# Financial Burden of General Surgeries by Insurance Status: A Single-Center Case Study from a Quaternary Care Teaching Hospital in Karnataka, India

## TL;DR

This study examines how insurance status affects the financial burden of common surgeries in India, finding that public insurance significantly reduces out-of-pocket costs.

## Contribution

The study provides empirical evidence on financial risk protection from a public health insurance scheme for surgical care in India.

## Key findings

- Uninsured patients faced the highest out-of-pocket expenditure for surgeries.
- AB-PMJAY beneficiaries experienced negligible out-of-pocket costs.
- Private insurance offered partial financial protection but not as effectively as AB-PMJAY.

## Abstract

Background: Surgical care is being increasingly recognized as a critical component of universal health coverage (UHC), with unmet surgical needs contributing substantially to morbidity, mortality, and financial hardship in low- and middle-income countries. In India, out-of-pocket expenditure (OOPE) remains the dominant mechanism for financing surgical care, raising concerns regarding financial risk protection. Publicly financed health insurance schemes such as the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) have been introduced to reduce OOPE for inpatient services. Methods: A hospital-based single-center case study with a cross-sectional analytical design was conducted in a tertiary care teaching hospital in coastal Karnataka, India. A total of 150 patients undergoing common general surgical procedures (laparoscopic cholecystectomy, laparoscopic appendicectomy, inguinofemoral hernia repair, and umbilical hernia repair) were enrolled. Patients were categorized into three groups: uninsured, privately insured, and AB-PMJAY beneficiaries. Direct medical expenditure components were captured, and OOPE was compared across groups. Post hoc comparisons were performed following one-way ANOVA. Results: OOPE varied substantially across insurance categories. Uninsured patients incurred the highest mean OOPE, followed by privately insured patients, while AB-PMJAY beneficiaries reported negligible OOPE. Differences across groups were statistically significant (p < 0.001). Conclusions: Uninsured patients incurred a high financial burden for common surgical procedures, while private health insurance offered partial financial protection compared to no insurance. AB-PMJAY substantially reduced point-of-care expenditure for eligible beneficiaries. Expanding financial risk protection for surgical care may be essential for advancing equitable access and achieving UHC in India.