The trust and insurance models of healthcare purchasing in the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana in India: early findings from case studies of two states.

BACKGROUND: The Pradhan Mantri Jan Arogya Yojana (PMJAY), a publicly funded health insurance scheme for the poor in India, was launched in 2018. Early experiences of states with various purchasing arrangements can provide valuable insights for its future performance. We sought to understand the institutional agencies and performance of the trust and insurance models of purchasing with respect to; a) Provider contracting b) Claim management c) Implementation costs. METHODS: A mixed methods case study design was adopted. Two states, Uttar Pradesh (representing a trust model) and Jharkhand (representing the insurance model) were purposively selected. Data sources included document reviews, key informant interviews, quantitative scheme data from the provider empanelment and claims database, and primary data on costs. Descriptive statistics were reported for quantitative data, content analysis was used for thematic reporting of qualitative data. RESULTS: In both models, the state was the final authority on empanelment decisions, with no significant influence of the insurance company. Private hospitals constituted the majority of empanelled providers, with wide variations in district-wise distribution of bed capacities in both states. The urgency of completing empanelment in the early days of the scheme created the need for both states to re-review hospitals and de-empanel those not meeting requirements. Very few quality- accredited private hospitals were empaneled. The trust displayed more oversight of support agencies for claim management, longer processing times, a higher claim rejection rate and numbers of queries raised, as compared to the insurance model. Support agencies in both states faced challenges in assessing the clinical decisions of hospitals. Cost-effectiveness showed mixed results; the trust cost less than the insurance model per beneficiary enrolled, but more per claim generated. CONCLUSIONS: Efforts are required to enable a better distribution and ensure quality of care in empanelled hospitals. The adoption of standard treatment guidelines is needed to support hospitals and implementing agencies in better claim management. The oversight of agencies through enforcement of contracts remains vital in both models. Assessing the comparative performance of trusts and insurance companies in more states at later stages of scheme implementation, would be further useful to determine their cost-effectiveness as purchasers.

Credentials That Matter While Selecting a Surgeon for Major Surgical Treatment.

Purpose: The credentials of surgeons, which include elements such as medical degree and length of practice, are vital information that forms a perception of their expertise in the patients' minds. The specific credentials that matter to patients and how important they are have not been sufficiently studied. The objective of this study was to assess the relative importance that patients assign to the specific credentials of a surgeon while selecting one for surgical treatment. Methods: This study was conducted using the constant-variable-value vignette (CVVV) method. Four credentials- medical degrees, duration of practice, medical college attended, and type of surgeries performed - were assessed for their relative importance to patients. The participants were provided with vignettes of medical situations that required major surgical intervention and profiles of surgeons who could perform the required surgery, each dominating the others in a specific credential. The participants allocated a total of 10 points across the four surgeons proportionate to their preferences. The response data were analyzed using descriptive statistics, ANOVA and t-tests. Results: The highest mean score of 3.73 (SD 2.21) was observed for the surgeon with focused experience, followed by 2.55 (1.57) for the surgeon with the best medical degrees, 2.17 (1.65) for the surgeon with the longest practice experience, and 1.54 (1.47) for the surgeon from a higher-ranked medical college. The mean of the surgeon with focused experience was significantly higher than that of other surgeons, and the mean of the surgeon with the best medical degrees was significantly higher than that of surgeons with the longest practice experience and the surgeon from the topmost medical college (p < 0.05). Preference did not vary with respondents' age or gender. Conclusion: Patients seem to prioritize the focused surgical experience and superior medical degrees in their selection of surgeons.