What’s the news?

• A recent report has revealed disturbing incidents of deception against poor patients at Safdarjung Hospital (‘Bypassing Ayushman Bharat, doctor at a top government hospital duped patients and made killings on implants).

Central Idea

• Designing a government-sponsored health insurance scheme for the poor presents significant challenges, including the issue of information asymmetry between doctors and patients, which may lead to the denial of benefits for the disadvantaged.

What is Ayushman Bharat?

• Pradhan Mantri Jan Aarogya Yojana (PMJAY), also known as Ayushman Bharat or the National Health Protection Scheme (NHPS), is a flagship government-sponsored health insurance scheme launched by the Government of India in September 2018. The primary aim of PMJAY is to provide financial protection and access to quality healthcare to economically vulnerable sections of society.

Key features

• Health Insurance Coverage: PMJAY provides health insurance coverage to eligible beneficiaries, especially those belonging to economically weaker sections (EWS) and low-income families. It aims to cover around 10 crore (100 million) families across India.
• Cashless and Paperless Treatment: Under PMJAY, eligible beneficiaries can avail of cashless and paperless treatment in empaneled public and private hospitals across the country. The scheme ensures that beneficiaries are not required to pay for the treatment at the time of hospitalization.
• Pre-Defined Medical Packages: The scheme offers a comprehensive set of pre-defined medical packages covering various medical and surgical treatments. These packages are designed to provide essential healthcare services, including diagnostics, medicines, and other treatments.
• Coverage for Pre-Existing Conditions: PMJAY provides coverage for pre-existing illnesses and health conditions from the date of enrollment. This ensures that beneficiaries with existing health conditions can also access healthcare services under the scheme.
• No Cap on Family Size: There is no restriction on the family size covered under PMJAY. All eligible family members can avail of the benefits of the scheme.
• Portability: PMJAY is portable across the country, meaning beneficiaries can avail of treatment in any empaneled hospital in any state or Union Territory, irrespective of their place of origin
• Identification of Beneficiaries: Beneficiaries under PMJAY are identified through the Socio-Economic Caste Census (SECC) data and are issued the Ayushman Bharat – PMJAY Golden Card, which serves as proof of eligibility.
• Online Verification: The scheme employs an online verification process to ensure seamless and efficient identification and validation of beneficiaries.
• Collaborative Effort: PMJAY is a joint collaboration between the central and state governments, and each state has the flexibility to implement the scheme based on its specific requirements.

The Incident of deceptive practices at Safdarjung Hospital

• Misleading Patients: The report reveals that certain doctors deceive patients by providing false information about delays in Ayushman Bharat Clearance. This deceptive tactic aims to divert patients towards private alternatives rather than enrolling them in the PMJAY scheme.
• Influence of Treating Doctors: The incident highlights the significant role of treating doctors in determining the medical package for patients and whether they are enrolled under the PMJAY scheme.

Concerns raised over the implementation of government-sponsored health insurance schemes

• Deceptive Practices: Misinformation about Ayushman Bharat Clearance delays is used as a tactic to divert patients towards private alternatives instead of enrolling them in the PMJAY. Such practices can deprive eligible patients of government-sponsored health insurance benefits and lead to potential financial exploitation.
• Doctor’s Influence: The treating doctors wield significant influence in determining the medical package for patients and their enrollment in the PMJAY scheme. This discretionary power can create an environment where some doctors prioritize their personal interests, such as financial gains from private channels, over the best interests of their patients.
• Lack of Active Interest: Although the time taken to settle claims was reasonable, the proportion of settled claims in public facilities was lower compared to private facilities. This points to potential issues in operational dynamics that may hinder the effective implementation of the scheme and limit its benefits for the poor.
• Inadequate Incentives: The financial incentives provided to doctors in public facilities under PMJAY may not be sufficiently attractive to encourage them to actively participate in the scheme. Some doctors may find greater financial gains through rent-seeking practices with private players, leading to a preference for private alternatives over the government-sponsored scheme.
• Limited Supporting Staff: The presence of limited supporting staff, such as Arogyamitras, responsible for registering patients under PMJAY, may impact the smooth implementation of the scheme. The Arogyamitras’ remuneration being linked to pre-authorizations rather than claim settlement may result in less emphasis on claim follow-up and documentation.

Way forward: Steps to improve operational dynamics

• Enhancing Doctor Incentives: Reviewing and revising the financial incentives provided to treating doctors could make the PMJAY scheme more attractive and encourage greater participation.
• Strengthening Arogyamitras’ Role: Linking the remuneration of Arogyamitras to the successful claim settlement and providing necessary support staff can incentivize them to be more proactive in claim documentation and follow-up.
• Streamlining the Claim Settlement Process: Simplifying and expediting the claim settlement process can encourage public facilities to actively participate in PMJAY, ensuring timely reimbursements and improving their financial viability.
• Increased Oversight: Implementing regular audits and stringent penalties for fraudulent practices can help curb deceptive activities and enhance transparency and accountability within public facilities.

Conclusion

• While the potential of PMJAY has been extensively discussed in the context of private hospitals, the operational dynamics within public facilities have received less attention. A collaborative effort involving doctors, Arogyamitras, and state governments can unleash the true potential of these schemes, contributing to improved health outcomes and greater inclusivity in healthcare services.

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