The nationwide lockdown had a significant negative impact on inpatient care utilisation under the Pradhan Mantri Jan Arogya Yojana (PMJAY) , where claim volumes fell by over 50%, with wide variation across the States and procedure types. The steepest decline (over 75%) was registered in Assam, followed by Maharashtra and Bihar, while much smaller declines (about 25% or less) were observed in Uttarakhand, Punjab and Kerala. Of particular concern were significant declines in admissions for child delivery and oncology. There was also a sharp fall in cardiovascular surgeries, according to “PMJAY Policy Brief (8): PM-JAY Under Lockdown: Evidence on Utilization Trends’’.
PMJAY is the flagship scheme by the Government of India and is essentially a health insurance scheme to cater to the poor, lower sections of society and the vulnerable population. The scheme offers financial protection in case of hospitalisation due to medical emergencies.
The brief says that demographic groups, women, younger and older populations (under 20 and over 60) reduced their utilisation by more than men, young adults or the middle-aged. Among procedures, planned surgeries such as cataract operations and joint replacements suffered a decline of over 90%, while hemodialysis declined by only 20%.
Overall, average weekly claim volumes in 10 weeks of lockdown were 51 percent lower than the weekly average observed during the 12 weeks prior to the lockdown. The decline in claim value was even steeper.
The brief states that there was a small but perceptible shift in PMJAY utilisation from public to private hospitals, with several possible explanations for this trend.
“The 64% decline in oncology volumes across India during lockdown was concentrated in a few States. In the public sector, which plays a smaller role in oncology care under PMJAY, there was a 90% decline in claims in Maharashtra, and a 65% decline in Tamil Nadu. The utilisation of neo-natal packages declined by 24 percent during lockdown. There was a slight shift from public to private hospitals for neo-natal care, and the largest declines have been observed in the public sector in Tamil Nadu and Madhya Pradesh. The health implications for newborns of such a sharp decline are of course a concern,’’ points out the brief.
Health experts have said that ensuring least possible impact on key health programmes will be an ongoing challenge that merits continued close monitoring.
Careseeking behaviours hit
The 12-page brief notes that while access to medical facilities was one of the few exceptions to stay-at-home orders during the lockdown, careseeking behaviours and healthcare provision were nevertheless significantly affected.
“Several factors could explain this -- On the supply side, hospitals may be preoccupied with COVID-19 preparations or caseloads, resulting in fewer resources for non-COVID-19 cases. This may be particularly relevant in public hospitals, which have been the primary focus of the policy response, and could extend to activities such as submitting pre-authorisation requests or claims documents as required under PMJAY.’’
It says that private hospitals may reduce services out of fear among health workers that they will become infected or among owners that their business outlook will be jeopardised if they are perceived to be treating COVID-19 patients. On the demand side, PMJAY beneficiaries might delay or forego treatment due to fear of infection at a hospital, they may not be able to reach hospitals due to public transport shutdowns and mobility constraints, or the nascent economic crisis may affect financial considerations related to seeking care.
22 weeks of data
The analysis covers 22 weeks of data, from January 1 to June 2, and while the national lockdown started on March 25, it was significantly relaxed as of June 1.
“The analysis is based on claims data drawn from the PMJAY Transaction Management System (TMS). The main indicator of claim volumes [utilization] is non-rejected pre authorisation requests. It should be noted that not all States are fully captured in TMS, including Goa and Rajasthan. Less than half of Gujarat’s hospitals use the TMS portal but the authorities report aggregates, meaning that overall trends are accurately captured in the analysis, but procedure wise analysis heavily underreports Gujarat trends,’’ adds the brief.