The state government in Gujarat has ordered a blanket ban on medical camps pending strengthening of regulatory frameworks of the PMJAY-MA (Pradhan Mantri Jan Arogya Yojana-Mukhyamantri Amrutam) scheme. Deployment of specialist and super-specialist doctors to crosscheck claims, new enforcement directives for the State Anti-Fraud Unit (SAFU) and implementation of SOPs regarding stringent checks in empanelment of hospitals and allocation of packages under the national health insurance scheme amid alleged abuse by several hospitals and doctors that has not just put people’s lives at risk but also taken several lives: these are said to be the aspects in focus amid concerns over recent deaths and fraud cases linked to the government scheme in Gujarat.
The order for the statewide ban on medical camps was received by the Chief District Health Officers (CDHOs) on Thursday. The Indian Express has also accessed a copy of the order, which says that the state government “discourages all hospitals under the Ayushman Bharat PMJAY-MA scheme to conduct medical camps and if they do so, disciplinary action will be taken against them as per guidelines of the scheme.”
The Indian Express has further learnt that when the ban on medical camps is finally lifted, the state government will make it mandatory to seek permission from the CDHOs. Any hospital will be able to conduct such camps only after the permission is granted and even after that, a strict eye will be kept on their activities, officials suggested.
Giving details of the new procedure put in place, a senior health department official said, “Once permission is granted by the CDHO, the particular Taluka Health Officer (THO) will appoint an officer to attend and scrutinise the proceedings of the medical camp. At the end of this camp, the officer will collect the details of all patients who attended this camp. When and if these patients undergo procedures under the PMJAY-MA scheme, it will help in cross checking and stalling any fraud attempts and foul play right at the initial stage.”
The action comes in light of a case linked to the government health scheme that was unearthed at Khyati Multispeciality Hospital in Ahmedabad. Nine officials of the private hospital stand accused of culpable homicide not amounting to murder, attempt at culpable homicide, and criminal conspiracy among other serious crimes after two men — Mahesh Girdhar Barot (52) and Nagar Moti Senma (75) — died. The two men died after angioplasty was conducted on seven scheme beneficiaries from Borisana village in Mehsana on November 11 following a medical camp.
Senior officials confirmed that the surgeries on the five survivors and the two deceased were conducted without a medical cause.
A joint health and police investigation into this scam has revealed that the hospital conducted 13 free medical camps in as many villages in a very short amount of time. Further, health officials confirmed that investigation was underway into at least three more deaths reported by families of the two deceased whose angioplasty were conducted following free camps in their villages — all in Mehsana district. These complaints were filed with the Vastrapur police in Ahmedabad on November 20.
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State Health Minister Rushikesh Patel, in a review meeting of PMJAY-MA scheme on Saturday, sought detailed information regarding the entire operation, management, pre-authorisation generation and claim approvals. “Malpractice of doctors or hospitals that compromise human life in the guise of treatment will not be tolerated at any cost. The strictest and exemplary action will be taken against those who engage in such activities,” he said. The Minister also urged officials to take steps to ensure that no errors or loopholes remain in the system.
Additional Safeguards to be Implemented for PMJAY-MA
A statement from the Gujarat Health Department on Saturday underlined that additional regulatory frameworks and safeguards are being incorporated into the scheme. These include regular and flying squad inspections of empanelled hospitals by SAFU, visits during treatment of patients, new guidelines for cardiovascular, cardiology, pediatrics, radiology and chemotherapy; two visits by CDHO to each hospital per month; performance based incentives to hospitals; informed consent through Audio-Visual method for specialised treatment; and mandatory uploading of CDs showing details of Angiography (CAG) & Angioplasty (PTCA) procedure for claims.
Further, changes are also on the anvil in the Gujarat Clinical Establishment (Registration and Regulation) Act. Officials said that the National Anti-Fraud Unit (NAFU) will also be informed of the loopholes found in Gujarat so that they can be fixed at the national level.
However, in the cases related to Nihit Babycare Children Hospital in Rajkot and Khyati Multispeciality Hospital in Ahmedabad where forged medical documents were allegedly uploaded to make illicit claims under the PMJAY-MA scheme, the fraud was said to have gone undetected for several months.
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When asked about a possible solution, a senior official said, “False claims cannot be triggered by the system itself. So, for these cases, we are strengthening the manpower of the SAFU which will inspect hospitals at any time, even during surgeries. Further, we are hiring more specialist doctors to check the claims because we need experts with expertise equal to those making the claims.Also,, the insurance companies associated with PMJAY-MA have been asked to make sure they regularly seek opinions from super-specialist doctors to crosscheck claims.”
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