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PMJAY Will Not Cover Cataract Ops, Dialysis, and Normal Deliveries

In the first trimming of the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana since its launch, the National Health Authority (NHA) is planning to remove procedures covered under existing national programs from the list of packages approved for reimbursement under PMJAY. This means procedures like cataract surgeries, dialysis and normal deliveries will not be covered by the flagship health scheme. “PMJAY has just completed 150 days and our learning is that there is a need to streamline packages, so that there is no duplication. Procedures or diseases for which there is already an existing national program, do not need to be covered under our packages. We are looking at the packages and will trim them so that there is no overlap,” NHA CEO Dr Indu Bhushan told The Indian Express. Cataract surgeries have topped the list of claims submitted under PMJAY. In the first three months of PMJAY — until November 24, 2018 — 6900 claims had been submitted for cataract surgeries even though they are done for free under the National Blindness Control Program (NBCP).

In 2017-18 alone, 15,91,977 surgeries were performed under NBCP, which dates back to 1976. While the NHA is planning to leave out normal deliveries from the ambit of PMJAY because there are a host of national programs for mother and child health, high-risk deliveries will continue to be covered. The Pradhan Mantri National Dialysis Program was rolled out in 2016 under which dialysis is already provided free of cost. Diseases for which there are existing national programs and for which treatment is reimbursed under PMJAY for specified rates include tuberculosis, chronic kidney disease (dialysis), leprosy, malaria, HIV-AIDS and mental health disorders. For many diseases like malaria, where surgeries are not established protocol for treatment, PMJAY approves a daily hospitalization cost of Rs 2000. The NHA is also in talks with the National Pharmaceutical Pricing Authority (NPPA) to negotiate special rates for implants or other devices that are used under PMJAY to further bring down costs.

While the board of the newly constituted health authority is yet to have its first meeting, the NHA with more than 1.5 crore cards already issued is looking at ways to ensure quality of services in hospitals that are empanelled under the program. Working with the Department of Health Research (DHR), NHA has fallen back on the standard treatment guidelines (STGs) that were prepared mostly during the UPA rule for the implementation of the Clinical Establishments Act (CEA). The Act was designed to be the instrument of regulation for the private sector in healthcare but with most states choosing to go with their own Acts rather than adopt the central act, the STGs fell between the governance cracks. “We are looking at those STGs with the DHR. We will probably make some changes in them but we are committed to ensuring quality. There is also a lot of work we need to do for raising awareness about the scheme especially in states like Uttar Pradesh and Bihar which were late entrants into the scheme,” Bhushan said. – Indian Express


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