The free cashless health insurance scheme for the poor, Pradhan Mantri Jan Arogya Yojana (PM-JAY) or Ayushman Bharat completed a year on September 23. The National Health Authority (NHA) which implements the scheme stated that 46.4 lakh had received treatment through hospitalisation under the scheme. However, the past year has thrown up multiple challenges for the plan.

One such challenge is to strengthen its fraud control mechanisms. NHA said in its press release that patients availed free treatment worth nearly ₹7,500 crore . This means that the average cost of treatment per patient in the scheme comes up to ₹16, 164. The average promised annual cover of five lakh rupees per family is way higher than the average cost of treatment of a patient, considering that it is highly unlikely that all family members will avail the benefit in the same year.

Read also: Fraudsters threaten to bleed Ayushman Bharat scheme

Health officials had earlier told BusinessLine that a higher cover opens up a window for fraud, where unrelated ineligible beneficiaries are admitted based on forging a relationship with the head of the beneficiary family, thus exhausting the wallet of the family. This fraud is perpetrated by forging marriage certificates or adoption papers, for instance, by local entrepreneurs at common service centres (CSCs) who make e-cards for enrolling patients. This has led to the NHA filing multiple police complaints. While NHA claims in its statement that nine hospital admissions are made every minute, and over ten crore e-cards have been created, there is no full-proof way for the government to instantly know if that admission is fraudulent or a ghost admission. The challenge that lies ahead for NHA is to strengthen artificial intelligence to pick up all such instances of fraud.

After a year of rolling out the scheme, political skirmishes have led to Delhi, West Bengal, Odisha and Telangana keeping an arm’s length from the scheme. NHA has also said that close to 18,236 hospitals, of which 53 per cent are private, especially multi-speciality. Be that as it may, big corporate hospitals have chosen to stay away saying that the scheme is non-viable and that they are not able to meet their costs if they met out treatment at prices that the scheme demands.

Even after a year, the cost revisions in PM-JAY for package procedures, for example, an angioplasty, or a knee replacement have not been made public. Officials have suggested that the cost revisions will mostly be upward, to attract the big corporate hospitals to participate. Meanwhile, as states who were already running state-based government-run insurance programmes, like Maharashtra and Tamilnadu, protested saying PM-JAY procedure rates were non-viable, the centre gave them levy to stick to old rates designed by the state before the scheme was launched. Thus PM-JAY rates remained a mere guideline, which has either kept big hospitals at bay or have not been followed by states.

While patients in 32 states and union territories sought benefit of the scheme since the past year, including Jammu and Kashmir, what sticks out like a sore thumb in midst of laurels, is the impact that abrogation of Article 370 and subsequent clampdown on internet has had, on the functioning of the scheme, in months of August and September.

NHA has said that to enable PM-JAY swiftly and effortlessly, Information Technology provides a robust backbone to the scheme’s implementation throughout the county. With the internet down, private hospitals who were earlier striving to keep the scheme functional in Kashmir, on the treat first pay later offline mode, have incurred pending payments of lakhs of rupees. They are slowly citing non-affordability as a reason to discontinue treatment under the scheme. In August, hospital admissions saw a sharp decline, while they were rising month-on-month before August.

Ensuring seamless connectivity in regions of turmoil like Kashmir or empanelling hospitals in remote areas like the north-east and Leh remains a challenge. Going forward, hopefully, there will be more equanimity in access for Ayushman Bharat, which remains crucial for the treatment of sick people, a year down.