The Gujarat government on Monday issued new guidelines for Pradhan Mantri Jan Arogya Yojana-Mukhyamantri Amrutam (PMJAY-MA), noting violations by some private empanelled hospitals.
Health Minister Rushikesh Patel issued the guidelines for the three main procedures: cardiology, neonatal and oncology, and others such as total knee and hip replacement. While issuing these new guidelines, he said the new guidelines have been made with all the aspects in mind so that there is no scope for malpractice or criminal activity.
PMJAY is the Centre’s health insurance scheme, which aims to provide health cover of Rs 5 lakh per family per year. In Gujarat, it has been merged with the state government’s MA scheme.
Cardiology
It has been decided that only centres providing full-time cardiology services with a cardiologist and a cardiothoracic surgeon will be recognised within the cardiology cluster. Additionally, these hospitals must employ a full-time cardiac anaesthetist and physiotherapist. Patel further stated that, in special circumstances, centres that exclusively offer cardiology services might perform angioplasty when emergency treatment is critical. Hospitals are required to upload the CD or videography of angiography and angioplasty procedures at the time of the pre-operative assessment. In emergency situations, this CD or videography must be uploaded after the treatment is completed.
Oncology
Patel discussed the SOP for cancer treatment, emphasising that a treatment plan will be developed based on the specific needs of each cancer patient. During a tumour board meeting, a joint panel of medical oncologists, surgical oncologists, and radiation oncologists will make this decision. Additionally, uploading the tumour board certificate as part of this process will be mandatory.
Necessary amendments have been made to the radiation therapy packages to provide more flexibility in selecting the appropriate treatment options for cancer patients. To ensure that patients receive the best possible treatment, obtaining a CBCT (Cone Beam Computed Tomography) image in kilowatts during Image Guided Radiation Therapy (IGRT) is now mandatory.
Detailed guidelines have been established outlining which tumours are eligible for this therapy. Additionally, hospitals must maintain records per the quality control standards set for the radiotherapy machines.
Furthermore, in the case of cancers affecting women, such as cancer of the oral cavity or the vaginal tract, or other types of cancer requiring brachytherapy, treatment must be provided under PMJAY only at hospitals equipped with brachytherapy facilities. There will be no collaborations with hospitals for brachytherapy services.
Neonatal care
New guidelines have been established in response to feedback received regarding neonatal care, particularly for children in the ICU. Hospitals must install CCTV systems while respecting mothers’ privacy to ensure quality treatment for infants in the Neonatal Intensive Care Unit (NICU) or Special Newborn Care Unit (SNCU). Additionally, the Taluka Health officer is required to visit the NICUs periodically and submit reports to the State Health Agency. An online visit module portal will be operational soon to facilitate effective monitoring of these visits. Furthermore, full-time paediatricians have been made mandatory for hospitals to be empanelled in the neonatal speciality, ensuring that children receive round-the-clock care.
Orthoplasty
The state government previously established a new SOP for TKR and THR under the PMJAY scheme. As part of this procedure, hospitals performing TKR and THR must also treat “orthopedic and polytrauma” cases. Specifically, hospitals must handle at least 30 per cent of their cases for orthoplasty. If a hospital fails to meet this requirement, it faces penalties. Additionally, if a hospital does not adhere to this ratio for nine consecutive months, it will be suspended from providing services in the “Orthoplasty” speciality. As many as 75 hospitals under the PMJAY scheme have been fined Rs 3.51 crore for non-compliance with TKR regulations.
It is important to note that more than 14 private hospitals empanelled under the PMJAY scheme in Gujarat have faced suspension, de-empanelment, and penalties due to complaints regarding violations of scheme guidelines and criminal conduct. As of 2024, a fine of approximately Rs 18 crore has been imposed on these hospitals for malpractices.
In some cases, in addition to permanently removing doctors from the scheme, the medical council has also taken necessary steps.
Additional guidelines
Patel stated that in addition to the new guidelines for three major surgical procedures, additional guidelines have also been developed under the scheme.
According to the provisions of the Clinical Establishment Act, 2024, obtaining a consent form with video recording is now mandatory while providing a detailed explanation of the predefined treatment process to the patient and their relatives.
These include angiography, angioplasty, coronary artery bypass surgery, amputation, all “ectomy” surgeries, and organ donation/transplantation/retrieval surgery. Video consent will be mandatory for surgeries such as spinal, brain, and cancer surgeries.
All diagnostic reports, including laboratory and radiology findings, must be provided with the discharge summary to facilitate future treatment.
All hospitals in Gujarat must adhere to the Government of India’s guidelines for infection control and prevention. The State Anti-Fraud Unit (SAFU) has been strengthened to monitor treatment-related activities intensively at all hospitals in the state.
A separate team has been established (consisting of representatives from the government and GMERS medical colleges) to prevent fraud by private hospitals. Following the directions of the SAFU team, this group will visit the empanelled hospitals in their respective districts to conduct thorough checks on treatments. If any complaints arise from beneficiaries, they will report these issues to the government.
Chief district health officer (CDHO)/medical officer of health (MOH) will have to conduct monthly audit visits to at least two hospitals.
As part of the third-party audit, a field audit will be planned through the tender process, during which the field audit team will conduct field audits on two to three per cent of the cases daily.
Desk audits and field audits have been intensified by providing more specialists and super specialists through the insurance fund.
National Health Authority (NHA) has been requested to generate necessary triggers to prevent possible misuse of treatment packages by hospitals.
PMJAY-MA in numbers
Patel said 72,79,797 claims have been paid under the PMJAY-MA scheme in the state as of December 4, 2024, amounting to Rs 15,562.11 crore.
From July 11, 2023, to July 10, 2024, 24,701 claims, amounting to Rs 41.18 crore, were rejected, while 1,16,266 cases, totalling Rs 121 crore, were deducted under the PMJAY-MA scheme in the state.
Patients admitted under the PMJAY-MA scheme are contacted through the 104 helpline, and their feedback regarding treatment is collected.
From November 2023 to November 2024, 4,96,184 patients were called. Among them, 99 per cent provided a positive response, while only 0.3 per cent (1,488 patients) reported a poor response, and 0.6 per cent (2,897 patients) indicated a moderate response.
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