As govt hospitals battle Covid, ‘Modicare’ business shifts to private sector

Analysis of govt data since February shows that the share of pvt hospitals in PM-JAY claims has increased as govt facilities shoulder maximum burden of Covid pandemic.

Representational image | Praveen Jain | ThePrint

New Delhi: Two months of unlocking have brought the use of the Pradhan Mantri Jan Arogya Yojana (PM-JAY) to pre-lockdown levels in most states, but with a twist. With government facilities caught up in Covid care, the share of private hospitals in PM-JAY claims is significantly higher in most states. 

PM-JAY is the government’s flagship medical insurance scheme. It is the secondary and tertiary care arm of Ayushman Bharat, also known as Modicare, under which the government aims to provide an annual health cover of Rs 5 lakh per year to 10.74 crore families that form the bottom 40 per cent of India’s population.

An analysis done last month by the National Health Authority (NHA), which is the implementing agency for PM-JAY, found that hospitals empanelled under the scheme have recovered 77 per cent of their pre-Covid business. However, while the recovery stands at 99 per cent for private hospitals, it is 63 per cent for government facilities. 

ThePrint looked at state-wise PM-JAY use data for the last six months and found that the share of claims from private hospitals has registered an increase since pre-Covid levels. 

In Tamil Nadu, PM-JAY claims from the private sector rose to 68 per cent in July as compared to 42 per cent pre-lockdown (in February). In Madhya Pradesh, the share has gone up to 63 per cent from 41 per cent and, in Bihar, to 67 per cent from 48 per cent. While the extent of the surge varies from 26 percentage points in Tamil Nadu to 2 percentage points in Gujarat, there has been an upward trend across the country.

Speaking to ThePrint, NHA sources said some of these numbers are because of the easy empanelment module launched during the lockdown to ensure that people do not miss out on necessary non-Covid hospital care.

Under the module, hospitals could request for temporary empanelment — that is, registration under PM-JAY — with minimum details and documents. 

However, the sources noted that the most important hurdle in the recovery of the public sector is the fact that the majority of government hospitals are still grappling with Covid care.

How the numbers stack up

In February, 68 per cent of the 98,260 claims from Gujarat were from private hospitals. In July, the number stood at 70 per cent of 96,136 claims. In Kerala, the share of claims from private hospitals rose to 25 per cent of 70,484, from 23 per cent of 90,591. Government hospital claims fell to 52,863 in July from 69,755 in February.

“Merely looking at the percentages will not give the exact picture of lower uptake in government hospitals,” said an NHA official. “You have to also look at it in the context of the fall in absolute numbers, and the fact that even a 5 per cent rise in private sector usage has implications. For example, if the ratio has changed from 50-50 to 45-55, that difference is significant,” the official added. 

The official then cited the NHA’s July assessment of business recovery to explain the possible implications. “Last month, we did an analysis over a two-week window of recovery and found that private sector is at 99 per cent of pre-Covid level but government sector is just at 63 per cent.”

In Tamil Nadu, the recovery has been over 100 per cent for private hospitals, with the number of claims rising (in absolute numbers) to 46,584 in July from 31,978 in February. 

In Madhya Pradesh, the number of claims from government hospitals has slipped to 11,244 from 18,621.

A drop after lockdown kicked in

In the initial lockdown months, almost all states saw dramatic drops in PM-JAY claims. 

Karnataka was down from 79,595 claims in February to 27,173 in April. Of the February claims, 12 per cent were from the private sector. Of the 37,561 claims in July, 21 per cent were from the private sector.

Punjab is an outlier in the sense that PM-JAY claims were higher in July (47,783, or 61 per cent, from the private sector) than in February (33,975 claims, or 55 per cent, from the private sector).

“While the absolute numbers may not be high there, some of the states where private sector usage has gone up noticeably, are the northeastern states, where update of the easy enrolment was also high,” said the aforementioned NHA officer. “In some NE states, the usage in the private sector has doubled, others have posted over 100 per cent recovery.” 

Bihar lags

PM-JAY numbers in Bihar have not recovered from the Covid blow. In February, there were 15,056 claims from the state, of which 48 per cent were from the private sector. July saw 4,913 claims, of which 67 per cent were from the private sector. 

The continued slump has caused concern and the NHA has had discussions with state officials to understand the problem.

“In Bihar, facilities are not opening up — neither government nor private. Some private facilities have opened now, but from what we understand, that is still just about a third of the pre-Covid numbers,” said the official quoted above. “Right at the beginning, in April, everything shut down there, whether that was fear or concern about cash flows, it is difficult to understand,” the official added. “But even now things are not picking up.”