Patients seeking care at private hospitals tend to be older and a larger share consist of males when compared to those seeking medical care at public hospitals as per data release by the National Health Agency (NHA).
In its briefing on “The role of Private Hospitals” published recently, the Agency says private hospitals account for over half of the empanelled hospitals, nearly two-thirds of claim volumes, and three-quarters of claim outlays in the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY). This, when private hospitals are making a smaller contribution in terms of extending the geographic reach of PM-JAY to underserved areas. The top PM-JAY packages by value — including knee replacement, cataracts, hemodialysis and cardiovascular surgeries — are overwhelmingly provided by private hospitals.
The time period for the analysis was from September 23, 2018 to February 29, 2020.
Medical audits have also revealed that private hospitals are more likely to indulge in fraud and abuse than public hospitals and more likely to discharge patients early post-surgery in an attempt to cut costs. “Regular audits and fraud detection triggers help to identify and flag such suspicious cases,” the report says.
“Ensuring the accountability of private hospitals to provide efficient and high-quality care is a pre-eminent challenge for scheme implementation. Offering a robust public sector alternative in the form of high- performing government hospitals serving as a market anchor will be one element of such an approach,” states the report.
The Agency’s survey also found that over 72% of all private empanelled hospitals are located in just seven States: Uttar Pradesh, Rajasthan, Tamil Nadu, Gujarat, Maharashtra, Punjab and Karnataka.
“There is huge State-wise variation in the share of empanelled private hospitals from less than 25% in most of the northeastern and hill States to 80% in Maharashtra,” states the report which also notes that private hospitals have fewer beds than public hospitals and are more likely to be empanelled for surgical packages and super-specialties. They also report better infrastructure for clinical and support services than their government counterparts, although data is incomplete.
As per the data, private hospitals account for 63% of all PM-JAY claims and 75% of total claim value. It was also found that average claim size is about 80% higher in private hospitals, reflecting a different case mix. Consistent with empanelment trends, private hospital claims are more oriented towards surgical packages and tertiary care.
The data further states that claims processing appears to be more efficient in the case of private hospitals than for public hospitals. While private hospitals account for 63% of claim volume, they account for 40% of non-submitted claims (i.e., pre-authorized, neither cancelled nor rejected, but no claim forthcoming) and 43% of unpaid (outstanding) claims.
“The average claim size is ₹17,260 in private hospitals and ₹9,869 in public hospitals. This reflects the different case mix treated across the two sectors, with private hospitals providing care for a larger share of tertiary and complex cases. There is significant overlap across private and public hospitals in terms of their respective top 10 lists of most common specialties and packages by volume,” notes the data.
Previous survey evidence shows that prior to the launch of PM-JAY, patients often paid out-of- pocket for private hospital care, citing quality, trust, and availability of services as the major reasons for doing so.