After two beneficiaries of the Pradhan Mantri Jan Arogya Yojana (PMJAY), the world’s largest health insurance scheme, died at the Khyati Multispeciality Hospital in Ahmedabad on November 11, following unnecessary angioplasty at medical camps organised by it, the Gujarat health authorities are considering new monitoring mechanisms. These are expected to rein in any money-making efforts by hospitals through surgeries and interventions just because patients have insurance cover.
The hospital had carried out 13 free medical camps, allegedly luring villagers to Ahmedabad and prescribing heart surgeries without consent.
The corrective mechanism will operate on two fronts. First, the State Health Agency (SHA), that monitors the PMJAY scheme, has come out with guardrails for conducting free medical camps. Two, it has revised standard operating procedures (SOPs) for cardiology packages offered by empanelled hospitals. These, it hopes, will ensure checks and balances and prevent wrongdoing in the name of a scheme that is meant to make quality healthcare accessible to all and strengthen public health status. “False claims through forged medical records cannot be flagged by the system itself. So we have to do a manual inspection of hospitals at any time, even during surgeries. Further, we are hiring specialist doctors to cross-check the claims. Also, we have asked insurance companies to seek opinions from super-specialist doctors before clearing claims,” says a senior health official.
Over 36 crore Ayushman cards have been issued till date leading to 6.86 crore hospital admissions under the scheme as of December 3, 2024. These admissions have taken place across 30,900 empanelled hospitals of which 17,094 are public sector and 13,806 are private sector healthcare facilities.
What’s the role of the State Health Agency (SHA)?
The SHA, which falls under the National Health Authority (NHA), is a nodal agency responsible for implementing PMJAY in any state. The SHA can hire additional staff or engage Implementation Support Agencies (ISA) to perform required tasks. The CEO is appointed by the state government. This person is also the ex-officio member secretary of the SHA governing council, which, in turn, is headed by the state’s Chief Secretary. Along with day-to-day operations related to implementation of PMJAY in the state, the SHA is responsible for data-sharing, verification and validation of family members, awareness drives, monitoring of the scheme and fraud detection.
The SHA has district Implementation units (DIUs), which are headed by district collectors with the primary functionary being the chief district health officer (CDHO). This person coordinates with the insurer and other implementation agencies.
What is the function of the SHA ?
Since health is on the State list of subjects, each state can make its own additional regulations, incentives, safeguards, punitive measures, benefits, package price revisions, management of funds and third party evaluations for a national scheme like PMJAY. For example, the Gujarat government, under the hybrid Ayushman Bharat Pradhan Mantri Jay Aarogya Yojna – Maa Amrutam (AB-PMJAY-MA) scheme, increased the insurance cover for beneficiaries from Rs 5 lakh to Rs 10 lakh on July 11, 2023. The (public or private) insurer has a liability to pay claims up to Rs 1 lakh and the remaining is paid from a state government endorsed trust.
Why could not the Gujarat SHA detect the racket?
That’s because unscrupulous hospitals forge medical records and submit them for claims. For example, Khyati Hospital had shown up to 80-90 per cent artery blockages in both the deceased beneficiaries in order to justify angioplasty surgeries. However, the angiography CDs showed minor or no blocks at all. Similarly, 18 pathological reports of a laboratory had been manipulated by the Nihit Babycare Children Hospital in Rajkot while 98 X-rays mentioned in claims had not even been issued by the said labs. These fraudulent reports and bogus claims were uploaded to the PMJAY site. The number of healthy children unnecessarily treated at this hospital was 116.
What about SOPs for specific packages?
Principal Secretary of Health Dhananjay Dwivedi has announced that the government is in the process of introducing additional (Standard Operating Procedures) SOPs for strengthening the PMJAY scheme.
Hospitals will be empanelled for cardiology package only if:
1. Both specialties — Cardiology and Cardiovascular Surgery — must be available at the hospital. An exception has been made for angioplasty in emergency cases of heart attack patients.
2. The CD of angiography (an image of heart blockage) must be submitted while putting up the claim.
3. Hospitals must have a full-time cardiologist with minimum two-year experience post their DM/MCH degrees. A visiting cardiologist or a cardiovascular surgeon will not be recognised under PMJAY.
4. Hospitals must have a cardiac operation theatre (OT) in addition to a cath lab.
Apart from this, specific provisions on “informed consent” of the patient will be introduced for specific procedures under the Gujarat Clinical Establishment (Registration and Regulation) Act. An additional super specialist will be engaged for monitoring PMJAY’s high package volume claims.
For a hawk’s eye vigil, there will be regular inspections of empanelled hospitals, surprise visits during treatment of patients, two visits by the CDHO to each hospital per month and performance-based incentives to hospitals.
Will health camps be stopped?
According to a state government notification, the SHA will continue to “discourage” any and all hospitals empanelled under the scheme from conducting these medical camps. However, if they wish to do so, the hospital must take permission from the Chief District Health Officer (CDHO) before holding such a camp.
All medical and social data gleaned from the screening camp must be shared with the district health administration. These include the number of persons who attended the camp, the doctors and their qualifications, the primary medical diagnosis of all patients who attended the camp, and how many of the camp attendees were also PMJAY beneficiaries.
Further, the hospital will also have to inform both the district and state health departments if any of the camp attendees develop adverse reactions during follow-up treatment at the hospital. At least one taluka-level health officer has to be present for the entire duration of the medical camp.
The notification makes it clear that if, before or during the camp, there is any sort of form of coercion, false information or luring of patients that forces them to visit the hospital for a follow-up check-up, the state government would suspend the hospital from the scheme and make a legal case.