On Monday, the Gujarat government released updated rules for the Pradhan Mantri Jan Arogya Yojana-Mukhyamantri Amrutam (PMJAY-MA), pointing out infractions committed by certain private institutions that are empanelled.
Guidelines for the three primary treatments—cardiology, neonatal, and oncology—as well as additional surgeries including complete knee and hip replacements, were released by Health Minister Rushikesh Patel. He claimed that when he released these new standards, every detail was considered to ensure that there would be no room for malpractice or illegal behavior.
The Center’s health insurance program, PMJAY, seeks to offer each family Rs 5 lakh in annual health coverage. In Gujarat, it has been combined with the MA program run by the state government.
Cardiology
The cardiology cluster will only recognize centers that have a cardiologist and a cardiothoracic surgeon on staff full-time. These hospitals also need to have a physiotherapist and cardiac anesthetist on staff full-time. Patel added that when emergency care is required, facilities that only provide cardiology services may occasionally perform angioplasty. At the time of the pre-operative evaluation, hospitals must upload the CD or video footage of the angiography and angioplasty operations. After therapy is over, this CD or videography needs to be uploaded in an emergency.
Oncology
Patel talked on the standard operating procedure (SOP) for cancer therapy, stressing that each cancer patient’s unique needs will be taken into account when creating a treatment plan. This choice will be made by a multidisciplinary panel of radiation, surgical, and medical oncologists during a tumor board meeting. It will also be necessary to upload the tumor board certificate as part of this procedure.
The radiation therapy packages have undergone the necessary changes to give cancer patients greater freedom in choosing the best course of treatment. It is now required to collect a CBCT (Cone Beam Computed Tomography) image in kilowatts during Image Guided Radiation Therapy (IGRT) in order to guarantee that patients receive the best care possible.
Comprehensive guidelines have been developed that specify which tumors qualify for this treatment. In accordance with the quality control requirements established for the radiotherapy equipment, hospitals also have to keep records.
Additionally, only hospitals with brachytherapy facilities are permitted to treat women with diseases that need brachytherapy, including as tumors of the vaginal tract or oral cavity, under PMJAY. Hospital partnerships for brachytherapy services will not exist.
Neonatal care
In response to input on neonatal care, especially for children in the intensive care unit, new recommendations have been developed. To guarantee that babies in the Neonatal Intensive Care Unit (NICU) or Special Newborn Care Unit (SNCU) receive high-quality care, hospitals must install CCTV cameras while protecting the privacy of mothers. The Taluka Health officer must also make routine visits to the NICUs and report back to the State Health Agency. To enable efficient monitoring of these visits, an online visit module site will shortly be up and running. In order to guarantee that children receive treatment around-the-clock, institutions that are empanelled in the neonatal specialty are required to employ full-time pediatricians.
Orthoplasty
Under the PMJAY program, the state government had earlier created a new SOP for TKR and THR. Hospitals that conduct TKR and THR are required to treat “orthopedic and polytrauma” cases as part of this process. In particular, at least 30% of hospital cases must need orthoplasty. A hospital will be penalized if it does not comply with this criteria. A hospital will also be prohibited from offering services in the “Orthoplasty” specialty if it fails to maintain this percentage for nine months in a row. Due to their failure to comply with TKR standards, up to 75 hospitals under the PMJAY plan have been penalized Rs 3.51 crore.
It is significant to note that complaints about criminal activity and system norms have resulted in suspension, de-empanelment, and penalties for over 14 private hospitals in Gujarat that are affiliated with the PMJAY plan. Due to wrongdoing, these hospitals have been fined over Rs 18 crore as of 2024.
In certain instances, the Medical Council has taken the required actions in addition to permanently dismissing physicians from the program.
Additional guidelines
According to Patel, the scheme has also produced other guidelines in addition to the updated guidelines for three main surgical procedures.
The Clinical Establishment Act of 2024 mandates that a consent form be obtained with a video recording while giving the patient and their family members a thorough description of the predetermined treatment process.
Amputation, coronary artery bypass surgery, angiography, angioplasty, all “ectomy” surgeries, and organ donation, transplantation, and retrieval surgeries are among them. For procedures including brain, spinal, and cancer surgery, video consent will be required.
The discharge statement must include all diagnostic data, including radiological and laboratory results, in order to assist further treatment.
The Government of India’s infection control and prevention guidelines must be followed by all Gujarati hospitals. In order to closely supervise treatment-related activities at all of the state’s hospitals, the State Anti-Fraud Unit (SAFU) has been reinforced.
To stop private hospital fraud, a distinct team comprising government and GMERS medical college members has been formed. This team will visit the hospitals that have been empanelled in their respective districts to perform comprehensive treatment checks, as instructed by the SAFU team. The government will be notified of any grievances that recipients may have.
At least two hospitals must be visited by the chief district health officer (CDHO) or medical officer of health (MOH) on a monthly basis for audit purposes.
The field audit team will perform field audits on two to three percent of the cases every day as part of the third-party audit, which will be organized through the tender process.
The insurance fund has increased the number of specialists and super specialists available for desk and field audits.
The National Health Authority (NHA) has been asked to provide the required triggers in order to stop hospitals from potentially abusing treatment packages.
PMJAY-MA in numbers
According to Patel, as of December 4, 2024, the state had paid out Rs 15,562.11 crore, or 72,79,797 claims, under the PMJAY-MA scheme.
Between July 11, 2023, and July 10, 2024, 24,701 claims totaling Rs 41.18 crore were denied, while 1,16,266 cases totaling Rs 121 crore were subtracted from the state’s PMJAY-MA program.
The 104 helpline is used to get in touch with patients admitted under the PMJAY-MA program and gather their opinions about their care.
The total number of patients phoned between November 2023 and November 2024 was 4,96,184. Only 0.3 percent (1,488 patients) reported a bad response, 0.6 percent (2,897 patients) showed a moderate response, and 99 percent of them gave a positive response.
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