A new model of care and insurance has started working in the US. Accountable Care Organisations (ACOs) are a group of doctors, hospitals and other care providers that together manage care of a group of patients.
By Sujata Saunik &
India has embarked on a major re-hauling of its publicly-funded health system. It includes, at the top, development of new AIIMS, renovations and expansion of old medical colleges, and at the bottom conversion of health sub-centres to health and wellness centres. There is also major health insurance upgrade via Ayushman Bharat National Health Protection Scheme. Finally, the government is getting serious in improving the health of the population. But, in this process, we need to learn from various models in the world.
A new model of care and insurance has started working in the US. Accountable Care Organisations (ACOs) are a group of doctors, hospitals and other care providers that together manage care of a group of patients. The ACO system works at the community health centre level and is designed for helping patients manage their illnesses and reduce healthcare costs by preventing and reducing unnecessary and preventable admissions to a hospital.
In the ACO model, the doctor and health insurance plan managers talk to each other to help coordinate the patient’s care for them. It is a payment mechanism that allows for quality care to be given to the people for their healthcare needs in a combination of public and private healthcare insurance plans. Support and guidance is also provided to patients for enrolling into a healthcare plan if they are uncovered. In addition, the ACO model works on health package integration to assist in helping patients get access to integrated behavioural health and substance use services in the primary care setting. Patients requiring high-grade medical or surgical treatment are assisted with quick referrals to nearby hospitals. Often, the ACO model in a community health centre does not have in-patient services, although it works seven days a week with reduced hours during the weekends.
All Medicare (the US national health insurance programme for Americans aged 65 and over and young people with end-stage diseases, funded by a combination of payroll tax, premiums and surtaxes from beneficiaries) and Medicaid patients (low-income families, pregnant women, people with disabilities and elderly requiring nursing care) are covered by the local community health centre under the ACO model. This is the main driver of the fund flow to the centre. The integrated healthcare model also helps provide support to patients for alcohol, tobacco and substance abuse. A range of services, including lab tests, primary medical care, geriatric care, nutrition, dental and ophthalmic care with shorter waiting periods helps people to visit community healthcare centres and receive expert advice, drugs and vaccines without having to visit the nearest hospital for minor ailments. There could be lessons from the ACO model in the US for the Indian public healthcare system reform.
India’s public healthcare system provides free medical consultation, basic lab tests, free drugs and vaccines and referral when needed. Hence this system should be strengthened. Free provision of medical consultation, tests and drugs and routine immunisation should form the main plank of the wellness centre programme. It should be supplemented by screening for blood pressure, diabetes and risk factors for heart diseases such as lipid levels in blood. Screening for cancer, kidney diseases and eye problems should be also added in the public healthcare system.
There should be integration of primary healthcare services under one roof, with AYUSH, as these services are non-invasive and popular with communities, along with the facility for rapid referral to hospitals when needed for high-level care. This may work very well for the population covered under each such centre. State-run insurance schemes can provide a gateway by helping advise people on their benefit packages, which are already being planned under NHPS.
Several sub-centres staffed by auxiliary nurse midwife (ANMs) are the primary maternal and child care service delivery centres in rural India. These ANMs can be equipped with staff, facilities such as freezers for vaccine, and a full drug dispensation pharmacy including AYUSH medicines to start running wellness centres in the ACO model. The government is already planning to put a community health officer in each health and wellness centre.
Another unique feature could be making this community centre the hub for people to get information of all social sector welfare schemes. Community workers involved in various schemes could come together on a fixed day or two each week and provide information and paperwork support to the intended beneficiaries.
This is an unique opportunity for India to leapfrog to a new healthcare delivery model and move towards universal health coverage, provided the scheme is designed well to have an array of services under one roof, empathy and respect for the patient, a payment model for fund flow, community outreach and quality care delivery. It is unrealistic to expect doctors to be everywhere and work round the clock, and for people to pay nothing for quality healthcare. For this model to be sustainable there should be a system of enrolment based on income criteria, linked to ration/Aadhaar cards, and provided free to low incomes groups but with co-payments for the rest.
One of the ways to link the primary care system and NHPS could be to make each sub-health centre and public health centre the registration point for NHPS. One can also make a medical examination mandatory before enrolling in NHPS so that many problems can be detected early and treated under NHPS. It will also help establish a referral system for NHPS and a link in the minds of the people that they have to go first to the public healthcare system to get benefits of NHPS. Such gatekeeping can reduce the cost by promoting prevention and reducing fraud.
Saunik, an IAS, is Takemi fellow at Harvard University; Mavalankar is director, IIPHG. Views are personal