Delay in empanelling hospitals, failure to meet standards plague PMJAY scheme: CAG

Availability of EHCPs per 100,000 beneficiaries in Assam, Dadra & Nagar Haveli-Daman & Diu, Maharashtra, Rajasthan, Uttar Pradesh was low  

By Seema Prasad
Published: Thursday 10 August 2023
In Andhra Pradesh, Jharkhand, Punjab, Tamil Nadu and Uttar Pradesh, no treatment was provided by the EHCPs. Photo: iStock

Some Empanelled Health Care Providers (EHCP) failed to meet the minimum criteria of the standards and quality prescribed, according to a performance audit of the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PM-JAY) tabled in the parliament August 8, 2023.

The EHCPs that failed to meet the standards were in 12 states and Union territories — Andaman and Nicobar Islands, Assam, Bihar, Chandigarh, Gujarat, Himachal Pradesh, Jammu & Kashmir, Manipur, Nagaland, Puducherry, Tripura, and Uttar Pradesh.

“There were deficiencies such as medical equipment being out of order, lack of basic infrastructure such as inpatient beds, operation theatres, intensive care with ventilator support systems, pharmacy, dialysis unit, blood banks, round-the-clock ambulance services,” the audit report said.

Under PMJAY, state health authorities through State Empanelment Committees (SEC) are authorised to empanel private and public health service providers in their states. This is for both secondary and tertiary care hospitalisation services.

Health cover of up to Rs 5 lakh per family per year on a family floater basis, for secondary and tertiary care hospitalisation, is provided through a network of public and private EHCPs. A beneficiary can avail of AB-PMJAY benefits in empanelled hospitals from any state.

The availability of EHCPs per 100,000 beneficiaries was very low in some states / UTs, according to the report. This was found in Assam (3.4), Dadra & Nagar Haveli-Daman & Diu (3.6), Maharashtra (3), Rajasthan (3.8), Uttar Pradesh (5).

Further, the availability of EHCPs per 100,000 beneficiaries ranged from 1.8 EHCPs in Bihar to 26.6 EHCPs in Goa. 

According to the guidelines, the states are free to decide the mode of verification of empanelment applications, either through physical verification through the district empanelment committee or using a selected insurance company. 

Physical verification was not conducted by the District Empanelment Committee (DEC) before empanelment in 163 EHCPs in Manipur (17), Tripura (103) and Uttarakhand (43). 

Moreover, in Assam (18), Chhattisgarh (65), Gujarat (20), Jharkhand (08) and Manipur (15), EHCPs treated beneficiaries for non-empanelled specialties, the CAG report stated.

In Andhra Pradesh (524 EHCPs), Jharkhand (59 EHCPs), Punjab (5 EHCPs), Tamil Nadu (19 EHCPs) and Uttar Pradesh (40 EHCPs), no treatment was provided by the EHCPs, the audit observed.

Furthermore, in 14 states / UTs, 2,733 hospitals were empanelled with delays ranging from one day to 44 months. 

In Bihar, Gujarat, Jharkhand, Punjab, Rajasthan and Uttar Pradesh, empanelment of 418 hospitals was under process with delays from two days to 873 days, with reasons like non-submission of replies of required documents, details of manpower, hospital infrastructure from hospitals as required by the DEC, the report added.

Additionally, in Himachal Pradesh (50) Jammu and Kashmir, (459), Jharkhand (36) and Meghalaya (13,418) beneficiaries were charged for their treatment in empanelled EHCPs. This resulted in an increase in the out-of-pocket expenditure for the poor beneficiaries, the report said.

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