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Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY)

Topics Covered: Issues related to Health.

Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY):


Context:

The National Health Agency (NHA) has released its data on “The role of private hospitals”. Key findings:

  1. Patients seeking care at private hospitals tend to be older and a larger share consist of men compared with those seeking medical care at public hospitals.
  2. Private hospitals account for over half of the empanelled hospitals, nearly two-thirds of claim volumes, and three-quarters of claim outlays in the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY).
  3. The top PM-JAY packages by value — including knee replacement, cataracts, haemodialysis and cardiovascular surgeries — are overwhelmingly provided by private hospitals.
  4. Over 72% of private empanelled hospitals are located in just seven States: Uttar Pradesh, Rajasthan, Tamil Nadu, Gujarat, Maharashtra, Punjab and Karnataka.

Challenges and Concerns:

  1. Medical audits have also revealed that private hospitals are more likely to indulge in fraud and abuse than public hospitals and more likely to discharge patients early post-surgery to cut costs.
  2. Ensuring the accountability of private hospitals to provide efficient and high-quality care is a pre-eminent challenge for scheme implementation.
  3. There is huge State-wise variation in the share of empanelled private hospitals from less than 25% in most of the northeastern and hill States to 80% in Maharashtra.
  4. Private hospitals have fewer beds than public hospitals and are more likely to be empanelled for surgical packages and super-specialties.

What needs to be done?

Offering a robust public sector alternative in the form of high-performing government hospitals serving as a market anchor will be one element of such an approach.

Key Features of PM-JAY:

  1. The world’s largest health insurance/ assurance scheme is centrally sponsored and is jointly funded by both the central government and the states.
  2. It provides cover of 5 lakhs per family per year, for secondary and tertiary care hospitalization across public and private empaneled hospitals in India.
  3. Coverage: Over 10.74 crore poor and vulnerable entitled families (approximately 50 crore beneficiaries) are eligible for these benefits.
  4. Provides cashless access to health care services for the beneficiary at the point of service.

Eligibility:

  • No restrictions on family size, age or gender.
  • All pre–existing conditions are covered from day one.
  • Covers up to 3 days of pre-hospitalization and 15 days post-hospitalization expenses such as diagnostics and medicines.
  • Benefits of the scheme are portable across the country.
  • Services include approximately 1,393 procedures covering all the costs related to treatment, including but not limited to drugs, supplies, diagnostic services, physician’s fees, room charges, surgeon charges, OT and ICU charges etc.
  • Public hospitals are reimbursed for the healthcare services at par with the private hospitals.

InstaLinks:

Prelims Link:

  1. Components of Ayushman Bharat.
  2. PMJAY- Key features.
  3. Eligibility.
  4. About the National Health Agency.

Mains Link:

Discuss the significance and potential of PMJAY.

Sources: the Hindu.