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Fraud was detected at 341 hospitals in 16 Indian states during the first year of the Ayushman Bharat scheme’s implementation, the Union government said. An amount of Rs 230 lakh has been recovered by the government from these hospitals.
Action against as many as 55 hospitals was taken in Gujarat for frauds under the scheme and Rs 12.63 lakh recovered from them, according to the annual report released by Union Minister of Health and Family Welfare Harsh Vardhan on September 30, 2019.
The maximum recovery was in Uttarkahand — Rs 1.05 crore from 18 hospitals against which fraud had been detected.
Sixty-three hospitals in Maharashtra had been under the scanner and Rs 53 lakh was recovered from there. Tamil Nadu, Chhattisgarh and Uttar Pradesh also figured in this infamous list, with action being taken against 51, 76 and 30 hospitals respectively in these states.
“We are aware and have therefore delisted 111 hospitals to send a message,” Vardhan said at an event, ‘Arogya Manthan’, celebrating a year of the Modi government’s ambitious health scheme.
He added that the names of these hospitals had been put on the website of National Health Authority (NHA) under the ‘name and shame’ policy. He also said artificial intelligence would be used to detect frauds.
According to the annual report, 46.5 lakh hospital treatments were given under the scheme. Out of these, 24.7 lakh patients were treated by private hospitals in the last one year and the rest by public ones.
As many as 8,571 government hospitals and 9,665 private hospitals had been empanelled in one year.
Key data missing
However, there was no data available on the NHA website or in the public domain about which surgeries had been performed the most.
Experts said this was the most crucial information as it might reveal whether those surgeries which provide undue profits to hospitals were being performed the most.
The non-availability of this set of data remains one of the major criticisms of the scheme. There is a dashboard of the scheme but it has not been made accessible to the public. Just not the surgeries but some of them which require implants, like hip implant or a stent for the heart, are also part of the package under this scheme.
Another document released by the government on the occasion, Lessons learnt in one year of implementation of PM-JAY (Pradhan Mantri Jan Arogya Yojana) stated that as the scheme matured, it was observed that with the imposition of implants, the potential for arbitrary variation in quality arose. Huge rate differences of the same procedures in different states could also lead to irregularities in the scheme, the document stated.
PM-JAY is an umbrella health scheme under which Ayushman Bharat is implemented.
Quality control
Quality control remains another grey area in the scheme. “It was observed that low volumes of certified hospitals are currently empanelled under PM-JAY,” Lessons learnt said. Out of 18,019 empanelled hospitals, only 603 were quality accredited or certified.
To remove this anomaly, the minister said the hospitals now being empanelled under the scheme would have to be uncredited by the National Accreditation Board for Hospitals (NABH), which certifies that hospitals are providing a certain quality of care according to the standards prescribed by it.
Among the 32 states and union territories which are part of the scheme, Rajasthan had the maximum number of hospitalisations. As many as 122 hospitalisations per lakh population took place in a year there.
It was followed by Chhattisgarh and Kerala, with 114 and 98 hospitalisations per lakh population in their respective states. Tamil Nadu, Haryana and Andhra Pradesh paid the highest per cent of claims to the insurance companies under the scheme.
IMA’s concerns
Vardhan refused to look into the concerns expressed by the Indian Medical Association (IMA) regarding the scheme’s rates being low for the private sector.
Addressing the event, Vardhan said the IMA’s demand of excluding government hospitals was also ill-founded. “The IMA neither has a vision nor rationale or any sort of understanding of the scheme. It needs to study the scheme afresh,” he said in response to a media query on the issue.
The IMA should understand that government hospitals had not reached where private hospitals had, he added.
Incidentally, a day before ‘Arogya Manthan’, the IMA had organised a meet where it had said even the revised rates of various treatments that were being offered to the private sector, were unviable for it operate.
It feared that the whole bid of the government to increase the participation of private hospitals in the scheme could end in vain with these revised rates. The rates of more about 270 packages were revised earlier this month
Odisha, Delhi, Telangana and West Bengal have refused to be the part of the scheme. “I can only hope that they come on board soon,” Vardhan said in response to a query.