Rajiv Arogyasri Essay Example

Rajiv Arogyasri Essay Rajiv Aarogyasri Health Insurance Scheme is being implemented in the state of Andhra Pradesh in India to assist poor families from catastrophic health expenditure. The scheme is a unique PPP model in the field of Health Insurance, Tailor made to the health needs of poor patients and providing end-to-end cashless services for identified diseases through a network of service providers from Government and private sector. The scheme introduced on 01. 04. 007 in three backward districts of Mahaboobnagar, Anantapur and Srikakulam on pilot basis was subsequently extended to the entire state in phased manner to cover 20. 4 million BPL families encompassing 70 million population spread across 23 districts of the state from 17. 07. 2008. The scheme started with coverage to 163 identified diseases in 6 systems was gradually extended to 330 diseases in 13 systems under Aarogyasri-I. The coverage under the scheme was extended to 942 procedures in 31 systems with addition of 612 procedures through Aarogyasri-I. The scheme was formulated in consultation with specialists in the field of Medicine, Health and Insurance to address the needs of catastrophic health expenditure among the BPL families of the state and at the same time not to sideline the existing infrastructure in government hospitals. However the scheme is designed in such a way that the benefit in the primary care is addressed through free screening and outpatient consultation both in the health camps and in the network hospitals as part of scheme implementation. Vision, objectives and goals: . Vision: Rajiv Aarogyasri is the flagship scheme of all health initiatives of the State Government with a mission to provide quality healthcare to the poor. The aim of the Government is to achieve â€Å"Health for All† in Aarogyandhra Pradesh (Healthy Andhra Pradesh state). In order to facilitate the effective implementation of the scheme, the State Government has set up the Aarogyasri Health Care Trust under the chairmanship of the C hief Minister. The Trust is administered by a Chief Executive Officer who is an IAS Officer. We will write a custom essay sample on Rajiv Arogyasri specifically for you for only $16.38 $13.9/page Order now We will write a custom essay sample on Rajiv Arogyasri specifically for you FOR ONLY $16.38 $13.9/page Hire Writer We will write a custom essay sample on Rajiv Arogyasri specifically for you FOR ONLY $16.38 $13.9/page Hire Writer The trust, in consultation with the specialists in the field of insurance and medical professionals, runs the scheme. b. Objective : To improve access of BPL families to quality medical care for treatment of identified diseases involving hospitalization, surgeries and therapies through identified network of health care providers through a hybrid model consisting of tailor-made policy (serviced by Insurer) and self funded reimbursement mechanism (serviced by Trust) to assist BPL families for their catastrophic health needs without compromising the importance of existing Health Care Delivery system of the Government. However the scheme is designed in such a way that the benefit in the primary care is addressed through free screening and outpatient consultation both in the health camps and in the network hospitals as part of scheme implementation and areas of catastrophic health expenditure is met by the insurance scheme. The scheme combined with existing public health infrastructure together meets the total health needs of people thus providing universal coverage. c. Goal : Since the scheme is unique and unparalleled in the country, and having introduced for the first time in the state, there is no available data to indicate the disease load and morbidity in the state. However, based on some non-specific data from the tertiary care government hospitals and incidence rate of certain diseases it is construed that around 10% of population suffer from ill health at any point of time. Out of this 60% require medical treatment and 40% require surgical treatment. Out of the total patients who require surgical treatment 10% require surgical interventions listed in the scheme. In addition, there is enormous pre-existing load in the state for which estimation is not available. †¢ Trust is aiming at providing universal coverage in the long run through extended coverage within the budget on account of constant decrease in the premium due to open bidding process for each phase and decrease in pre-load of diseases. Further the elimination of financial burden for catastrophic health expenditure because of the scheme and rehabilitation of working family member will lead to increased quality of life and purchasing power. †¢ Improvement of infrastructure in Govt. ealth Care Providers through utilization of funds earned by implementing the scheme thus enabling them to provide quality care in all areas of health care. †¢ The scheme takes care of screening and primary level treatment for common ailments through the interventions in health camps and distribution of medicines in these camps thus supplementing existing primary care providers in Govt. secto r. Founders and CEO’S: The chief minister Y. S. Rajasekhara reddy launched ‘Rajiv Aarogya Sri’, a health insurance scheme to provide free medical treatment to the poor and the downtrodden. About 1. 82 crore people holding white ration cards are assured under the scheme. The scheme covers health insurance, in cases of cancer, heart, kidneys, neurology and trauma. The Prime minister Dr Manmohan Singh was all praise for Dr Reddy’s pet scheme ‘Aarogya Sri’ and wanted to implement the health insurance scheme at the national level. Speaking to media, the Chief Minister, Dr. YS Rajasekhara Reddy, Finance Minister, K Rosaiah said that Rajiv Aarogya Sri would be a public private partnership scheme. Role of ICT(Information and Communication Technology): The Primary channel through which Rajiv Aarogyasri Scheme is utilized by the Target groups is through its ICT Website (http://www. aarogyasri. org). The Website Portal is a workflow oriented integrated system which takes care of the target groups right from the registrations of a patient to the discharge, claim settlement and then administering of follow up medicine to the patients. Each phase through which a patient goes through, be it In patient registration/Out Patient registration/Surgery Updates/Discharge Updates/Claim Settlements etc. , everything is taken care by the ICT itself. Every user who facilitates the Patient is provided with a Login Id and Password using which he/she should login to the system and operate on the patient pertinent details. The Users who facilitate the patients would have to use the ICT and provide their appropriate inputs and use the responses obtained from the ICT to help the patient get a successful treatment and happy discharge. Furthermore the ICT allows for online payments to the Service providers, aids in Auto generation of Tax filing information, Empanelment of Hospitals, Grievance handling etc. 1. General Information on the scheme. 2. Details of patients reporting and referrals from the PHC/CHC/ Government Hospitals/ District hospitals on daily basis 3. e-Health Camps system and daily reporting of health camps 4. Details of patients reporting and getting referred from the health camps. 5. e-Empanelment system. 6. Emergency approval system 7. Call centre application. 8. Patient registration by Aarogya mithra in Network Hospitals 9. Details of in-patients and out patients in the network hospitals 10. On-bed reporting system. 11. Costing of the Tests done in the network hospitals 12. e-preauthorization. 13. Surgery details. 14. Discharge details. 15. Real-time reporting, active data warehousing and analysis system. 16. Claim settlement 17. Electronic clearance of bills with payment gateway 18. Follow-up of patient after surgery 19. Distribution of Follow-up medicines. 20. Aarogyasri Messaging Services. 21. Enhancement workflow 22. Grievance and Feedback workflow 23. Bug Tracking system 24. e-Office management 25. Accounting system 26. TDS workflow. 27. Death reporting system. On the whole, the ICT forms the core of the Scheme which makes sure that the scheme is run in a smooth way and flags any irregularities to the appropriate authorities at appropriate points in time. The role of ICT: The ICT plays a very vital role in implementing Rajiv Aarogyasri in Andhra Pradesh. The ICT incorporates various software modules that cater to a gamut of services Viz. a Potential Beneficiary Calling the Call center and obtaining a suggestion, Registration of a Patient, Approval of Preauthorization’s, Settling of Claims, Management of Grievances, Online Empanelment of Hospitals, Health Camps, TDS, Online Accounting modules etc The following the Various important modules incorporated in Rajiv Aarogyasri and their brief descriptions. 1. General Information on the scheme: It Provides for comprehensive details of the Scheme, Organization of the Trust and contact details, recent happenings and updating of Guidelines, details of Health Camps such as place, date and name of the Hospital with details of treated Specialty, FAQ’s, Feedback etc. 2. Details of patients reporting and referrals from the PHC/ CHC/ Government Hospitals/ District hospitals on daily basis: User friendly interface is provided in the portal to capture the details of the patients reporting to the PHC’s, CHC’s etc through Call Centre mechanism. . e-Health Camps system and daily reporting of health camps: Planning, Scheduling and comprehensive information on Health Camps to all the Stake holders, obtaining confirmation on the Network Hospitals, details of personnel attending the camps, forwarding the information to the District Administration, monitoring of IEC activity and finally processing of Claims are being done through Online System. 4. Details of patients reporting and getting referred from the health camps: User friendly interface is provided in the portal to capture the details of the patients reporting to the Health Camps through Call Centre mechanism. 5. e-Empanelment system: Elaborate Online Empanelment procedure through portal ensures capturing of entire data related to the hospital such as Civil infrastructure, availability of equipment and professionals, details of Specialties available, past performance etc. The Online empanelment procedure carried through the portal ensures transparency in dealing with empanelment and disciplinary actions against the hospitals. 6. Emergency approval system: The portal provides for Emergency approvals through â€Å"Telephonic Approval† system where in a provisional preauthorization is given through Call conference facility between the treating doctor/Ramco, preauthorization executive and preauthorization medical officers to deal with life saving situations. 7. Call centre application through toll free no (1800-425-7788): 24*7*365 call centre with 280 executives provide facilitation services to the beneficiary by way of explaining the scheme, guiding the beneficiary for proper referral, answering specific queries, registration of complaints, coordination with other stake holders in resolving issues. Further it also helps in the collection and transmission of patient data. I virtually acts as a centralized reception for all the beneficiaries. 8. Patient registration by Aarogyamithra in Network Hospitals. 9. Capturing the Details of in-patients and out patients in the network hospitals. 10. On-bed reporting system. 11. Costing of the Tests done in the network hospitals. 12. E-preauthorization: Robust Online system provides for e-preauthorization unique to the scheme. It facilitates Online transmission of entire medical data of the Patient including reports, image logy films, video recordings of procedures such as Angiogram, Laparoscopic procedure etc for efficient and transparent approval procedure. 13. Capturing the Surgery details through Online. 14. Capturing the Discharge details through Online. 5. Real-time reporting, active data warehousing and analysis system. 16. Claim settlement: The Online system ensures outcome based claim settlement through screening of online evidence for error free and timely claims settlement. 17. Electronic clearance of bills with payment gateway: The ICT solution provides for online bill clearance through paperless mechanism directly into the payees acco unt without human intervention thus ensuring most transparent way of clearing and payment of the claims. Further payee receives mobile alerts on receipt of the payment. 18. Follow-up of patient after surgery: The solution enables Online follow up of the patient by way of capturing follow up treatment details in the portal even after discharge. 19. Distribution of Follow-up medicines: The follow up module captures details of consultation, evaluation tests and medication given to the patient with photographic evidence. 20. Aarogyasri Messaging Services: The AMS (Aarogyasri Messaging Services) provides for dedicated communication gateway for effective interaction with service provider, field force and other stake holders thus ensuring prompt dissemination of information in resolving the issues. 1. Enhancement workflow: Provides for Online enhancement of packages in specific cases. 22. Grievance and Feedback workflow: Ensures prompt and timely grievance redressal through efficient online system from registration to escalation and final disposal. 23. Bug Tracking system 24. e-Office management: The ICT solution is integrated with e-office management to enable paperless transaction within and o utside the project office for efficiency, transparency and accountability. 25. Accounting system: Online accounting system provides for error free management of finances in paperless manner. 6. TDS workflow: For the first time among government Institutions scheme established TDS deductions through Online System. 27. Death reporting system: Each of the above mentioned modules have two or more workflows where in the users intervene and take appropriate actions and continue the workflow and track it to closure. Target groups and impact: Target Groups: The Target Groups of the scheme are the members of below poverty line (BPL) families identified through digitally generated White ration card / Rajiv Aarogyasri Health Card with photograph and name of the beneficiary. Impacts: The following statement define the different target groups identified based on the health need and the way the project reaches the beneficiary and brief impact of the scheme on account of implementation for last 3 years viz. ,1st April 2007. i. Catastrophic health needs (identified tertiary care services – 942 procedures through insurance scheme) – 6,86,812 beneficiaries treated for identified diseases in 339 Network Hospitals. ii. Primary care through free screening and treatment of common ailments in health camps 3375655 -Patients Screened and treated for common ailments in 19504 -Health Camps iii. Preventive care through IEC activity – 339 Network Hospitals conducted IEC activity thorough 19504 health camps held predominantly in rural and remote areas. iv. Additional services provided by the Network Hospitals under the scheme. 794316 -In Patients 1120666 -Out Patients were counseled and treated in Network Hospitals. The scheme proactively reaches the beneficiaries through scheme details on health cards, patient education brochures, posters, bill boards, audio and video CD’s, health Camps, IEC activity, Aarogya mithra (facilitator)services in PHC’s, round the clock toll free call centers , 108 ambulance services Further independent evaluation of the scheme by IIPH (Indian institute of Public Health) established the fact that the scheme had profound impact on the health needs of the poor population as following conclusions were drawn by the agency after rapid evaluation. 1. CONCLUSION BY IIPH : RAJIV AAROGYASRI is a government funded scheme that ensures preferential benefit to vulnerable sections of population by providing targeted care to the BPL group. It fulfils in part an important recommendation of the WHO Commission on Social Determinants of Health to ensure universal access to health care regardless of ability to pay, building on targeted health care programmes for the poor as an important step towards universalism. Approximately half of the beneficiaries interviewed were illiterate and a similar proportion had a low Standard of Living Index (SLI). The unemployed together with unskilled laborers made up nearly half the sample, confirming that the scheme was appropriately benefiting economically poor households. 2. CONCLUSION BY IIPH: The beneficiaries were unanimous that the scheme had transformed their lives. Eighty seven percent of beneficiaries reported improvement following treatment of their condition. The beneficiary satisfaction survey elicited the highest scores for doctors, nurses and cleanliness. Approximately half of the beneficiaries interviewed were illiterate and a similar proportion had a low Standard of Living Index (SLI). The unemployed together with unskilled labourers made up nearly half the sample, confirming that the scheme was appropriately benefiting economically poor households. 3. CONCLUSION BY IIPH: The beneficiaries were unanimous that the scheme had transformed their lives. Eighty seven percent of beneficiaries reported improvement following treatment of their condition. The beneficiary satisfaction survey elicited the highest scores for doctors, nurses and cleanliness. Both the beneficiaries and providers of care acknowledge the transformational role played by the RAJIV AAROGYASRI in improving the access and availability of health care to the poor in AP. The evaluation has demonstrated that the RAJIV AAROGYASRI has reduced the financial burden of serious ill health among the BPL population of AP. The District Medical Health Officers (DMHOs), RAMCOs, MSs and PHC MOs applauded the equity of access achieved as a result of the RAJIV AAROGYASRI and the opportunity for BPL populations to avail of specialist treatment free of cost. The scheme had also enabled some infrastructure improvements in the hospitals. Working Pattern: Achievements, milestones and wins: Since inception of the scheme Trust faced many a challenges in its execution and implementation. As the Scheme is unique and first of its kind with no parallels either in the state or in the country, the Trust has to face the challenges on its own and find solutions for effective implementation of the Scheme. Apart from the unique and robust ICT solution many innovative implementation methods were incorporated to achieve best results in the scheme. The following are the few select achievements which needs mention under the scheme. 1. The Reach of the scheme: The Scheme launched on pilot basis on 01-04-2007 in three backward districts was quickly scaled up in phased manner to cover 23 districts of entire state within a period of 15 months. Scheme underwent continuous changes since inception due to overwhelming response from the beneficiaries. The following comparative average figures handled in the scheme over a period of time indicate the same: Refer to Diagram 1 2. Cashless packages: Cashless treatment to the patient was envisaged. For this the Trust constituted 31 teams of specialist doctors from government and private hospitals and analyzed all the diseases, listed more than 1500 medical and surgical procedures and finally basing on the criteria mentioned above finalized a list of 942 diseases and packages for inclusion in Rajiv Aarogyasri scheme. The package includes ? Screening in Health Camps. ? Consultation, medicines, diagnostics, specialist services, complications ? Implants, grafts, prosthetics ? Food. ? Cost of transportation ? Hospital charges etc. In other words the package should cover the entire cost of treatment of the patient from date of screening at villages/date of reporting at network hospital to his discharge from hospital and 10 days after discharge and any complications while in hospital, making the transaction truly cashless to the patient. 3. Preventive and primary care through Health Camps: Universal Coverage While Insurance scheme is addressing the needs of catastrophic health expenditure of poor patients, the health camp screening and treatment of common ailments coupled with Government health care setup is able to meet complete health needs of poor in the state. Further the upward revision of financial limit for BPL status by the Government enabled 85% of state population to get coverage under the scheme thus achieving universal health coverage in the state. 33. 38 lakh patients were screened and treated for common ailments in 19315 health camps held under the scheme 4. Facilitation Services: The following facilitation services are provided to the beneficiary to guide, counsel, facilitate referral and ensure quality medical services under the scheme. 1. 24 Hour Toll free Call Centre Number 2. Aarogya mithra at PHCs and Government Hospitals . Aarogya mithra at network hospital 4. District level grievance cell 5. Central level grievance cell 6. Services of RAMCO (Rajiv Aarogyasri Medical Coordinator) 7. Health Camps 8. Health Cards 5. E-Preauthorization: Rajiv Aarogyasri Health Insurance scheme envisages e-preauthorization through online data verification. Though preauthorization process is a common process in all insurances schemes the unique feature of Rajiv Aarogyasri scheme is the final approval by the Trust as the custodian of insured and not by the Insurance Company. The conflicting interest of service provider, insurer and Trust thus ensure fair approval of the cases and takes care of poor people insured under the scheme. 6. Follow-up Services: To optimize the benefit of the surgery/therapy taken under the scheme, packages are also approved for one-year follow-up services (Consultation, Testing and Treatment) to the beneficiary in 125 identified procedures. 7. Awareness In order to create awareness among the stake holders the following activities were successfully undertaken in the scheme: †¢ Health Cards: All the families below poverty line were given Health Cards based on the ration card database to make the people aware of their entitlement under the scheme. This has not only created awareness among the beneficiaries but brought in feeling of possessiveness, empowerment and financial protection among the illiterate people. †¢ Mega-Health Camps: The scheme was launched by Chief Minister through Mega Health Camps in all 23 districts where in around 50-60 network hospitals with their men and machines (including portable equipment such as CT, Endoscopy, Echo etc) participated. In each of these camps more than 10000 patients were screened. For this purpose assistance from NRHM was also received. †¢ Awareness Camps: Awareness camps were held to the stake holders in all the districts repeatedly, where in people’s representatives from village level, self help groups, Aarogya mitras, Anganwadi workers, ANMs, Para medical staff and Medical Officers were made aware of the scheme by explaining the scheme followed by lectures in the local language by Specialist doctors to guide these people in identifying diseases. Workshops: Separate Workshops were held for the Government Hospital Doctors, Network Hospitals and network hospital Aarogya Mithras to apprise them of the scheme and online processing. †¢ Health Camps: All the network hospitals have to conduct at least one free health camp in identified rural areas to screen the BPL population. Further the hospitals will conduct Information, Education and Communication activities, including that of preve ntive measures and provide basic treatment facilities for the common ailments for other patients. These health camps are providing advanced screening and treatment of common ailments at the door step of the patient. 8. Patient friendly SLA’s: The processing time in the patient workflow has been considerably reduced and made real-time by integrated use of online workflow, toll free call centre and 24*7*365 working pattern of the Trust. The following are the response timings: ? Registration – Immediate ? Pre-authorization-Within 12 working Hours ? Call Center Response- Round the clock and Immediate ? Aarogya mithra Services- Round the clock Claim Settlement-Within 7 days of claim submission. 9. Better beneficiaries feedback Trust it is initiated beneficiary feedback system . As per the system a letter from the Chairman of the Trust is dispatched independently to the beneficiary enquiring about his present health status after he underwent treatment at network hospital with details of treatment plan approved and package amount sanctioned to the identified hospital. It w ill also have a self addressed (Trust) post paid inland letter with a request to answer queries about the services of various people (i. . Aarogya Mithras, hospital reception, staff, doctors, satisfaction about treatment and present status about his health after the treatment and finally suggestions to improve) All this communication is done in local language. Till date Trust received more than 70000 feedback letters hand written by beneficiaries (see patients feed back in the home page www. aarogyasri. org). This system is working as a strong social auditing mechanism. 10. Improvement in measurable indicators: Before the initiation of the scheme the people below poverty line were not having access to such services and were suffering silently or getting in to debt trap. Hence the benefit as indicated below which are reaching the beneficiaries can be taken as first time benefit. Refer to Diagram 2: 11. Changing Tertiary care profile: As the scheme progressed the pre-load of diseases is coming down, particularly in relation to the high end diseases in cardiology, neurosurgery, gynecology and obstetrics etc. the following table indicates the change in disease load of top three performers (category wise) of the 3 pilot districts where the scheme completed 3 years of implementation. Refer to Diagram 3 The above table indicates the perceptible reduction in disease reporting under the scheme from 3 pilot districts of Anantapur, Mahaboobnagar and Srikakulam. As is evident from the table above the disease reporting in procedures involving Cardiac and Cardiothoracic Surgeries, Neurosurgery, Gynecolog y and obstetrics which were introduced in April 2007 in the above districts are showing decreasing trends. This may be attributed to the decrease in pre-load which is contributed by procedures under the scheme such as valve replacement surgeries and congenital cardiac defects, SOLs in brain and chronic disorders in gynecology. 12. Changing Disease predominance: The scheme also brought in changes in the disease predominance and changes in the priorities of disease treatment as shown in the profile of 3 pilot districts depicted below. Refer to Attachment Diagram 4 The above diagram indicates the upward change in disease reporting of the cases pertaining to the specialties of Nephrology, Genito Urinary Surgery and ENT in the 3 pilot districts of the scheme. The upward reporting may be due to two factors. 1. The treatment procedures in specialties like ENT, Nephrology were introduced into the scheme only in July, 2008. Hence, still pre-load is contributing to the disease load. 2. The increase in Genitourinary may be due to extended coverage for more procedures from Dec, 2007 thus the pre-load is yet to have an impact on disease reporting. . This is a relative phenomenon as the disease load of procedures introduced in the beginning is declining. 13. Disease stabilizing: While above data indicates changing trends of disease predominance, diseases in number of other systems such as Cancer, Neurosurgery, and Pediatrics are getting stabilized as the scheme is progressing in the state as observed in the diagram shown below. Refer to Attachment Diagram 5 14. Simplified procedures: With the introduction of total web based online solution, the entire process starting from registration of the patient till his discharge from hospital and post discharge follow-up are all real time, transparent, fool proof and simplified to the end user. 15. Regulatory effect on Hospitals : The empanelment procedure, defined diagnostic and treatment protocols, capturing of admission notes, daily clinical notes, operation notes, discharge summary and uploading of diagnostic reports including films, webex recording of Angio and Laparoscopic procedures and other photographic evidences have profound regulatory effect on the hospitals. 6. Quality improvement in services: Continued monitoring of the services both online and in the field by the elaborated field mechanism coupled with disciplinary action against erring hospitals is greatly contributing to the quality of treatment under the scheme. 17. Establishing Medical Protocols tailor-made to local situations: Though laid down internati onal diagnostic and treatment protocols are available, the hospitals were not able to follow these protocols due to various reasons such as non-availability of infrastructure, affordability of the patients and lack of monitoring by authority. The scheme by taking into consideration of availability of local infrastructure and standard medical practices successfully redefined the medical protocols with the help of senior specialists in each field. 18. Employment Generation: The scheme generated indirect employment potential as the insurance company, network hospital and other stake holders have to employ number of people in different cadres such as Aarogya mithra, RAMCO, AAMCO, duty doctors, Para medical technicians, staff nurses etc. , 19. Health Awareness: Since implementation of the scheme 15,909 health camps held in rural areas not only screened 27, 82,303 people but also played key role in bringing health awareness among the population through IEC activity. Counseling by field staff and Para- medical staff is also contributing to the health awareness among rural poor. As pre-evaluation of the patient is also cashless under the scheme, the people are motivated to approach network hospitals as and when suspected of suffering from identified diseases. 20. Morbidity pool and Disease Mapping: As the entire patient data of people attending health camps, network hospital OP, in-patient treatment details and treatment details of the beneficiaries approved under the scheme are captured online, it created huge morbidity data of the population. 21. Early recognition and Disease Prevention: The IEC activity, health camps, counseling by field staff and awareness campaigns by Trust and district administration is helping in early recognition and disease prevention. 22. Changing Scenario in Government Hospitals: Hospitals from Govt. sector with requisite infrastructure are empanelled to provide services under the scheme. All the network hospitals from Govt. and Private hospitals thus empanelled are entitled to the same package amount on providing services. This is helping Govt. hospitals to earn much needed finances for improving infrastructure, provide quality care to the patients and improve the performance by recouping the deficient services through outsourcing and by providing incentives to the performing team. As on date 95 Govt. hospitals, 26 Tertiary care and specialty hospitals under the control of Director of Medical Education and 69 APVVP Hospitals (District Hospitals, Area Hospitals and CHCs) are empanelled under the scheme . Till 21. 01. 20