pm-jay: the role of private hospitals

PM-JAY Policy Brief 9: PM-JAY: The Role of Private Hospitals | 1

Authors: Di Dong, Pulkit Sehgal, Sheena Chhabra, Parul Naib and Owen SmithNovember 2020

Highlights• 56 percent of all hospitals empanelled

under PM-JAY are private, of which 50 percent are active, but these shares vary widely across states. Private hospitals have a denser network in brownfield states, but they have a smaller presence in aspirational districts than public hospitals.

• Privatehospitalshavefewerbedsthanpublic 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.

• Privatehospitalsaccountfor63percentofall PM-JAY claims and 75 percent of total claim value. Average claim size is about 80 percent 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.

• Thereissignificantoverlapacrossprivateand public hospitals in terms of their respective top 10 lists of most common specialties and packages by volume. However, the top PM-JAY packages by value – including knee replacement, cataracts, hemodialysis and cardiovascular surgeries – are overwhelmingly provided by private hospitals.

• Patientsseekingcareatprivatehospitalstend to be older, and a larger share is male than those at public hospitals.

• Differencesinaveragelengthofstayandre-admission rates between private and public hospitals may reflect a combination of factors including efficiency, quality, and case mix.

PM-JAY PolicY Brief 9

BackgroundPrivate hospitals play a central role in Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY). As this brief will show, they account for over half of empanelled hospitals, nearly two-thirds of claim volumes, and three-quarters of claim outlays. Their prominent role in PM-JAY and in earlier central and state government-sponsored health insurance schemes in India over the past 10 to 15 years has been a source of much debate.

In principle, private hospitals can add capacity for services where government hospitals are already overloaded, deliver care that has not been a traditional focus area of public hospitals, and expand supply in under-served regions. They can enhance patient choice and introduce an element of competition to publicly funded hospital care, with potentially positive impacts on access, quality, efficiency and patient satisfaction. 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.1

At the same time, the inclusion of private hospitals presents many challenges. They may attempt to increase revenues or profits by cutting corners on quality of care, admitting patients for unnecessary care, denying admission to complex cases, converting outpatient cases into inpatient, charging informal payments, or committing outright fraud. Ensuring that private hospitals can be held accountable is a major challenge for PM-JAY implementation. It is notable that private hospitals play a secondary role in most advanced health systems; instead public hospitals

1. NSSO 75th round (health).

PM-JAY: The Role of Private Hospitals

2 | PM-JAY Policy Brief 9: PM-JAY: The Role of Private Hospitals

Box 1: Methodology

Time period for the analysis: Launch of PM-JAY on September 23, 2018 to February 29, 2020.

Datasource: Claims data are from PM-JAY’s Transaction Management System (TMS) claims database. Rajasthan and Goa are excluded from analysis as their claims data is not integrated in TMS, while only some hospitals from Gujarat are reflected in TMS data. Only selected UTs are shown. Basic hospital information and empanelment status are drawn from the Hospital Empanelment Management (HEM) system.

Definitionofempanelledhospitals: Hospitals that were empanelled with PM-JAY as of February 2020 are included for analysis. In most states Primary Health Centers (PHCs) are automatically empanelled under the scheme, but as they do not typically provide care, they are excluded from the analysis. Community Health Centers (CHCs) are included.

Definitionofactivehospitals: Hospitals that are actively empanelled with PM-JAY and have submitted at least 1 claim to PM-JAY in the month of February 2020 are considered active.

Definition of PM-JAY beneficiaries: These include all families covered by PM-JAY (co-financed by the Government of India and states) and all additional “extension” families fully funded by states under their own expanded coverage initiatives.

Data limitations: A significant share of empanelled hospitals have not reported information on their infrastructure, accreditation, and specialties available in the HEM system.

predominate.2 In India, over half of all inpatient utilization occurs in the private sector.3

This policy brief offers a snapshot of the role of private hospitals during the first 18 months of PM-JAY implementation, from September 2018 to February 2020. It does not address trends during the COVID-19 pandemic, which was the focus of the preceding Policy Brief #8. The brief explores the characteristics of private hospitals empanelled under PM-JAY vis-à-vis public hospitals, total claim volume and value, the top specialties and packages provided by private vs. public hospitals, general patient characteristics, and some indicators of efficiency and quality.

Key Findings and Implications

Private hospital empanelment

There are 16,410 hospitals empanelled under PM-JAY (excluding 4,855 PHCs), of which 56 percent are private. Over 72 percent 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 hospitals that is private, from less than 25 percent in most Northeast and hill states to 80 percent in Maharashtra. This may reflect several

2. Paris, V., M. Devaux and L. Wei (2010), “Health Systems Institutional Characteristics: A Survey of 29 OECD Countries”, OECD Health Working Papers, No. 50.

3. NSSO 75th round (health).

factors, including geography, income levels (and hence profitability), availability of health personnel, private health care market structure, and different state policies towards the empanelment of public and private hospitals.

Private hospitals account for 61 percent of the total in brownfield states (i.e., those with long-standing state insurance schemes preceding the launch of PM-JAY – Andhra Pradesh, Assam, Chhattisgarh, Gujarat, Karnataka, Kerala, Maharashtra, Rajasthan and Tamil Nadu) compared to 51 percent in greenfield states (those without extensive previous experience managing insurance schemes). In terms of density, there are 1.7 private hospitals and 1.1 public hospitals per 1 lakh beneficiaries in brownfield states. In greenfield states, the density is very similar (1.5 private vs. 1.4 public per 1 lakh beneficiaries). While empanelled private hospitals outnumber public ones on a pan-India basis, the opposite is true in the 91 aspirational (lagging) districts where PM-JAY is implemented. About 9 percent of all empanelled private hospitals are located in aspirational districts, compared to 13 percent of public hospitals.

Overall, empanelled private hospitals are more active than public ones. During February 2020, 50 percent of all private empanelled hospitals were active (submitting at least one claim during the month), while 45 percent of public hospitals were active. In 16 of 23 states, private hospitals were more active than public ones, although public hospitals are slightly more active in aspirational districts. The reasons why


hospitals are empanelled but not active have not been systematically analyzed, but they likely extend beyond an absence of footfall by eligible patients. Other reasons may include facing pressure to empanel during the scheme launch phase despite a lack of interest to participate, robust performance with self-paying patients alone, concerns about the adequacy of package rates and the timeliness of reimbursement, or an unwillingness to accede to greater government oversight of hospital operations.

Private hospitals are relatively small, with over 77 percent reporting 50 or fewer beds and 44 percent with fewer than 25 beds. By contrast, the corresponding figures for public hospitals are 62 percent and 18 percent. A majority of empanelled hospitals with over 100 beds are in the public sector. It should be noted, however, that fewer than half of all empanelled hospitals have reported their bed capacity in the HEM database.

Figure 1: Wide state-wise variation in private hospital shares

Figure 2: Private hospitals have fewer beds

437

1,09

8

1,15

7

498 190 100

135

127

646

216

153 188

PublicPrivate

0

Num

ber

of e

mp

anel

led

hos

pita

ls

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

Bed distribution

11-25 26-50 51-100 101-250 251+1-10

0%3%

5%9%

14%15%

23%24%24%24%

31%37%

47%47%47%48%48%

51%52%

56%59%

64%64%

65%66%67%68%68%

80%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

LadakhTripura

Arunachal PradeshSikkim

ManipurJammu & Kashmir

NagalandMeghalaya

MizoramMadhya Pradesh

Himachal PradeshUttarakhandChhattisgarh

KarnatakaBihar

Tamil NaduPuducherry

AssamKerala

IndiaUttar Pradesh

JharkhandChandigarh

GujaratAndhra Pradesh

PunjabRajasthan

HaryanaMaharashtra

Empanelled private hospitals as % of total


Figure 4: Private hospitals are the main providers of super-specialty care

Over 60 percent of empanelled public and private hospitals provide both medical and surgical packages under PM-JAY. However, private hospitals are more likely to offer surgical packages only, whereas public hospitals are more likely to offer medical packages only (Figure 3). Private hospitals also predominate among super-specialties such as cardiology, cardiothoracic and vascular surgery (CTVS), neurosurgery, plastic surgery, and surgical oncology. For all these specialties, private hospitals account for at least two-thirds of hospitals empanelled to offer such care (Figure 4). Private hospitals are more likely to empanel as multi-specialty facilities than public hospitals (79 percent vs. 69 percent). These patterns reflect in part the large number of CHCs empanelled.

Private hospitals appear to account for a disproportionate share of hospitals with better clinical and support services capacity. While they account for 56 percent of empanelled hospitals, private hospitals account for over 80 percent of those reporting an operating theater or intensive care unit, and over two-thirds of those reporting a blood bank, radiology diagnostic centers, clinical labs, and other services. However, the quality of empanelment data reported by public hospitals might distort this picture. Lastly, the share of private hospitals that are accredited (26 percent) is double that of the public sector (13 percent). The most common accreditation body is the National Accreditation Board for Hospitals (NABH), whereas a small number of hospitals are accredited by Joint Commission International (JCI).

Volume and Value

Almost 63 percent of PM-JAY’s total claim volume up to February 2020 can be attributed to private hospitals, with huge variation across states in this share (Figure 5). Private hospitals account for over three-quarters of PM-JAY’s claims in Jharkhand,

Gujarat, Haryana, Uttar Pradesh, Maharashtra, and Chhattisgarh. In contrast, private hospitals are less active and account for less than one-quarter of claims in Kerala (which has a strong public sector), Karnataka (which requires public referrals to private hospitals), Himachal Pradesh and four Northeastern states (where private hospitals are relatively few).

In financial terms, 75 percent of PM-JAY’s total claim value is reimbursed to private hospitals, amounting to INR 10,680 crores, compared to INR 3,600 crores disbursed to public hospitals (Figure 6 and Table 1). Again, significant state-wise variation is evident. In several states – both brownfield and greenfield – over 75 percent of the total claim value is paid to private hospitals. Meanwhile, 7 of the lowest 8 states in terms of the private hospital share of total claim value are special category states.

Private hospitals are more prominent in brownfield states, which account for over 80 percent of total private hospital claim volume and value under PM-JAY. In fact, 19 of the top 20 private hospitals by claim

Figure 3: Most private hospitals are empanelled for surgical packages

0%

100%

Private Public

% o

f tot

al e

mp

anel

led

hos

pita

ls

5%

28%

67%

25%

13%

62%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Medical only Surgical only Both

PublicPrivate

0%% o

f hos

pita

ls e

mpa

nelle

d fo

r sp

ecia

lty

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

75%

25%

Cardiology

82%

18%

Neurosurgery

66%

34%

Cardio-thoracic &

vascular surgery

79%

21%

Plastic & reconstructive

surgery

48%

52%

Radiationoncology

75%

25%

Surgicaloncology


Figure 5: Wide variation in the private share of total claim volume across states

value are empanelled by just two states, Gujarat and Tamil Nadu. The smaller presence of private hospitals in the more lagging states and districts of the country poses a challenge to ensuring that the benefits of PM-JAY can be spread broadly.

The average claim size is INR 17,260 in private hospitals and INR 9,869 in public hospitals (Table 1). 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.

Figure 6: Wide variation in the private share of total claim value across states

0% 10% 20% 30% 40% 50% 60% 70% 80% 100%90%

Private hospital share of total claim volume

0%1%

6%14%

21%21%

24%28%

35%35%

37%42%

48%49%49%49%

52%63%64%

65%72%

77%79%79%

80%82%

88%

Arunachal PradeshTripura

MizoramHimachal Pradesh

SikkimKarnataka

KeralaChandigarh

ManipurAssam

Madhya PradeshBihar

NagalandPunjab

MeghalayaTamil Nadu

UttarakhandIndia

PuducherryJammu & Kashmir

Andhra PradeshChhattisgarhMaharashtra

Uttar PradeshHaryanaGujarat

Jharkhand

0% 10% 20% 30% 40% 50% 60% 70% 80% 100%90%

Private hospital share of total claim value

TripuraMizoram

Himachal PradeshKerala

ManipurSikkimAssam

Jammu & KashmirBihar

NagalandUttarakhand

MeghalayaKarnataka

Madhya PradeshPunjab

Tamil NaduIndia

Uttar PradeshAndhra Pradesh

MaharashtraChhattisgarh

HaryanaGujarat

Jharkhand

6%10%

15%23%

30%31%

32%42%43%

53%57%

61%61%

64%68%

70%75%

78%79%

82%83%

84%86%

92%


Packages and Patients

A closer look at claims data for private hospitals reveals several differences from their public counterparts. First, private hospitals focus more on surgical than medical packages. Almost two-thirds of private hospital claims are for surgical packages, compared to less than half for public hospitals (Figure 7). In financial terms, 77 percent of private hospital claim value is for surgical packages, compared to 66 percent in public hospitals. Second, private hospitals are more strongly oriented towards tertiary care, which accounts for 51 percent of private claim volume and

75 percent of claim value. At public hospitals, only 36 percent of claim volume and 56 percent of claim value is associated with tertiary care packages. These patterns are consistent with the empanelment profiles shown above.

There is significant overlap between private and public hospitals in terms of top specialties and packages. 8 of the top 10 specialties by claim volume are common across private and public hospitals, and 5 of the top 10 packages by volume are common across both sectors (Figures 8 & 9)4. However, the private share in the top 10 packages by volume

Table 1: Private hospitals have higher claim volume, claim value and average claim amount

Private Public Total

Total number of claims 61,91,945 36,60,082 98,52,027

Total claim value (INR crore) 10,687 3,612 14,299

Average claim amount (INR) 17,260 9,869 14,514

Figure 7: Private hospital claims are more oriented towards surgical packages and tertiary care

Figure 8: Significant overlap in top 10 specialties by volume in private and public hospitals

Medical Surgical

0%

100%

Private Public

% o

f cla

im v

olum

e

20%

40%

60%

80%

36%54%

64%46%

Secondary care Tertiary care

0%

100%

Private Public

% o

f cla

im v

olum

e

20%

40%

60%

80%

49%64%

51%36%

Unspecified Speciality

non-common top public packages

Pediatric Medical Management

Cardiology

OPD Diagnostics

Orthopaedics

Urology

Medical Oncology

General Surgery

Obstetrics & Gynecology

General Medicine

Otorhinolaryngology

Obstetrics &Gynecology

Orthopaedics

Unspecified Speciality

Ophthalmology

Cardiology

Medical Oncology

General Medicine

General Surgery

Urology

58,090

187,077

331,025

392,212

472,674

618,328

499,570

808,404

938,616

1,059,802

85,565

114,219

131,908

140,642

197,897

288,304

234,999

368,240

357,579

1,080,266

non-common top private packages

0

200,

000

400,

000

600,

000

800,

000

1,00

0,00

0

1,20

0,00

0

Private hospitals - claims volume

0

200,

000

400,

000

600,

000

800,

000

1,00

0,00

0

1,20

0,00

0

Public hospitals - claims volume

4. Note that hemodialysis is booked under different specializations by different states (general medicine, general surgery, or urology).


varies significantly, reflecting different specializations (Figure 10). For some, like cataract, PTCA/single stent, and hemodialysis, the private sector accounts for over 75 percent of total volume, indicating that patients are opting for the private sector for those services, possibly due to the weak public hospital capacity in these areas or better perceived quality in the private sector. For other packages, such as treating acute febrile illness, acute gastrointestinal illness, or tubectomy, about three-quarters of the volume is delivered in the public sector. For these packages the private sector is providing moderately more capacity for services that have been the traditional focus area of India’s government hospital system. In the case

of C-sections, the larger role played by the public sector in part reflects widespread state policies that exclusively reserve these packages for public hospitals, arising from concerns that private hospitals may abuse these packages.

In terms of claim value, 9 of the top 10 specialties are common across both private and public sectors, with the exceptions being that the private sector generates significant revenues from ophthalmology, while the public sector does the same for obstetrics and gynecology services. Meanwhile 5 of the top 10 packages by value are common across private and public sectors, of which three are various types of

Figure 9: Some overlap in top 10 packages by volume in private and public hospitals

Figure 10: Large differences in public/private shares among top 10 packages by volume

Cataract

Enteric Fever

PalliativeChemotherapy

Caesarian Delivery

Hemodialysis

35,469

38,654

47,049

50,795

61,708

71,886

150,004

177,682

350,259

2,134,832

0

500,

000

1,00

0,00

0

1,50

0,00

0

2,00

0,00

0

2,50

0,00

0

PTCA - AdditionalStent

PET Study

PTCA - 2 Stent

Fracture - HipInternal Fixation

PTCA - Single Stent

54,075

55,738

56,369

59,708

66,945

78,655

84,168

98,552

142,315

714,314

0

100,

000

200,

000

300,

000

400,

000

500,

000

600,

000

700,

000

800,

000

AcuteGastroenteritis

Cataract

MRI

Enteric Fever

ConventionalTubectomy

Acute FebrileIllness

Normal Delivery


Caesarian Delivery

Hemodialysis

non-common top public packagesnon-common top private packagesPrivate hospitals - claims volume Public hospitals - claims volume

PublicPrivate

0%

% o

f cla

im v

olum

e

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

86%

14%

86%

14%

82%

18%

75%

25%

64%

36%

43%

57%

31%

67%

27%

73%

22%

78%

25%

75%

Cataract Fracture -Hip Internal

Fixation

PTCA -Single Stent

Hemodialysis PalliativeChemotherapy

EntericFever

CaesarianDelivery

Acute FebrileIllness

ConventionalTubectomy

AcuteGastroenteritis


PTCA/stents, and the others are bypass operations (CABG) and hemodialysis (Figure 11). Knee and hip surgeries are among the top 10 procedures by value in the private sector that do not appear on the public hospital top 10 list. Unlike in the case of claim volumes, where several of the top 10 packages were mainly provided by public hospitals, the top 10 packages by claim value are all overwhelmingly (at least 75 percent) provided by private hospitals (Figure 12).

Private and public shares for the same specialization vary across states (Figure 13). General medicine and OB/GYN are mostly public, but reach almost 80 percent or more at private hospitals in some states. General surgery, urology, medical oncology and cardiology are mostly private, but in outlier states

private hospitals account for less than one-third of such claims.

On the patient side, there are differences in the profiles of those seeking care in the private and public sectors. Average patient age in private hospitals (48 years old) is higher than those in public hospitals (42 years old), in part because childbirth is more common in (and often reserved for) government hospitals. But even excluding deliveries, men are still more likely to use private hospitals than women. This could reflect differences in disease burden, benefit package design, or social barriers impeding access by women.

When patients seek care outside their home district or home state, they are more likely to be admitted

Figure 12: Top packages by claim value are overwhelmingly delivered by private hospitals

Figure 11: Some overlap in top 10 packages by value in private and public hospitals

215

221

231

261

290

338

512

531

879

1,052

0 200 400 600 800 1,000 1,200

Cataract

Primary KneeReplacement

RAPIDARC/VMAT

CABG

PTCA -Single Stent

PTCA - 2 Stent

PTCA -Additional Stent

Fracture - HipInternal Fixation

Total KneeReplacement

0 50 100 150 200 250

PTCA -Single Stent

38

42

48

53

62

102

119

126

203

210

Open Reduction InternalFixation (Large Bone)

Mitral Valve Replacement(Mechanical Valve)


CABG

Normal Delivery

Caesarian Delivery

Hemodialysis

PTCA - 2 Stent

PTCA -Additional Stent

Hemodialysis

non-common top public packagesnon-common top private packagesTop packages in private hospitals (claim value wise) Top packages in public hospitals (claim value wise)

PublicPrivate

0%

% o

f cla

im v

alue

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

98%

2%

96%

4%

91%

9%

90%

10%

89%

11%

86%

14%

83%

17%

82%

18%

81%

19%

75%

25%

PrimaryKnee

Replacement

RAPIDARC/VMAT

Cataract Total KneeReplacement

CABG Fracture -Hip Internal

Fixation

PTCA -Single Stent

PTCA - 2Stent

Hemodialysis PTCA -Additional

Stent


Figure 13: Wide variation in private hospital share of claim volumes across states

General Medicine General Surgery

Urology Medical Oncology

Obstetrics and Gynecology Cardiology

Note: Percentages denote the share of claim volumes at private hospitals; states above 50 percent are shaded in blue, states below 50 percent are shaded in green.


to public hospitals. While 64 percent of within-district claims and 60 percent of within-state claims are from private hospitals, only 47 percent of inter-state portability cases are from private hospitals (Figure 14). This partly reflects the prominent role of national health care providers (centers of excellence directly empanelled by NHA, most of which are large government hospitals) in inter-state portability.

Efficiency and Quality

Private hospitals have stronger incentives to keep costs low and generate additional revenues compared

5. While government hospitals retain some if not all insurance revenues (some states retain a portion for other purposes), there are typically limits on the share that can be allocated to staff performance incentives and there are some oversight mechanisms to monitor how claims are used.

to public hospitals.5 Hospitals are paid all-inclusive package rates per admission for surgical cases, and per-diem rates for medical cases (up to a package-wise limit). The incentive for surgical cases is therefore to minimize costs (and thus perhaps quality) but also potentially to re-admit patients. For medical cases, the incentive is to extend the length of stay. Overall private hospitals have a slightly longer length of stay (7.7 days vs. 7.3 days at public hospitals), but with significant variation by package type. Consistent with the incentive structure, private hospitals have longer Average length of stay (ALOS) for medical packages but shorter for surgical packages (Figure 15).

Figure 15: Average length of stay is longer in private hospitals for medical cases, but shorter for surgical cases

PublicPrivate

0

Ave

rag

e le

ngth

of s

tay

(day

s)

2

4

6

8

109.0

6.2

7.1

8.7

Medical Surgical

Figure 14: Patients are more likely to cross borders for public hospital care

PublicPrivate

0%

% o

f tot

al c

laim

s

64%

36%

60%

40%

47%

53%

20%

40%

60%

80%

100%

Same district Different stateSame state,different district


However, an important caveat is that the case mix of private and public hospitals is quite different, requiring closer analysis before drawing any conclusions. In general, differences in ALOS may reflect either efficiency or quality considerations, and it can be difficult to unpack the two.

Medical audits have 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.

An earlier Policy Brief #7 assessed two indicators of quality of care, readmission rates and in-hospital mortality. It found that both 7-day and 30-day re-admission rates were slightly higher at private hospitals, although case mix could be one factor (i.e., different patient profiles, packages, severity) (Figure 16). But in-hospital mortality, a rare event, was slightly higher in the public sector.

Claims processing appears to be more efficient in the case of private hospitals than for public hospitals. While private hospitals account for 63 percent of claim volume, they account for 40 percent of non-submitted claims (i.e., pre-authorized, neither cancelled nor rejected, but no claim forthcoming) and 43 percent of unpaid (outstanding) claims. The latter figure could reflect better documentation by private hospitals, or a perception by insurers and Third-Party Administrators (TPAs) that government hospitals are an easier target for claim denial. The average time for pre-authorization

approval is also faster for private hospitals (22 hours) than for public hospitals (51 hours). However, claim payment timelines are very similar (33 days for private vs. 35 days for public).

Summary

Private hospitals are front and center in PM-JAY implementation, as shown by their higher numbers for empanelment, claim volume and claim value compared to public hospitals. While their prominence varies widely across the country, in general they are adding significant additional capacity for specialties and packages offered by government hospitals as well as extending supply into specialties and packages traditionally neglected by the public hospital network. This is particularly true for tertiary care. However, private hospitals are making a smaller contribution in terms of extending the geographic reach of PM-JAY to underserved areas. 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. But the levers of strategic purchasing – including package pricing, benefit package design, quality metrics, beneficiary empowerment, incentives for new supply, and many other areas – will also be critical. Future research into these specific topics can play a valuable role.

Figure 16: Readmission rates are similar across private and public hospitals, while the in-hospital mortality rate is higher in the public sector

PublicPrivate

7-day 30-day

Rea

dm

issi

on r

ate

(%)

Private Public

In-h

osp

ital m

orta

lity

rate

(%

)

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

2.5%

5.2%

2.1%

5.0%

0.0%

0.1%

0.2%

0.3%

0.4%

0.5%

0.6%

0.7%

0.8%

0.5%

0.7%


References:

1. National Sample Survey Office (NSSO) 75th round survey (health), 2017-18.

2. Paris, V., M. Devaux and L. Wei (2010), “Health Systems Institutional Characteristics: A Survey of 29 OECD Countries”, OECD Health Working Papers, No. 50.

3. National Sample Survey Office (NSSO) 75th round survey (health), 2017-18.

Disclaimer:

The findings, interpretations, and conclusions expressed in the policy brief are entirely those of the authors, and do not represent the views of any author’s employer, official policy or position of any agency of the National Health Authority (NHA). The PM-JAY data used in the analysis should not be utilized/quoted without prior permission of NHA.

Acknowledgements:

We acknowledge with gratitude the contribution and support extended by NHA colleagues for providing the required procedure-level data from PM-JAY data warehouse. We also gratefully acknowledge the inputs of the monitoring and research team in helping to provide the data for the analysis. Special thanks to CEO, Additional CEO and Deputy CEO at NHA for their overall strategic guidance and facilitating the necessary approvals.

List of PM-JAY Policy Briefs Published so far:

1. Raising the Bar: Analysis of PM-JAY High-Value Claims (July 2019).

2. PM-JAY Across India’s States: Need and Utilization (September 2019).

3. PM-JAYandIndia’sAspirationalDistricts (September 2019).

4. Supply Side Response to Insurance Expansion: Evidence from RSBY/MSBY in Chhattisgarh (October 2019).

5. PM-JAY Without Borders: Analysis of Portability Services (February 2020).

6. Empowering Government Hospitals: The Potential of Insurance (May 2020).

7. Quality of Care in PM-JAY: A First Look at Unplanned Readmissions and Mortality (May 2020).

8. PM-JAY Under Lockdown: Evidence on Utilization Trends (June 2020).

9. PM-JAY: The Role of Private Hospitals (November 2020).

pm-jay: the role of private hospitals

Documents