Working Paper – 011

Cancer Care under AB PM-JAY Focus on Radiation Specialty Packages Access and Utilization

Authors:

Sudha Chandrashekar1, Parul Naib1, Shubhashree Patra2, Anmol Mishra2, Sheena Chhabra1

1 World Bank 2 National Health Authority

Disclaimer: The main objective of the working paper series of the National Health Authority (NHA) is to help staff, consultants, advisors and partners to speedily share their research findings based on AB PM-JAY experience with professional colleagues and test their research findings at the pre-publication stage. The opinion(s), view(s) and conclusion(s) expressed in the working paper are those of the authors and do not reflect the view of any author’s employer, official policy or position of any agency of the NHA. The AB PM-JAY data used in the analysis should not be utilized/quoted without prior permission of NHA. The papers do not themselves represent policy advice.

Acknowledgements: We acknowledge with gratitude the contribution and support provided by all NHA colleagues, especially the Analytics team (Abhay Sharma, Vichitra Kumar), and the Medical Team (Dr Pradeep Maurya) for their feedback and suggestions.; Special thanks to CEO and Deputy CEO at NHA for their overall strategic guidance and facilitating the necessary approvals.

2

ABSTRACT

Ayushman Bharat Pradhan Mantri-Jan Arogya Yojana (AB PM-JAY), the world’s largest health assurance scheme fully funded by the Central and State government of India, aims to provide quality secondary and tertiary care to the poor and vulnerable families as identified by SECC 2011 data. With the ongoing demographic and epidemiological transition, cancer is emerging as a major public health concern in India and thus the scheme has included oncology packages in its scope. Studies say that the out of pocket expenditure on cancer treatment is among the highest for any ailment.

Utilisation of oncology packages under AB PM-JAY are covered broadly under three categories medical, surgical and radiation oncology. The present paper is an attempt to understand the access to radiation treatment and preliminary trends observed in the utilization of radiation oncology packages by the states under the AB PM-JAY across public and private hospitals.

Keywords – Radiation, Oncology, AB PM-JAY, Cancer

INRODUCTION & BACKGROUND

Cancer is the second leading cause of death globally, and was responsible for an estimated 9.6 million deaths in 2018. Approximately 70% of deaths from cancer occur in low- and middle- income countries and globally about 1 in 6 deaths is due to cancer. It is predicted that the global burden will double to about 29-37 million new cancer cases by 2040 (Figure 1). Tobacco use is the most important risk factor and is responsible for 22% of the cancer deaths.

3

Figure 1 Ranking of premature mortality due to cancer across countries

INDIA: CANCER COGNIZANCE With the ongoing demographic and epidemiological transition, cancer is emerging as a major public health concern in India. As per the 2016 WHO Report, the cancer mortality rate in India is 79 per 100,000 deaths and accounts for over 6% of total deaths1. According to the estimates, there are nearly 25 lakh cases in our country and 4 lakh deaths occur annually due to cancer2.According to GLOBOCAN data, in 2018 there were 11,57,294 new cancer cases in India in both men and women, 7,84,821 deaths and 22,58,208 people living with cancer (within 5 years of diagnosis). The top 5 cancers that affect Indian population are Breast, oral, cervical, gastric and lung cancer3. Report of National Cancer Registry Programme, 2020 says that the leading sites of cancer among males are lung, mouth, oesophagus and stomach cancer while breast cancer was the leading site of cancer among females.4 The cancer burden of India is expected to rise by 12% by 2025.

Given the high cost of treatment for cancer, being diagnosed with it often leads to catastrophic

1 WHO; NCD Country Profile Geneva: World Health organization;: http://www.who.int/nmh/countries/ind_en.pdf?ua=1 2 Economic burden of cancer in India: Evidence from cross-sectional nationally representative household survey, 2014 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5826535/ 3 http://cancerindia.org.in/common-cancers/ 4 https://www.ncdirindia.org/All_Reports/Report_2020/default.aspx

4 personal health expenditures that possibly affects the well-being of the entire family. As per estimates, treatment for about 40% of cancer hospitalization cases is financed mainly through borrowings, sale of assets and contributions from friends and relatives.5 Earlier hospital-based studies found that, on an average, a household spends about Rs. 36,812 for the entire cancer therapy excluding non-medical costs. It is also noted that out of pocket (OOP) expenditure on cancer hospitalization is about 2.5 times of overall average hospitalization expenditure. These compelling results urge for the need for building a large-scale inclusive health infrastructure specific to cancer care.

CURRENT RADIATION FACILITIES IN INDIA National and international guidelines recommend radiotherapy for optimal management of many solid tumours as well as certain haematological malignancies. These are extremely limited in India, where for 1.2 billion people only 559 machines are available, i.e. 1 machine per 2.1 million people as compared to the recommended standard of 1 machine per 120,000 individuals.6 Based on the number of existing installed units in India, this still would mean a shortfall of >4500 machines7. There is also a lack of specialist’s staff in this field and to meet India’s needs, 2756 radiation oncologists, 1533 medical physicists and 4737 radiation therapists need to join the healthcare workforce by 2020. Nevertheless, the acute shortage is startling and with current figures of 198, 150, and 250 graduates of radiation oncology, medical physicist, and radiation therapists available respectively, it would take many more years to reach the required staff8.

The supply of oncology facilities is extremely concentrated and skewed with state-of-the-art technology available mostly within the private sector and a few hospitals in the public sector, but 75% of patients in public sector in India do not have access to timely radiotherapy9. This inequity s׳India of most where areas, rural in amplified is sector public the in radiotherapy to access in population is concentrated. A long-term government commitment to purchase of machine and human resource development in the public sector is needed to improve access.

5 Economic burden of cancer in India: Evidence from cross-sectional nationally representative household survey, 2014 https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0193320 6 Datta NR,Samiei M,Bodis S:Radiationtherapy infrastructure and human resources in low- and middle- income countries: Present status and projections for 2020. Int J Radiat Oncol Biol Phys 89(3):448-457, 2014 7 http://www.indianjcancer.com/article.asp?issn=0019- 509X;year=2019;volume=56;issue=4;spage=359;epage=363;aulast=Munshi 8 http://www.indianjcancer.com/article.asp?issn=0019- 509X;year=2019;volume=56;issue=4;spage=359;epage=363;aulast=Munshi 9 Radiation Oncology in India: Challenges and Opportunities https://www.researchgate.net/publication/310390860_Radiation_Oncology_in_India_Challenges_and_Opportun ities

5 The radiotherapy centres in India have either teletherapy facilities alone or both teletherapy and brachytherapy facilities (Table 1)8.

Table 1: Distribution of radiotherapy machines across geographical regions

The conventional radiotherapy treatments use Cobalt 60 technology while three-dimensional conformal radiotherapy (3D CRT), Intensity modulated radiation therapy (IMRT), and Image guided radiation therapy (IGRT) are said to minimize exposure to radiations and increase precision of treatment, restricting the radiations only to malignant cells10. Currently India has approximately 545 teletherapy machines (180 telecobalt units and 365 medical accelerators), 22 advanced therapy machines (7 Gamma knife units, 8 Tomotherapy machines, 7 Cyber-knife machines and 2 intra-operative radiotherapy machines). The number of remote after loading brachytherapy units is estimated at around 2508 (Table 2). Studies have concluded that advanced techniques like IMRT have advantages over conventional treatment techniques in a number of cancer sites11. Thus, widely replacing the classical approach of treatment. IGRT procedure is most utilized package in male. Brachytherapy is used more often in females.

Table 2: Brachytherapy facilities

10 https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/radiation/external-beam- radiation-therapy.html 11 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3097603/

6 The latest technologies in radiation therapy include Stereotactic Radio Surgery (SRS). SRS is a non-surgical radiation therapy used to treat functional abnormalities and small tumours of the brain. It can deliver precisely targeted radiation in fewer high-dose treatments than traditional therapy, which can help preserve healthy tissue. The more uniform and frequent availability of high-quality radiotherapy can improve cancer outcomes and may be regarded as a marker of a comprehensive and equitable system of health care delivery.12

FINANCIAL ASSISTANCE FROM GOVERNMENT SCHEMES

In India, the Centre along with many State Governments have provided for the access to cancer treatment through social protection schemes for supporting the disadvantaged.

Health Minister’s Cancer Patient Fund (HMCPF) – Under this scheme, patients living below the poverty line are provided with a financial assistance of up to Rs 2 lakh per patient for treatment in 27 regional cancer centres (RCC) in the country 13. The Health Minister’s Discretionary Grants (HMDG) with a maximum cover of Rs. 50,000 is set up to assist with part of the hospitalisation/treatment in government hospitals14. Rashtriya Arogya Nidhi (RAN) was set up under the Ministry of Health & Family Welfare, Government of India and provides financial assistance of up to Rs 1 lakh which is released as a one-time grant to the Medical Superintendent of the Hospital where treatment is being done.15 State Illness Assistance Fund (SIAF) releases financial assistance to patients living in their respective States/UT of up to Rs. 1.5 lakh on an individual case basis for cancer treatment at government hospitals within the state. The Central Government Health Scheme (CGHS) is applicable for all working and retired Central Government employees & their dependents. However, these schemes often have limitations such as providing treatment only at government hospitals with an upper limit of Rs 2 lakh per patient and the process for seeking approval to utilise this fund is a long-drawn process.

The National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS)16 was launched in 2010 in 100 districts across 21 States to prevent and control the major NCDs and later scaled up to the whole country. As part of the cancer component, the Tertiary Care Cancer Centres (TCCC) Scheme, supports setting up/strengthening

12 https://www.researchgate.net/publication/310390860_Radiation_Oncology_in_India_Challenges_and_ Opportunities 13 https://main.mohfw.gov.in/sites/default/files/254789632565878966552HMCPF%20%281%29.pdf 14 https://main.mohfw.gov.in/major-programmes/poor-patients-financial-assistance/health-ministers- discretionary-grant-hmdg 15 https://main.mohfw.gov.in/major-programmes/poor-patients-financial-assistance/health-ministers- discretionary-grant-hmdg 16 https://dghs.gov.in/content/1363_3_NationalProgrammePreventionControl.aspx

7 20 State Cancer Institutes (SCI) and 50 TCCCs for providing comprehensive cancer care in the country. Under the scheme there is provision for giving a ‘one-time grant’ of Rs. 120 crore per SCI and Rs. 45 crore per TCCC, to be used for building construction and procurement of equipment, with the Centre to State share in the ratio of 60:40 (except for North-Eastern and Hilly States, where the share is 90:10).

Government sponsored health schemes of various states have been working towards helping the vulnerable population in their respective states even prior to AB PM-JAY. Mediclaim Scheme is offered by the state of Goa for the permanent residents of Goa. Mediclaim facility can be used for Radiotherapy and Chemotherapy of up to Rs 5 lakhs per patient. State Illness Assistance Fund offered by Madhya Pradesh assists any cancer diagnosed person domiciled in M.P. who is below poverty line. Assistance varies from Rs 25,000 to Rs 2,00,000. Cancer Suraksha scheme has been launched by Government of Kerala for children below the age of 18 years who suffer from cancer and belong to poor families. The cost of treatment along with the cost of diagnosis is taken care of by the hospital through the funds provided by the Mission subject to a ceiling of Rs 50,000 per child. Cancer patients in Telangana and Andhra Pradesh have access to free treatment if their annual family income is below Rs 5 Lakh/annum.

While Central and State sponsored initiatives have helped in providing timely critical care, they also involve various limitations such as manual processing of claims, upper limit in the financial assistance amount, restriction of treatment in home state or individual based treatment cover only. Ayushman Bharat helps in bridging these gaps by providing cancer treatment across a large network of Empanelled Health Care Providers (EHCPs) that provide quality tertiary care services. The introduction of the AB PM-JAY scheme has played an important role in financial assistance to the poor and vulnerable populations in getting treatment in any public or private hospitals across the country with a treatment health benefit cover of Rs 5 lakh per family per year. They are inclusive of single-speciality or super-speciality hospitals. This scheme ensures that the beneficiary can avail the benefits and access to service providers in a fully paperless and cashless manner. The financial cover of Rs 5,00,000 per year is on a family floater basis which means that it can be used by one or all members of the family. Even if the cancer ailment is pre-existing, the patient can avail treatment in any empanelled facility. As access to radiation therapy facilities in India is limited, the portability functionality of AB PM-JAY is one of the key features of the scheme that allows the beneficiary to seek treatment in any of the leading cancer care facilities present outside the home state as well.

8 OBJECTIVES

The utilisation of oncology packages under AB PM-JAY will be covered broadly under three categories- medical, surgical and radiation oncology. The present paper is an attempt to understand the access to radiation treatment and preliminary trends observed in the utilization of radiation oncology packages by the states under the AB PM-JAY across public and private hospitals whereas the other approaches shall be discussed in different working paper. This paper utilizes the data:

a) To analyse the access and utilization trends of radiation oncology packages across different States/UTs b) To understand the demographic profiling of beneficiaries availing cancer care under PM-JAY c) To assess the portability claims under radiation oncology packages

METHODOLOGY

Data Source - The analysis utilizes claims data for radiation oncology packages from the Transaction Management System on dashboard for 27 PM-JAY implementing States and UTs (Union Territories). For Andaman and Nicobar Islands, Daman & Diu, Lakshadweep the claims volume data is low hence they are not considered. Goa and Rajasthan data are not fully captured in TMS. The States & UTs of Odisha, Telangana, West Bengal and Delhi have not yet joined the scheme. National Healthcare providers have not been included in this study.

Time Period - The time-period for this analysis covers data from 01st October 2019 – 29th February 2020

Data variables analysed at the state level were pre-authorization and claim submissions for oncology packages, age-gender dimensions, utilisation of packages based on hospital type (private/public) and portability data between States.

9 Results and Findings

RADIATION ONCOLOGY PACKAGES UNDER AB PM-JAY

Radiation therapy is commonly applied to the cancerous tumours to control cell growth. Ionizing radiation works by damaging the DNA of cancerous tissues leading to cellular death. There are total of 14 procedures under the national package master (refer Annexure 1). Amongst these, 90% of the utilisation under radiation is utilised by the following packages:

Cobalt 60 - In cobalt therapy, gamma rays are emitted from radio isotope cobalt-60 whereas linear accelerator (LINAC) delivers high energy x-rays or electrons to the malignant lesions. It has a half-life span of 5 years and then it is disposed of. Now it is almost replaced by linear accelerators. Linear accelerator with photons: It uses photon beams to get to the tumour but also can damage healthy tissue around the tumour. Photons are used in treatments that are given by a machine called a linear accelerator. The photon beams are invisible and cannot be felt when they are passing through the skin to the cancer. 3D-CRT- Three-dimensional conformal radiation therapy incorporates the use of imaging technologies to generate three-dimensional images of a patient’s tumour and nearby organs and tissues. Linear Accelerator (IGRT) - Image-guided radiation therapy (IGRT) is the use of imaging during radiation therapy to improve the precision and accuracy of treatment delivery. IGRT is used to treat tumours in areas of the body such as the lungs. Linear Accelerator (IMRT) - Intensity-modulated radiotherapy (IMRT) uses linear accelerators to safely deliver precise radiation to a tumour while minimizing the dose to surrounding normal tissue. Linear Accelerator -Involved-Site Radiotherapy (ISRT): is used to treat lymphomas. It selectively treats the lymph nodes where the cancer started and the cancerous masses near those nodes. With a special machine, carefully focused beams of radiation are directed at the cancer. This is also called “External Beam Therapy” (EBT). The size of the targeted area is restricted to minimize radiation exposure to adjacent, uninvolved organs, and to decrease the side effects associated with radiation therapy. Brachytherapy High dose radiation (Intracavitary, Interstitial, Intraluminal ) - Brachytherapy is a procedure that involves placing radioactive material inside your body. Brachytherapy allows doctors to deliver higher doses of radiation to more-specific areas

10 of the body, compared with the conventional form of radiation therapy (external beam radiation) that projects radiation from a machine outside of your body.

Overall utilization of radiation oncology as a proportion of all claims

For the time-period of study, a total number of 36.84 L claims have been submitted under all packages with a treatment value cost of Rs. 3434 Cr claim amount. Out of which, 2.63 lakh number of claims (7%) have been submitted under oncology speciality only with a treatment value of Rs. 278 Cr (8% of total claims amount) (Figure 2).

Figure 2: Overall utilization of Oncology packages in comparison to other specialities

Oncology speciality comprises of medical oncology, surgical oncology and radiation oncology claims. As seen in Figure 3, it is observed that 15% (i.e. 40.306 packages) of claims volume have been submitted under radiation oncology which comprises 38% (i.e. Rs. 105 Cr) of the total claims amount under oncology speciality.

11

Figure 3: Utilization of Radiation Oncology compared to Oncology Sub -speciality

Gender-based distribution of radiation oncology claims Looking at gender-wise distribution it is seen that females (60%) have a higher utilization of package as compared to males (40%) (Figure 4). According to studies, it has been recognized that males are more prone to develop cancer17. Men report a 25% higher incidence of cancer than women all over the world. It is also seen that especially in cancer in adults, males suffer from lower survival and higher mortality rates.

Figure 4: Gender-wise distribution of radiation oncology claims

However, the interpretation in AB PM-JAY can be explained because of the reverse trends seen in Indian population. As per studies, while women in India are more prone to cancer, the mortality rate of men in India, is higher than in women. 70% of cancer in women in India is

17 Gender Differences in Cancer Susceptibility: An Inadequately Addressed Issue https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3508426/

12 because of breast, cervical, ovarian and uterine cancer where the survival rate is higher. While Indian men suffer largely from lung or oral cancer – both related to smoking and chewing tobacco –with lower survival rates18. Due to limitation of data availability, there is currently no supporting analysis in for gender-based distribution of cases based on site of cancer.

Age-wise profiling of radiation oncology claims Figure 5 highlights the frequency of radiation oncology claims submitted for different age groups. The number of cases for children aged 0-15 years is the least in number (less than 1%) while the 61+ aged group of people with 11,961 (30%) and the middle-aged group of people (aged 46-60) with 16,967 (42%) contribute to highest number of cases. This is followed by cases in age group of 31-45 with 9,689 (24%) cases. With ageing, as one is exposed to more potential hazards the immunity of the body weakens to respond to pre-cursors of cancer. According to a report published by National Cancer Registry Programme, the age groups most affected by cancer among all registries are 35-64-year which is the most productive age group19.

Figure 5: Age-wise distribution of radiation oncology claims

Oncology empanelled hospitals overview Out of the total number of hospitals empanelled nationally for all packages, 269 hospitals were actively providing oncology related treatment as seen in Figure 6. Active hospitals include those hospitals where at least one claim is being raised by the hospital per week. Tamil Nadu (54), Maharashtra (40) and Karnataka (36) sees the highest number of total empanelled hospitals for radiation oncology indicating better availability of facilities towards the western and south India. The northern region and north-east region saw as low as 1 hospital empanelled. This may be

18 Why Cancer Strikes More Women Than Men In India http://cancerindia.org.in/cancer-strikes-women- men-india/ 19ncdirindia.org/All_Reports/Report_2020/PB/Policy_Brief.pdf

13 related to many reasons, such as geographical terrains (hilly areas) or remote access to EHCPs, as well as limited supply of private facilities which needs to be explored further.

Total No. of Active Hospitals - 269

Figure SEQFigure Figure6 :\ *Distribution of active hospitals ARABIC 7 Distribution of empanelled for radiation oncology hospitals vs active status

The break-up of hospitals providing different sub-specialities under oncology is shown in Figure 7. The availability of care is not uniform across sub- specialities and radiation facilities are comparatively less compared to the other two medical and surgical oncology care.

Figure 7: State-wise hospitals providing radiation oncology care

14 If we look at the distribution of the active hospitals, based on type of hospital (Figure 8), it is seen that public hospitals contribute to only 31% of claims volume while majority of the treatment is done in private hospitals (69%) which may reflect the limited supply of radiation facilities and specialists in the public healthcare sector.

Figure 8: Distribution of Active Hospitals, Public vs Private

If we compare the claims volume data of patients treated based on hospital type, it shows similar trends where private hospitals comprise 76% of the total treatment cost. Of the 26,128 claims volume in private hospitals, the average cost of treatment is ₹ 30,394 and while the remaining 14,178 claims are in public hospitals where the average cost of treatment is ₹ 17,874. The variation in cost of treatment in private facilities which is higher may suggest more complicated and advanced radiation treatment being performed.

Utilization of packages based on hospital type Looking at the utilization of the packages by hospital type (Figure 9), it is observed that utilization at private hospitals is significantly higher than public hospitals across many states. In larger greenfield states such as Jharkhand (94%) or Madhya Pradesh (73%), a significant majority of utilization is seen in private hospitals. The higher share of private hospitals in these states could indicate better infrastructure leading to a preference of demand for it. It can also be said that there may be a limited availability of quality medical care in public health care facilities and the presumption that private hospitals provide better quality of care.

15

Figure 9: State-wise utilisation of radiation oncology packages (Public vs Private hospitals)

However, the trend was entirely reversed in the case of Kerala and Manipur wherein more than 80% of the cases came from public hospitals indicating the reservation of these packages for public hospitals in the state (Kerala) and lack of availability of private hospitals (Manipur). Also reviewing the brownfield states, Maharashtra, Andhra Pradesh, Gujarat, Tamil Nadu and Karnataka have raised majority of claims from the private sector. In Uttar Pradesh (public – 46%, private – 54%) and Chhattisgarh (public – 57%, private – 43%) both had an almost equivalent share in the number of radiation packages utilized under AB PM-JAY indicating the demand for both public and private hospitals for oncology treatment.

There is an evident disparity between states in terms of the proportion of public and private healthcare institutions utilizing radiation oncology packages.

Top Packages utilization under radiation oncology (Public vs Private)

By observing the utilization trend of top oncology procedures (Figure 10), it is evident that conventional techniques for the treatment like Cobalt 60, has a strong presence in the services offered by the public healthcare sector at 81% Cobalt 60 (palliative) and at 85% Cobalt 60 (with external beam radiation) when compared to private share of 15% and 19% respectively. Private healthcare service sector is dominated by more advanced and sophisticated techniques like IGRT, IMRT or Electron beam with linear accelerator, with the numbers standing at 81%, 87% and 86% respectively. This disparity in facilities or limited access of the more technologically sound technique is often attributed to the high capital and operational costs of these technologies which is trying to bridge.

16 Figure SEQ Figure \* ARABIC 10 Distribution of radiation package utilization by type of radiotherapy

Figure 10: Package wise distribution of radiation oncology claims

Age and Gender specific utilisation of package

As may be seen from Figure 11, IMRT treatment is most prevalent in males (38%) while brachytherapy is more commonly performed treatment in females (34%). This maybe as IMRT is regarded as an innovative treatment for prostate cancer that delivers higher doses of radiation with improved precision compared to alternative radiotherapies.20

Figure 11: Gender wise distribution radiation oncology package

20 Growth Of High-Cost Intensity-Modulated Radiotherapy For Prostate Cancer Raises Concerns About Overuse https://www.healthaffairs.org/doi/10.1377/hlthaff.2011.1062

17

Prostate cancer is among the top ten leading sites of cancers in India 21. Brachytherapy is a commonly used form of treatment for women suffering from uterine cancer or treating cervix cancer22.

In age-group wise utilization of radiation oncology packages (Figure 12), IMRT is widely prevalent form of treatment across all age groups signifying as a newer preferred accurate form of conventional radiotherapy.

Figure 12: Age-group wise distribution of radiation oncology packages

Package -specific average claim amount

There are total of 14 packages in NHA national packages under radiation oncology speciality. Certain States have further revised these packages as per the procedure name or package rates. This claims dataset including the state specific packages has been mapped and compiled to the NHA packages under AB PM-JAY. Table-3* shows the average claim size for each of the NHA packages.

21 http://cancerindia.org.in/prostate-cancer/

22 https://www.targetingcancer.com.au/radiation-therapy/brachytherapy/brachytherapy-for- gynaecological-cancer/

18 Table 1 Average claim size for radiation oncology packages

Sum of Cases Sum of Claim Average Claim PM-JAY Package Name Count Amt (lakhs) Amount (in Rs) SRS (Stereotactic radiosurgery) 6 6.7 1,11,708 Tomotherapy (Radical/Adjuvant/Neoadjuvant) 12 8.8 74,133 IGRT (Image Guided radiotherapy) 2310 147.9 64,057 SRT(Stereotactic radiotherapy) 34 16.1 47,380 IMRT (Intensity Modulated Radiotherapy) 10,223 4341.2 42,466 Electron beam with Linear accelerator (Radical) 3229 1019.6 31,577

3D CRT/2D Planning (Radical/Adjuvant/ Neoadjuvant) 5296 1357.2 25,629

Linear Accelerator External Beam Radiotherapy 3792 701 18,489 (Palliative) Brachytherapy High Dose Radiation (Interstitial) - for 400 61.2 15,320 one application, multiple dose Cobalt 60 External Beam Radiotherapy 4161 530.7 12,753 (Radical/Adjuvant / Neoadjuvant) Brachytherapy High Dose Radiation (Intracavitory) - per 7888 628.5 7,969 fraction, maximum of 4 sessions Cobalt 60 External Beam Radiotherapy (Palliative) 1567 120.9 7,717 Brachytherapy High Dose Radiation (Intraluminal) - per 126 7.8 6,219 fraction, maximum 4 sessions *Respiratory Gating along with Linear Accelerator planning package amount was not available. Claims Volume was insignificant

Utilization Rate – State-wise Overview

The map in Figure 13, indicates utilization rate of states and the patterns of treatment under the radiation oncology. The data of the same has been normalised for per lakh population. The Utilization Rate has been calculated as the number of radiation oncology cases per lakh population. Utilisation trend varies across the states with the rate being as low as 1 person per lakh population in greenfield states of Bihar (0.98), J&K (0.31) and highest in states like Manipur (55.3) and Kerala (46.3) respectively. Such variation can be attributed to factors like the demographic and lifestyle diversity while from the bigger states like Uttar Pradesh (2.4) & Jharkhand (4.9) the rate recorded is low despite having large number of hospitals. The low numbers may suggest lack of awareness and that the scheme is yet to reach stabilization in the state. It can also suggest that the cases are either not being reported or not brought under medical scrutiny. Hence it is necessary to spread awareness and educate the eligible beneficiaries about the scheme benefits.

19

Figure 13: Utilisation rate across States

Amongst the brownfield states Andhra Pradesh (26.30) has the highest utilization rate followed by Maharashtra (25.99) and Tamil Nadu at (24.46) suggesting better awareness and penetration of scheme or infrastructure. Madhya Pradesh from where many people seek medical care out of their home state observes the utilization rate at 8.37 (per lakh population) and Gujarat the state with the highest influx of patients from other states has a utilization rate of 5.80 (per lakh population).

Table: 4 Top 10 Radiation Oncology Active Hospitals (by hospital type)

CLAIMS PUBLIC HOSPITAL NAME HOSPITAL STATE VOLUME Regional Cancer Centre Kerala 1,027 Kidwai Memorial Institute Of Oncology Karnataka 976 Regional Institute Of Medical Science Manipur 754 Pt. J. N. M. Medical College Chhattisgarh 690 Malabar Cancer Centre Thalassery Kerala 627 Sri Venkateswara Institute Of Medical Sciences Andhra Pradesh 599 Tata Memorial Hospital & Research Centre Maharashtra 540 Govt. Medical College Hospital Kottayam Kerala 486 Government Medical College And Cancer Hospital Maharashtra 463 Kerala

20 Medical College Kozhikode, Kerala 461

CLAIMS PRIVATE HOSPITAL NAME HOSPITAL STATE VOLUME Rashtriya Sant Tukdoji Maharaj Cancer Hospital & Research Centre Maharashtra 682 Jawaharlal Nehru Cancer Hospital And Research Centre Madhya Pradesh 680 Ashwini Rural Cancer Research And Relief Society Maharashtra 642 Erode Cancer Center, Erode Tn. Tamil Nadu 634 Omega Hospitals A Unit Of Kurnool Institute Of Oncology Pvt Ltd Andhra Pradesh 559 Ms Mahatma Gandhi Cancer Hospital And Research Institute Andhra Pradesh 456 Kolhapur Cancer Centre Maharashtra 451 Mahavir Cancer Institute & Research Center Bihar 442 Curie Abdur Razzaque Ansari Cancer Institute Jharkhand 413 MMRI Kamalnayan Bajaj Hospital Maharashtra 399

As seen in Table 4, under government facilities, the leading cancer hospitals in the country providing radiation oncology treatment under AB PM-JAY are Regional Cancer Centre, Kerala (1027) with highest claims and Kidwai Memorial Institute of Oncology, Karnataka (976) a close second. The other hospitals seen are spread across the regions such as in north east, Manipur, three hospitals in southern State of Kerala and two hospitals from Maharashtra in the west.

Under private hospitals, similar trend of regional distribution is seen as a comparison to public hospitals. Rashtriya Sant Tukdoji Maharaj Cancer Hospital & Research Centre, Maharashtra and Jawaharlal Nehru Cancer Hospital And Research Centre, Madhya Pradesh are the top 2 hospitals. Maharashtra with a total of four hospitals in the list, reflects better access to cancer care facilities. Mahavir Cancer Institute & Research Center (442) in Bihar and Curie Abdur Razzaque Ansari Cancer Institute (413) reflect that the eastern regions with dense population also have availability of tertiary care in this region. There are no hospitals in top ten seen in the northern region (excludes national healthcare providers NHCPs).

PORTABILITY Portability is defined wherein a beneficiary takes treatment in empanelled hospitals outside his/her home state and in any other state implementing AB PM-JAY scheme. It is a key feature under AB PM-JAY, that allows equal access to quality health care for an eligible beneficiary seeking treatment anywhere across the country.

During the period under consideration, a total of 1725 patients had taken treatment under Radiation Oncology (as seen in Table 5). It is observed that Gujarat receives the maximum

21 patients (427) from other states followed by Maharashtra (409) and Uttarakhand (239) indicating that probability of better hospital infrastructure, better quality of care or access to healthcare.

Table 2: State-wise radiation oncology utilization through portability

Total Radiation Incoming % of Outgoing Parent State Oncology cases Outgoing Cases cases Cases

Andhra Pradesh 5,237 NA NA 0%

Arunachal Pradesh 16 2 0 13%

Assam 323 3 96 1%

Bihar 545 104 53 19%

Chandigarh 4 3 44 75%

Chhattisgarh 1,309 28 43 2%

Dadra and Nagar haveli 33 33 0 100%

Daman and Diu 19 19 0 100%

Gujarat 1,223 0 427 0%

Haryana 158 56 13 35%

Himachal Pradesh 223 56 0 25%

Jammu and Kashmir 10 5 0 50%

Jharkhand 686 101 6 15%

Karnataka 4,093 0 10 0%

Kerala 3,357 NA NA 0%

Madhya Pradesh 3,094 685 91 22%

Maharashtra 9,355 26 409 0%

Manipur 782 12 1 2%

Meghalaya 137 60 4 44%

Mizoram 75 6 1 8%

22 Nagaland 49 11 4 22%

Puducherry 11 7 0 64%

Punjab 397 71 52 18%

Tamil Nadu 7,042 5 7 0%

Tripura 145 17 0 12%

Uttar Pradesh 1,593 414 106 26%

Uttarakhand 390 1 239 0%

Grand Total 40,306 1725 1725 4%

It was observed that maximum outgoing patients from their home state was from Madhya Pradesh (685) followed by Uttar Pradesh (414) indicating the need for better access to care (Figure 14).

46% portable cases are going to Gujarat and Maharashtra (42%)

55% portable cases are going to Uttarakhand

Figure 14: State-wise Portability claims % going outside home-state Figure SEQ Figure \* ARABIC 14 State-wise Portability claims % going outside home-state

23 DISCUSSION

Key trends suggest that PM-JAY is empowering the beneficiaries with inadequate monetary resources to access oncology treatment at both public and private hospitals. Since the inception of the scheme, the number of beneficiaries availing radiation therapy under cancer treatment cycle has increased across states and the trend is likely to continue with the steady increase in the number of verified beneficiaries’ overtime.

For poor underprivileged households, the primary challenge in access to radiotherapy treatment had been high cost in private institutions and limited availability of advanced technology in public health facilities. PM-JAY has addressed the problem by empanelling both public and private healthcare providers. As seen from the analysis, PM-JAY is delivering cancer care with a mix of Cobalt 60, 3D CRT, IMRT and IGRT. This approach has a huge benefit as it enables clinicians to choose the most appropriate technology for the treatment of a beneficiary. Overcoming the barriers of accessibility will help the beneficiary to get diagnosed and avail care in a timely manner.

For successful implementation of cancer care under the PM-JAY, it is crucial to harness the potential of the private healthcare sector by empanelling more oncology facilities especially for radiation therapy. Since there are already only limited hospitals with radiation facilities states should target to saturate and empanel all oncology hospitals to improve access to radiotherapy for the beneficiaries (database of all facilities with radiation therapy could be obtained from Atomic Energy regulatory board (AERB). Also , the availability of infrastructure, specialist personnel and quality of care available at public hospitals needs to be enhanced to ensure better access for all poor and marginalized people.

Further public private partnerships and viability gap funding for private sector in states/districts which do not have cancer care facilities could be explored. It is also equally critical to monitor the quality and appropriateness of care and have a clear set of standard treatment guidelines for hospitals to prevent waste and abuse especially booking of high-end radiation therapy packages for palliative cases. There is also a requirement to spread awareness amongst beneficiaries to avoidable risk factors especially the use of tobacco and ensure timely diagnosis by adequate screening through the NPCDCS programme has to be enhanced so that life-saving treatment can start in time.

24 LIMITATIONS OF THE STUDY

This study involves claims data with inherent data issues such as lack of complete information regarding the diagnosis, stage and site of the cancer provided by the hospitals. Further it was not possible to determine the completeness of radiation treatment in terms of number of fractions provided. We also could not determine whether the patient has received all modes of treatment (surgery and chemotherapy) necessary for his type of cancer. Oncology care packages considered were of those in HBP 1.0 as many states had not transitioned to HBP 2.0. Quality and outcome of the care in terms of survival or improvement in health has not been analysed.

CONCLUSION AND RECOMMENDATIONS

Oncology-related care is a key component of AB PM-JAY but the availability and utilization varies widely across states due to differentials in access and supply especially in relation to the cancer burden in India. There is an urgent need to scale up availability of radiation facilities and specialists especially in public hospitals across the states in proportion to the cancer burden. Further there is significant need to upgrade the radiation facilities to more advanced technology which provide better precision and less damage to surrounding normal tissues which reduces adverse effects.

It is required to improve the quality of patient health outcome data collected regarding the treatment provided to ensure better monitoring and tracking of results and ensure that follow- up care can be provided to cancer patients especially in their end stage. Hospitals should be sensitized to register in the National Cancer Disease Informatics and Research Centre Hospital Registry Portal so that all patient level and treatment data are captured. Hospitals should be encouraged to follow the standard treatment guidelines developed by National Cancer Grid which have been adapted for AB PM-JAY packages and being rolled out to ensure quality of care.

To reduce the burden of non-medical expenses on the low- and middle-income people, accommodation allowance and travel charges can be introduced as part of the health benefit package for patients availing radiation therapy under PM-JAY outside their usual place of residence.

PM-JAY should make efforts to empanel additional centres to provide better access to beneficiaries. Hospitals empanelled for one sub-specialty of oncology should have tie up with

25 nearest hospitals for other specialty and ensure good referral mechanisms to provide multimodal treatment for cancer as per the National Cancer Grid guidelines. Developing a single unified longitudinal view of treatment data for a patient would help in assessing complete and comprehensive care for the patient and more effective tracking of outcomes than multiple pre- authorization and claims for the same condition. The hospital empanelment portal needs to be updated to capture both speciality and sub speciality of EHCP’s . This will facilitate better comparison. The Transaction Management System of PM-JAY needs to ensure that data is collected as per National Cancer Disease Informatics Registry (NCDIR) format to generate better insights and effective monitoring. Thus, with better quality of data, analysis and adherence to the treatment protocols, appropriateness of care would be assessed appropriately.

26

Annexure 1

Proc Proc. Procedure Proc value S.No. Spec. Spec. Procedure Name code (In Rs.) code Name RADIATION Cobalt 60 External Beam Radiotherapy 1 M6 ONCOLOGY M600001 (Radical/Adjuvant / Neoadjuvant) 20000 RADIATION Cobalt 60 External Beam Radiotherapy 2 M6 ONCOLOGY M600002 (Palliative) 10000 RADIATION Linear Accelerator External Beam 3 M6 ONCOLOGY M600003 Radiotherapy (Palliative) 20000 Linear Accelerator External Beam RADIATION Radiotherapy 3D CRT/2D Planning 4 M6 ONCOLOGY M600004 (Radical/Adjuvant/ Neoadjuvant) 50000 Linear Accelerator External Beam Radiotherapy IMRT (Intensity RADIATION Modulated Radiotherapy) 5 M6 ONCOLOGY M600005 (Radical/Adjuvant/Neoadjuvant) 75000 Linear Accelerator External Beam Radiotherapy IGRT (Image Guided RADIATION radiotherapy) 6 M6 ONCOLOGY M600006 (Radical/Adjuvant/Neoadjuvent) 120000 RADIATION SRT (Stereota1036ic radiotherapy) 7 M6 ONCOLOGY M600007 70000 RADIATION SRS (Streotactic radiosurgery) 8 M6 ONCOLOGY M600008 70000 RADIATION Respiratory Gating along with Linear 9 M6 ONCOLOGY M600009 Accelerator planning 70000 RADIATION Electron beam with Linear accelerator 10 M6 ONCOLOGY M600010 (Radical) 50000 RADIATION Tomotherapy 11 M6 ONCOLOGY M600011 (Radical/Adjuvant/Neoadjuvant) 75000 Brachytherapy High Dose Radiation RADIATION (Intracavitory) - per fraction maximum 12 M6 ONCOLOGY M600012 of 4 sessions 4500 Brachytherapy High Dose Radiation RADIATION (Interstitial) - for one application 13 M6 ONCOLOGY M600013 multiple dose 30000 Brachytherapy High Dose Radiation RADIATION (Intraluminal) - per fraction maximum 14 M6 ONCOLOGY M600014 4 sessions 4500

27