Not Quite Healthy- PMJAY has design flaws which may limit its potential to lower out-of-pocket expenditure

Source: The post is based on the article “Not Quite Healthy- PMJAY has design flaws which may limit its potential to lower out-of-pocket expenditure” published in “Times of India” on 11th August 2023.

Syllabus: GS2- Welfare schemes for vulnerable sections of the population by the Centre and States and the performance of these schemes;

News: In this article author reviews the five-year performance of Pradhan Mantri Jan Arogya Yojana (PMJAY), India’s health insurance scheme, referencing a CAG report that found database errors. The article also discusses hospital disparities in states and suggests improvements to decrease out-of-pocket costs.

What does the CAG report say about PMJAY?

1. Data Issues: The CAG report revealed several problems with PMJAY’s data. Notably, the PMJAY Id, which should be a unique 9-digit alphanumeric code, had duplicates. This means multiple beneficiaries could have the same identification, leading to confusion and potential fraud.
2. Age Discrepancies: There were inaccuracies related to beneficiaries’ ages. Some of the records showed beneficiaries born in the 19th century, indicating significant errors in the database.
3. Impact on Costs: GOI data showed that the average hospitalization cost in 2022-23 was ₹13,703, which is less than 3% of the total cover of ₹5 lakh per family. This figure seemed inconsistent with the typical rise in medical expenses, making it a potential concern in the CAG report.
4. Need for Stronger Oversight: The report suggests that without proper data and process controls, dubious healthcare providers could exploit the system, emphasizing the need for a tighter grip on information and procedures.

What should be done?

Data Integrity: Rectify database issues, ensuring PMJAY Ids are unique and correct age discrepancies, like those born in the 19th century.

Hospital Availability: Increase the number of empaneled hospitals, especially in poorer states like Bihar which, despite having a population exceeding Tamil Nadu by 50 million, has less than half its number of empaneled hospitals.

Protect Patients: Address issues in public hospitals where patients are reportedly defrauded or denied PMJAY benefits.

State Health Authorities Role: SHAs, being the primary administrators, should enhance their oversight and efficiency.

Independent Audit: The government should commission an independent audit to assess PMJAY’s impact on out-of-pocket expenses.