NEW DELHI: An internal analysis of cancer care offered under the Centre’s big-ticket health insurance scheme Pradhan Mantri Jan Aarogya Yojana (PMJAY) has shown that the average claim size for various oncology packages is far higher — by up to 250 per cent — in private hospitals as compared to government hospitals.
This finding has raised concerns about possible over-treatment of cancer patients to make more money under the scheme through which hospitalisation benefits of up to Rs 5 lakh is given to a large number of poor patients across the country.
The assessment of oncology package utilization from September 2018, when the scheme was launched, to July this year showed that the average claim size was nearly 113-250 per cent higher in private hospitals in case of surgical procedures, 94-113 per cent higher in case of radiology and 66% higher in case of medical oncology.
Oncology comprised 9 per cent of total claims submitted, and 34 per cent of all tertiary claims submitted with two states — Tamil Nadu and Maharashtra generating 60 per cent of all oncology claims.
The variations were noticed in the proportion of average claim size across states and within the states — between public and private.
“Profit motive is a big and undeniable agenda for a large number of private hospitals and that could explain the trend,” said Pritam Datta, a fellow in health economics with the National Institute of Public Finance and Policy.
Concerned with the findings, the National Health Authority — which implements the PMJAY— has already begun talks with the National Cancer Grid to ensure that there is no under or over-treatment for the disease.
“We will soon find a way to ensure quality and standardized course of treatment under the scheme,” said a senior NHA official.
The assessment has said that the major reason for the differentials in any of the categories may reflect due to case mix -two or more packages combined and two or more packages claimed for the same beneficiaries.
“The stark variations between private and public hospitals within the states raises issues like cost of health product — covering treatment, surgeons fees, physiological care — or the provider induced demand,” the assessment has also noted.
Provider induced demand is often described as a big problem in health care that involves influencing the consumption of healthcare by medical professionals through increased procedures, more complex procedures or both.
Sukhvinder Kaur, a consultant with NHA who was a co-author of the analysis, however, said that state data needs to be examined further to draw conclusive inferences.
Sudhakar Shinde, CEO of Maharashtra State Health Authority said that standard treatment protocols were a must for cancer packages.