across regions, across the type of care providers (public/private), across genders, and across age groups. These disparities need to be addressed to make cardiac care more accessible to all beneficiaries.
High utilization of cardiac care was observed in the states with prior experience of state-funded health insurance schemes such as Gujarat, Maharashtra, Kerala, Tamil Nadu, Karnataka, and Andhra Pradesh. Likely reasons for this could be the higher level of awareness among beneficiaries regarding cardiac diseases and the availability of empaneled cardiac care facilities. More on-ground research is needed to substantiate the above. Further, these States also had a better cardiac care health infrastructure and availability of skilled medical personnel.
States that have recently launched health insurance need to accelerate their efforts to empanel more cardiac care facilities, creating beneficiary awareness, conducting more regular diagnostics, and testing for cardiac care.
High utilization states such as Gujarat, Maharashtra, and Andhra Pradesh showed significantly high cardiac claim volume by private hospitals. The capacity of public hospitals to provide cardiac care needs to be improved in most states. Capacity would refer to the infrastructure, medical equipment as well as superspecialists and other medical personnel required to perform high-end cardiac procedures/surgeries. A preliminary field audit has also confirmed that public hospitals in Kerala have adequate infrastructure and specialists even at the district and taluk levels while more detailed work is required to substantiate the same for other implementing states.
Cardiovascular disease develops 7 to 10 years later in women than in men, while one of the studies suggests that the risk of heart disease in women at younger ages is somewhat lower than in men but tends to equalize postmenopause as exposure to endogenous estrogens during the fertile period of life delays the manifestation of atherosclerotic disease in women. Even allowing for biological protection at early ages but the utilization of cardiac care does not equalize even at later ages.
Past studies have shown that gender has a direct impact on cardiac health. However, lower utilization of cardiac care among females under PM-JAY, especially in postmenopausal age group, might be indicative that females may have limited social mobility and hence access to healthcare due to sociocultural factors. In patriarchal societies such as India, most women are financially dependent on males and their health may often not receive the due attention, especially in poor families with limited means.,,, This may also lead to fewer females going for timely screening and diagnosis as compared to men. Lower awareness among women about the disease, symptoms, and available diagnostics makes them more vulnerable to life-threatening diseases. Accessibility to high-quality cardiac care near the place of residence is also an important factor given that women may not be able to travel long distances for care as compared to men. Identifying and addressing barriers for women to access necessary cardiac care will be important to effectively increase their percentage share in the utilization of cardiac care and improve women's health.
Focus on older age groups would also be essential as approximately 40% of claims are from those aged 60 and above years. Policies interventions for making cardiac care more accessible for the elderly population near their place of residence for timely diagnosis and treatment would be critical.
The high rate of portability of patients from Madhya Pradesh to Gujarat may be indicative of the limited availability of quality care facilities across the State.
The analysis emphasizes the need to strengthen the national level screening programs through developing linkages with health and wellness centers (HWCs) and NCD Cells. Seeking cooperation of empaneled hospitals would be an important step in this as well. States such as Maharashtra and Karnataka have experimented with private empaneled hospitals support to conduct camps for the screening of cardiac cases at taluk and district level public facilities. Early detection can prevent the emergency need for cardiac care which will have an impact on the outcome of the treatments provided.
Access to quality healthcare services is also critical, especially in states and in interior areas, as most heart institutes are concentrated in Tier 1 and Tier 2 cities. Greater awareness among women about heart diseases and a special focus on diagnosis will enable early detection and treatment. One way to enable this could be to incentivize ASHA workers (this has been piloted in Karnataka) in identifying potential high-risk cases, especially women and those from SC/ST populations and taking them to the nearest HWC for screening. It is also important to step up efforts and work toward convergence of PM-JAY and Rashtriya Bal Swasthya Karyakram for improving screening of congenital heart disease and ensuring identified cases are treated in a timely manner. Use of mobile services can help in increasing prevention and awareness regarding the disease: Text message-based prevention programs have demonstrated a reduction in cardiovascular risk factors among patients with CHD in selected populations.
Currently, PM-JAY covers follow-up care for 15 days postdischarge only. However, in case of cardiac ailments, treatment may be required for the remainder of the patient's life. Hence, coverage for maintenance medicines like antiplatelet drugs should also be provided through PM-JAY to control out-of-pocket expenditure post surgery.
Given the complexity of the treatment, enabling decentralized care for chronic management through HWCs and taluk/district hospitals for identifying any complications arising postdischarge after procedure/surgery would also be crucial. Necessary drugs could be covered through the national free drug service program at HWCs/taluk/district hospitals.
There is also a need to rationalize and cap the price of stents. Although some initial efforts have been made to cap the price of stents, there is a need to find ways to further rationalize its price and lower the cost of other consumables such as balloons, guide wire, and valves for which prices are not capped. Collective and centralized procurement of these consumables could be an effective solution for this. As access to care improves, more emphasis on assessing the quality of care by checking for readmissions and complications post treatment is required.
Complete data around morbidity and mortality were not available; hence, long-run outcomes could not be studied in the current paper. Further research in areas pertaining to underlying disease burden with a clinical history of the cardiac patients, outcome of the care in terms of survival or improvement in health, and quality issues like overuse of stenting needs to be done.
Financial support and sponsorship
This study was financially supported by the World Bank.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gupta R, Gupta VP. Meta-analysis of coronary heart disease prevalence in India. Indian Heart J 1996;48:241-5.
Ramachandran A, Snehalatha C, Kapur A, Vijay V, Mohan V, Das AK, et al
. High prevalence of diabetes and impaired glucose tolerance in India: National Urban Diabetes Survey. Diabetologia 2001;44:1094-101.
Ghaffar A, Reddy KS, Singhi M. Burden of non-communicable diseases in South Asia. BMJ 2004;328:807-10.
Women or Men – Who Has a Higher Risk of Heart Attack? How Gender is Involved in Coronary Artery Disease. Available from: https://health.clevelandclinic.org/women-men-higher-risk-heart-attack/. [Last accessed on 2021 Nov 15].
Verbrugge LM. Gender and health: An update on hypotheses and evidence. J Health Soc Behav 1985;26:156-82.
Baum A, Grunberg NE. Gender, stress, and health. Health Psychol 1991;10:80-5.
Culbertson FM. Depression and gender. An international review. Am Psychol 1997;52:25-31.
Das M, Angeli F, Krumeich AJ, van Schayck OC. The gendered experience with respect to health-seeking behaviour in an urban slum of Kolkata, India. Int J Equity Health 2018;17:24.
Thakkar J, Karthikeyan G, Purohit G, Thakkar S, Sharma J, Verma S, et al
. Development of macaronic Hindi-English 'Hinglish' text message content for a coronary heart disease secondary prevention programme. Heart Asia 2016;8:32-8.
[Figure 1], [Figure 2], [Figure 3]