Ayushman Bharat-PMJAY

Ayushman Bharat-PMJAY:

About:

• • The largest health insurance and assurance program in the world, PM-JAY is fully funded by the government. 
  • It was introduced in February 2018 and provides a sum insured of Rs. 5 lakh per family for both tertiary care which requires a super specialist and secondary care, which does not.
  • Beneficiaries of PMJAY are given cashless and paperless access to services at the point of service, which is the hospital. 

• • Health Benefit Packages pay for diagnostics, medications, surgery, medical care, and daycare expenses. 

Packaged rates: 

• • These are prices that cover everything, preventing separate charges for each good or service.
    These are adjustable, but once set, the hospitals are not allowed to charge the beneficiary more. 

Recipients: 

• • Based on the most recent socioeconomic caste census (SECC) data, the beneficiaries of this entitlement-based program are identified. 
  • The beneficiary is deemed insured once the database identifies them, and they are free to enter any hospital that has been accredited. 

Finances:

• • The program is funded in the following proportions: 100% central funding for UTs without a legislature, 90% in Northeastern states, Jammu and Kashmir, Himachal Pradesh, and Uttarakhand, and 60:40 for all states and UTs with their own legislatures.

Nodal Organization: 

• • Under the Society Registration Act, 1860, the National Health Authority (NHA) was established as an independent body to carry out PM-JAY in cooperation with state governments. 

Main Objectives of AB-PMJAY

• • To ease the beneficiaries’ financial burden of out-of-pocket (OOPE) medical expenses. 
  • To increase the beneficiaries’ access to and affordability of healthcare services.
  • To improve the nation’s healthcare delivery systems’ effectiveness and quality.
  • To encourage the beneficiaries’ use of preventive, promotive, and curative health interventions 
  • The State Government’s highest authority, the State Health Agency (SHA), is in charge of implementing AB PM-JAY throughout the State. 

Challenges of AB-PMJAY

Lack of Awareness:

• • Potential beneficiaries of the program are not well-informed, particularly in rural areas. 

• • A large number of eligible beneficiaries are unaware of their benefits or how to use them.

• • To raise awareness and demand, the program’s outreach and communication efforts must be strengthened. 

• • The country’s unequal distribution and availability of healthcare infrastructure and human resources present a supply-side constraint for the program.

• • There is a dearth of empanelled hospitals in many states, particularly in rural and tribal areas. 

Reimbursement Issues:

• • Ensuring prompt and sufficient reimbursement of claims to the empanelled hospitals, particularly the private ones, is a challenge for the scheme. 
  • Numerous hospitals have voiced concerns about lengthy procedures, low package rates, high denial rates, and delayed payments. 
  • To maintain the scheme’s sustainability and viability, it is necessary to expedite and streamline the claim settlement process and to periodically review the package rates. 

Fraud and Abuse:

• • The program must guard against and identify instances of fraud and abuse by dishonest people looking to take advantage of it for their own gain. 
  • The Comptroller and Auditor General of India recently disclosed that a single cell phone number (9999999999) was connected to almost 7.5 lakh beneficiaries. 
  • It is imperative to fortify the anti-fraud mechanisms and implement stringent measures against individuals who engage in fraudulent or negligent activities under the scheme. 

Future Prospects of AB-PMJAY

Transformation: 

• • By offering universal health coverage to half of India’s population, the program has the potential to completely change the country’s healthcare system.

• • The program can help achieve the Sustainable Development Goal, which calls for providing universal health coverage for all people by 2030. 

Integration: 

• • By connecting the nation’s primary healthcare system with the secondary and tertiary care systems, the program can also serve as a catalyst for bolstering that system. 
  • The program has the potential to enhance healthcare services’ accessibility, affordability, and quality by utilizing digital health technologies. 

Development:

• • By lowering poverty, raising productivity, and advancing social justice, the program can also have a positive effect on the nation’s socioeconomic development.
  • The program has the potential to create jobs and boost the health industry’s economy. 

Recommendations for Improving AB-PMJAY

Provision of Ayushman Card:

• • Every potential beneficiary should be given an Ayushman Card as part of the program, which can function as a pre-paid card worth Rs 5 lakh and be used to receive free medical care at any hospital that has an affiliation. 

• • Beneficiary identification and verification may be less complicated and time-consuming as a result.

Scope:

• • The program ought to broaden its scope and coverage by incorporating additional medical conditions, treatments, and services within its purview. 
  • A significant portion of OOPE for many beneficiaries is made up of outpatient care, diagnostics, medications, etc.; these should also be covered by the plan.
    

Convergence:

• • To prevent duplication, fragmentation, and confusion, the plan should improve its coordination and convergence with other health schemes and programs at the federal and state levels. 
  • In order to take advantage of their resources and experience, the plan should also promote cooperation and partnerships with a range of stakeholders, including academic institutions, businesses, and civil society organizations.