First analysis of moral hazard procedures finds the insurance scheme has paid for significantly more hysterectomies in the private sector in several states
First data coming in from Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PMJAY) have raised red flags about the number of hysterectomies that have happened under the scheme in the private sector.
In Chhatisgarh, Uttar Pradesh and Gujarat, the uptake of hysterectomies in the private sector under PMJAY is significantly more than what National Family Health Survey data warrants. In Chhattisgarh, 94.5% of the 3648 hysterectomies happened in the private sector – NFHS 4 data put the figure at 65%. In Gujarat 94.8% of the 1855 hysterectomies happened in private institutions – in NFHS the figure was 69.4. In Uttar Pradesh, 86.3% of the 3252 hysterectomies for which claims have been submitted under PMJAY, happened in the private sector. In NFHS the figure was 77%.
Hysterectomy, the surgical removal of the uterus, is among the most common “moral hazard” procedures in health insurance when a procedure is done not for medical reasons but because it is being paid for. Under PMJAY, hysterectomy comprised two percent of claims submitted for women; and one percent of all claims submitted till date across 24 States/UTs.
In the first such analysis of any procedure covered under the Pradhan Mantri Jan Arogya Yojana, the National Health Authority has also found that 75% of all hysterectomy claims under PM-JAY have been generated by 6 states: Chhattisgarh (21.2%); Uttar Pradesh (18.9%); Jharkhand (12.2%); Gujarat (10.8%); Maharashtra (9.0%); and Karnataka (6.6 %).
75% of all hysterectomy claims under PM-JAY have been generated by 6 states: Chhattisgarh (21.2%); Uttar Pradesh (18.9%); Jharkhand (12.2%); Gujarat (10.8%); Maharashtra (9.0%)
Just two states, Chhattisgarh and Uttar Pradesh generated 6900 of the total 17236 hysterectomy claims generated under PMJAY since its launch in September last year. In Karnataka and Maharashtra though most of the hysterectomies under PMJAY have happened in the public sector PMJAY is the tertiery care arm of Ayushman Bharat.
“Patterns of utilization for Hysterectomy: An analysis of early trends from Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY)” recommends more detailed reviews at the state level for Chhattisgarh and Uttar Pradesh hospitals. It has been authored by Sukhvinder Kaur, a consultant to the National Health Authority that is responsible for the implementation of PMJAY, Dr. Nishant Jain, a health economist based in Delhi and an advisor to the NHA and Dr. Sapna Desai is an Associate with Population Council of India.
The report documents the problematic relationship hysterectomies have had in the past with government funded insurance programmes. “Specific to health insurance, findings from Gujarat indicated that hysterectomy was the leading claim in a community-based health insurance scheme, at a mean age of 36 years. Facility-based media and fact-finding reports from Chhattisgarh, Rajasthan and Bihar highlighted medically unindicated use of the procedure, leading to additional checks on hysterectomy claims submitted under the Rashtriya Swasthya Bima Yojana,” the report says
