Will More Patients End Up Being Excluded From Insurance Cover Under PMJAY?

Ayushman Bharat, the National Health Protection Scheme, rechristened as Pradhan Mantri Jan Arogya Yojana (PMJAY) while being informally launched by Prime Minister Narendra Modi this Independence Day, was hailed as the saviour of 10 crore poor families across the country who were assured insurance cover worth Rs 5 lakh for hospitalisation charges. But the much publicised insurance scheme has put many premier hospitals, such as the All India Institute of Medical Sciences (AIIMS), Delhi and Bhubaneswar, in a fix with regard to reimbursements, which may result in non-inclusion of patients, especially those hailing from other states. For example, the patients hailing from Bihar may find it difficult to get treatment as the question of payment looms: who will pay for their treatment,the Bihar Government or the National Health Agency? Incidentally, AIIMS Delhi receives almost half of its patients from outside Delhi.

Both AIIMS (Delhi and Bhubaneshwar) have reportedly written to the Union Health Ministry seeking clarification on reimbursement for services given to patients coming from outside Delhi. The hospital authorities maintain that "in principle" they will be joining the scheme but the provisions should also consider their interests. 

AIIMS Delhi Director Rakesh Guleria said that the institute should have the liberty to negotiate the terms of the memorandum of understanding (MoU). “The MoU will have to build in these concerns. A PMJAY beneficiary who comes to the hospital will have to wait his turn along with other patients, he cannot jump the queue just because he is a PMJAY beneficiary. There are also other concerns — like we do not do normal deliveries, only complicated ones. That cannot change. We should be able to choose what procedures to do and what packages to offer under PMJAY,” Guleria was quoted by The Indian Express as saying.

Odisha and Delhi have still not signed the MoU with the National Health Agency, the nodal agency for implementing the scheme. Wary of the provisions of the scheme, Odisha announced its own scheme, Biju Swastha Kalyan Yojana, to protect 70 lakh families across the state.

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The stalemate is likely to engulf other hospitals like Ram Manohar Lohia and Lady Hardinge in the National Capital.

The entire scheme is to be implemented on the basis of the socio-economic census conducted in 2011 which had failed to identify many vulnerable families. Similarly, health experts maintain that the NHPS is already replete with lacunae and it will only make things worse. Also, the implementation of such a huge scheme should be accompanied by an enabling infrastructure, and with no investment in health sector, comprehensive coverage appears to be a distant dream.

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Prominent health expert, Indraneel Chatterjee,, said that the patients of Delhi already have access to many state government and municipal corporation hospitals. He said, "NHPS mandates coverage through private insurance companies. The experience of such schemes have already established that they have failed miserably in providing insurance coverage to a large section of marginalised families in rural areas." 

"The government has not addressed the question of investment and regulation. I think these questions require much attention", he added.