Study in Chhattisgarh Analysed PM-JAY Implementation

• 08 May 2024

Why in News?

Recently, a study by researchers from the state health resource centre in Chhattisgarh anaylsed the Pradhan Mantri Jan Arogya Yojana (PMJAY).

• PMJAY aimed to reduce out-of-pocket health expenses, particularly during hospital stays.

Key Points

• The study revealed that patients utilizing the scheme faced high out-of-pocket costs, notably in private hospitals, largely due to the common occurrence of dual billing.
• The study was conducted in 2022 by researchers of the State Health Resource Centre in Chhattisgarh, by interviewing 768 individuals who had used PMJAY for hospitalisation in the month preceding the interview. PMJAY has empanelled 1,006 public and 546 private hospitals in the state.
  • Private hospitals were found to be charging patients even though they are not supposed to under PMJAY or Ayushman Bharat.
  • They would then claim reimbursement from the government for the same treatment, engaging in dual billing, which is considered fraudulent.
• The utilization of private hospitals was identified as the primary factor leading to severe financial burden under PMJAY.
  • About 30% of stays in private hospitals resulted in catastrophic health expenses, exceeding 10% of a household's total yearly non-medical spending.
• The research revealed that marginalized groups like scheduled tribes and women heavily relied on public hospitals, despite the accessibility of private healthcare through PMJAY.
  • It pointed out that seeking treatment in public hospitals helped individuals avoid high out-of-pocket expenses, as public services were considerably more cost-effective for patients compared to private healthcare, regardless of being covered under publicly funded insurance schemes.
  • In India, private healthcare providers lack effective price and quality regulation, leading to the adoption of dual billing by private hospitals, which prioritize profits over patient care.
  • The study highlighted the government's failure to enforce a crucial condition in its agreements with hospitals, which prohibits additional charges to patients.

Ayushman Bharat-PMJAY

• About:
  • PM-JAY is the world’s largest health insurance scheme fully financed by the government.
  • Launched in February 2018, it offers a sum insured of Rs.5 lakh per family for secondary care and tertiary care.
    • Health Benefit Packages covers surgery, medical and day care treatments, cost of medicines and diagnostics.
• Beneficiaries:
  • It is an entitlement-based scheme that targets the beneficiaries as identified by latest Socio-Economic Caste Census (SECC) data.
    • The National Health Authority (NHA) has provided flexibility to States/UTs to use non- Socio-Economic Caste Census (SECC) beneficiary family databases with similar socio-economic profiles for tagging against the leftover (unauthenticated) SECC families.
• Funding:
  • The funding for the scheme is shared – 60:40 for all states and UTs with their own legislature, 90:10 in Northeast states and Jammu and Kashmir, Himachal and Uttarakhand and 100% Central funding for UTs without legislature.
• Nodal Agency:
  • The NHA has been constituted as an autonomous entity under the Society Registration Act, 1860 for effective implementation of PM-JAY in alliance with state governments.
  • The State Health Agency (SHA) is the apex body of the State Government responsible for the implementation of AB PM-JAY in the State.