J&K Government Considers Removing Key Surgeries Under Ayushman Bharat Scheme in Private Hospitals

Limited Insurance Coverage: Increasing the burden on private hospitals and patients, expected to start from March 15, 2025

AB-PMJAY policy shift can have a major impact on the patient and healthcare sector (Image: Wikimedia commons)Manoj Kumar

Published on:

23 Jan 2025, 6:15 pm

As per the latest policy shift by the Jammu & Kashmir Government (J&K) on January 22nd, it said, in the private sector the four key surgical procedures will no longer be available to claim under the Ayushman Bharat Scheme starting March 15.

However, J&K Chief Secretary Atal Dulloo who chaired the 9th Governing Council Meeting of the SHA, proposed to reserve certain surgeries only in public hospitals (including lap cholecystectomy, hemorrhoidectomy, appendectomy, and more) not in private hospitals.

The shift is under consideration and can have a major impact on the patient and healthcare sector.

Burden on Patients and Public/ Government Hospitals:

Long waiting hours for the patients in public hospitals (up to 4-5 months)
Increased work pressure on surgical staff and facilities
Prolong delays may lead to complications such as pancreatitis
The economic burden on poor patients

Patients will have dates for these procedures months ahead, as is the case for any procedure in our government hospitals which are so overloaded.

Atal Dulloo, IAS, J&K Chief Secretary

Private Hospital Under Financial Losses:

Private hospitals that perform 57% of these surgical procedures under the Ayushman Bharat Scheme, will face financial losses once the decision is official. Additionally, a 10% reduction in package rates at private hospitals would be implemented. To this a private hospital owner said, “This reduction may not keep pace with rising inflation, cost of medicines, supplies, and staff salaries”.

In the private hospitals key surgical procedures will no longer be available to claim under the Ayushman Bharat Scheme (Representational Image: Wikimedia commons)

SHA officials said that no final decision has been made yet.

The government is still evaluating the impact of these policy shifts and accordingly will make a decision on whether to continue the scheme under an insurance or trust mode.

Sanjiv Gadkar, CEO of the SHA highlighted the significant progress made under the AB-PMJAY and PMJAY-SEHAT. Out of 3.36lakhs claims submitted, 1.22 lakh claims worth ₹222.58 crore have already been paid. While over 3.19 lakh claims have been rejected, due to increased fraudulent activities and duplication of Ayushman Bharat Gold Cards.

The SHA has been requested to hire an insurance company to manage the plan, which could expedite the process and reduce administrative costs.

Summary

In conclusion, the Chief Secretary said to:

Implement stronger monitoring to prevent fraudulent activities
Develop new guidelines for claim utilization
Create a portal/website for public hospitals that facilitates improved fund transfer management
Implementing the updated AB-PMJAY guidelines, including ensuring coverage for those aged 70 and above.

In case these policy shifts get officially confirmed, they can reshape the healthcare dynamics in J&K.

(Input from various sources)

(Rehash/ Dr Disha Merlyn Mathias/MSM)

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