Ophthalmology in Ayushman Bharat

Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) was launched in 2018. It is the world’s largest tax-funded health insurance scheme and is jointly financed by the Central and State governments. It covers the lower socioeconomic strata with cashless hospitalization of up to ₹500,000 per year for a family.

PM-JAY is also aiming toward value-based care, which rewards providers for improving their patients’ health outcomes. Since 2018, PM-JAY has empanelled approximately 25,000 hospitals and covered approximately 50 crore beneficiaries. The scheme has spent ₹45,000 crores (450 billion rupees) in the past 4 years, covering top conditions such as heart diseases, tuberculosis, chronic kidney, and lung diseases.

Among the 800,000 ophthalmology-related claims submitted to PM-JAY from 2018 to 2022. The amount re-imbursed for ophthalmology was approximately ₹457 crores (4.5 billion rupees), which is only 1% of the overall amount spent in PM-JAY. More than 98% of ophthalmology reimbursements were for cataract procedures. During the same period, cardiology-related procedures were approximately 700,000 and the amount reimbursed was approximately ₹4000 crores (40 billion rupees).

Jharkhand as a state has 345 eye care specialists registered with the All India Ophthalmological Society (AIOS), which is <2% of the total number of registered ophthalmologists in India. However, Jharkhand performed the maximum number of ophthalmology-related procedures in PM-JAY, claiming more than 20% of the revenue spent on ophthalmology in PM-JAY. Maharashtra has almost 10% of registered ophthalmologists in AIOS, but claimed <1% of the PM-JAY reimbursements. This disparity of unequal utilization of the largest health insurance scheme, and there is a significant scope of improvement among various states.

While cataract is usually the top eye care procedure performed in all hospitals, PM-JAY covers more than 50 eye care procedures. There are close to 2000 packages in the latest PM-JAY list of procedures for all specialties. Cataract surgery is among the top reimbursed procedures by volume among all specialties. Ophthalmologists should be made aware of the opportunities available under the AB PM-JAY and claim for procedures other than cataract surgery.

Value-based health care focuses on the value delivered to patients by measuring outcomes that matter to patients, such as the quality of life and the reduction of disease burden. This approach requires collaboration between health-care providers, payers, and patients to align incentives, improve quality, and reduce costs. Value-based care is gaining increasing attention in recent years as health-care costs have raised, and there is a growing recognition that health-care outcomes are not always aligned with the amount of money spent. There is a strong need to evolve standard treatment guidelines though professional bodies such as AIOS which can be used to improve and monitor the quality of health outcomes, given the increase in spending on health care by the government. Ophthalmological societies should continuously strive to include novel procedures which are cost-effective to be included in the health benefit packages of AB PM-JAY, as well as provide rationale for price revision of certain procedures based on health economics evaluation. The AB PM-JAY scheme presents an opportunity for health-care providers to focus on the quality of health services rendered and improve health outcomes of our patients.