Study Reveals High Out-of-Pocket Spending for Patients Using Ayushman Bharat Scheme in Private Hospitals

Patients availing treatment at private healthcare facilities under the Pradhan Mantri Jan Arogya Yojana continue to spend substantial amounts from their own pockets despite being insured, according to a recent assessment commissioned by NITI Aayog.

The report indicates that beneficiaries admitted to private hospitals under the scheme paid an average out-of-pocket expense of ₹53,965 for each hospital stay, primarily towards medicines, transportation and diagnostic tests.

The evaluation was carried out by IQVIA Consulting and Information Services India Pvt Ltd and was submitted to the Development Monitoring and Evaluation Office of NITI Aayog.

The comprehensive review examined multiple centrally sponsored health initiatives implemented across the country, including the flagship PM-JAY programme.

The findings gain added importance as the central government is currently reviewing the performance of several welfare schemes ahead of decisions regarding their continuation during the financial period recommended by the forthcoming 16th Finance Commission, beginning April 1, 2026.

Queries seeking responses from NITI Aayog and the Ministry of Health and Family Welfare did not receive any immediate reply.

According to the report, researchers conducted a detailed survey covering 2,283 households across 13 states and Union Territories.

Among these families, 1,489 households — representing about 65 per cent — were enrolled in some form of health insurance coverage, while the remaining 794 households, accounting for roughly 3 per cent, had no insurance protection.

Among the insured households, the majority — 1,380 families — were covered under government-backed health insurance programmes.

In contrast, only 81 households, roughly five per cent of the insured group, were enrolled in privately purchased health insurance policies.

Within the government-sponsored schemes, the largest group of beneficiaries — 1,156 households — were covered under PMJAY.

The survey further revealed that during the past five years, 1,201 members from the surveyed households required hospitalisation, accounting for approximately 23 per cent of the individuals included in the study.

The report highlights that about 3 per cent of PMJAY beneficiaries did not spend any money from their own pockets during hospital treatment.

However, the remaining 65 per cent reported having to bear expenses related to medicines, transport to healthcare facilities and diagnostic investigations.

The financial burden was considerably higher for patients treated in private hospitals.

On average, beneficiaries admitted to private healthcare institutions under the PMJAY programme paid ₹53,965 per hospitalisation.

In contrast, those receiving treatment at government-run hospitals incurred a significantly lower average expense of ₹21,827.

The findings indicate that out-of-pocket costs at private medical facilities were more than twice as high as those faced by patients receiving treatment at public hospitals.

Overall, the study calculated that the average out-of-pocket expenditure among insured patients stood at ₹34,790. For individuals without any health insurance coverage, the average expense per hospitalisation was ₹38,084.

This suggests that PMJAY beneficiaries spent roughly ₹3,294 less on average compared with individuals who lacked any form of health insurance.

The disparity was even more pronounced among patients without insurance coverage.

These individuals reportedly spent an average of ₹74,847 per hospital stay in private healthcare facilities, whereas their expenses in government hospitals averaged around ₹11,146.

The report noted that despite the scheme’s promise of covering pre-hospitalisation and post-hospitalisation medical costs, beneficiaries still frequently incur additional expenses for medicines and diagnostic services.

It also observed that patients seeking treatment at public hospitals often face higher transportation expenses and may have to purchase medicines independently.

Meanwhile, the higher overall out-of-pocket expenditure recorded in private hospitals is largely driven by costs related to medications, diagnostic procedures and travel for patients and their attendants.

The report also acknowledged that travel expenses are not reimbursed under the current provisions of the scheme.

The PMJAY programme, launched under the broader Ayushman Bharat initiative, was formally introduced on September 23, 2018.

The scheme was initially allocated a budgetary outlay of ₹40,112 crore for the five years between 2019–20 and 2024–25.

Often described as the world’s largest publicly funded health assurance programme, the initiative aims to provide financial protection of up to ₹5 lakh per family each year for secondary and tertiary medical treatment requiring hospitalisation.

The government has set an ambitious target of extending the scheme’s benefits to more than 12 crore families, covering nearly 55 crore individuals across the country.

The programme currently offers cashless treatment for 1,961 medical procedures spanning 27 different clinical specialities.

In September 2024, the scheme’s coverage was expanded further to include all citizens aged 70 years and above, regardless of their economic background, significantly widening the beneficiary base.

#PMJAY #AyushmanBharat #HealthcareInIndia #PublicHealthPolicy #NITIAayog #HealthInsurance #MedicalCosts #IndiaHealthSector