PMJAY scheme: Centre looking to bring hospitals run by CPSEs, paramilitary forces under flagship, anti-fraud law on anvil

Yatish Yadav

New Delhi: A year after the launch of the world's largest fully funded health insurance scheme, the government is looking to bring more than 300 hospitals run by Central Public Sector Enterprises (CPSEs), some of the best operated by Navaratna companies, into the fold to fulfill its objective of universal health coverage.

A Cabinet meeting chaired by Prime Minister Narendra Modi last month examined the progress made under National Health Mission (NHM). During the meeting, several challenges related to Pradhan Mantri Jan Arogya Yojana (PMJAY), a component of Ayushman Bharat, were also discussed.

After a detailed deliberation, the suggestions were moved to Cabinet Secretariat, which decided that for the better effectiveness and wider reach, it would be important to bring the hospitals run by CPSEs, other central government departments and central paramilitary forces on PMJAY panel.

The Cabinet Secretariat note reviewed by Firstpost said Ayushman Bharat-PMJAY is a globally unique scheme in terms of its coverage and quality of medicare. "It is important that a list be prepared of all hospitals run by public sector undertakings, central police organisations as well as various ministries, central departments and these hospitals should be on boarded to PMJAY to increase the reach of the programme," the note said.

An assessment has been carried out by national health authority about one year of PMJAY, which aims to provide coverage to nearly 10.74 crore poor families with cashless cover of Rs 5 lakh per family. The assessment document said non-uniformity in quality standards, non-coverage of PSUs, multi super-specialty private hospitals, inconsistencies in package nomenclature, duplication of packages, unviable rates for packages, large difference in rates of similar procedures across different specialties and overlap with national health programmes, were some of PMJAY's key challenges.

With the maturity of the scheme, it was realised that contractual and ad-hoc staff at various public sectors are somehow missing the benefits under PMJAY. It further said the PMJAY initiative is addressing prevention of illness, promotion and ambulatory care at the secondary and tertiary levels and aiming to cover around 40 percent of the poor and vulnerable population: around 50 crore beneficiaries.

"Since the implementation of the scheme till 4 September, 2019, a strong network of nearly 18,019 empanelled hospitals are created under PMJAY, of which 603 are quality accredited or certified. Continuous Quality Improvement (CQI) efforts were planned to be undertaken in PMJAY network hospitals, so as to ensure that appropriate and consistent quality services are delivered to the beneficiaries," the assessment report said.

There have also been extensive reports of fraud and huge amounts swindled in connivance with hospitals. The government recently struck down 111 hospitals after charges of corruption and fraud, however, the assessment report said lack of integration in three key modules, hospital empanelment system, beneficiary identification system and transaction management system, as well as limited capacity at state level for effective implementation of anti-fraud framework remain major challenges to detect fraudulent activities.

The government has admitted there is insufficient legal provision to deal with fraud and lack of standard treatment protocols and care pathways to pin down unnecessary surgeries and procedures. Bringing an anti-fraud law with stringent provisions and punitive action for effective deterrence has been suggested.

"System level controls need to be strengthened. Fraud detection and risk scoring through artificial intelligence and machine learning layer on real time basis is being deployed to alert state health agency/insurer before approval of pre-authorisation or payment of a claim. Empanelment of independent agencies/professional experts for medical audit and field investigations is required at national level, to be used by States as need be. De-empanelment guidelines need a revision for making the same more effective along with guidelines for recovery of money," the government's assessment report further added.

The Cabinet Secretariat has asked the key stakeholders in Ayushman Bharat scheme to prepare a note on the priority basis, which will be subsequently examined for the time-bound implementation.

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