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Ayushman Bharat- Arogya Manthan Insights from scheme data

Key insights from the Ayushman Bharat-Arogya Manthan Scheme data shared by Dr. Sudhakar Shinde, CEO of State Health Assurance Society, Maharashtra, on 30th September 2019. Details on scheme implementation, hospital coverage, surgeries done, e-card distribution, disease burden, program sustainability, and more.

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Ayushman Bharat- Arogya Manthan Insights from scheme data

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  1. AyushmanBharat-ArogyaManthanInsights from scheme data Dr.SudhakarShinde Chief Executive Officer State Health Assurance Society Public Health Department Government of Maharashtra 30th September 2019

  2. Overview • Integrated PradhanMantri Jan ArogyaYojana (PMJAY) and Mahatma JyotibaPhule Jan ArogyaYojana (MJPJAY) launched in state of Maharashtra from 23rd September 2018 • Benefit cover: ₹ 5 lakhs for PMJAY and ₹ 1.5 lakhs for MJPJAY • Mode of implementation: Hybrid for PMJAY and Insurance for MJPJAY • Packages covered: 1300 (971 for MJPJAY and 971+329 for PMJAY) • Total empanelled hospitals: 492 (82 Public and 410 Private) • Population covered in PMJAY: 83.72 lakhs SECC families and MJPJAY covers 2.23 crore beneficiary families • Around 93 % of State population is covered under these schemes • Empanelled hospitals: 492 • Total surgeries/therapies done till 27.09.19 : 5,76,612 • Total e cards distributed till 27.09.19 : 46,18,378

  3. Maharashtra: Disease Burden India: Health of the Nation's States — The India State-Level Disease Burden Initiative. New Delhi: ICMR, PHFI, and IHME; 2017. ISBN 978-0-9976462-1-4.

  4. National Health ProgrammesUtilization and interventions to address high burden of disease in the state

  5. Top 15 Procedures

  6. Course correction taken and proposed

  7. Sustainability of PMJAY packages – Way forward Total Number of Talukas 358 • GR dated 26 February 2019- • Number of empaneled hospitals of Integrated PMJAY and MJPJAY will be 1000 • Minimum two hospitals in every Talukaand distance traveled by beneficiary will not exceed 30 km • Aspirational districts – 10% extra package rate At least one empanelled hospital 94 No empanelled hospital 264

  8. Sustainability of PMJAY packages –Way forward • Reduction in package rates: • Acute Pancreatitis and 19 other procedures • Hearing aid (reduced to ₹ 2500 from ₹ 5000) • Procedure reserved for Government hospitals • Behind the ear hearing aid • Increase in the package rate • Package rates of Dialysis is increased from ₹ 800 to ₹1100 • Package rate of ORIF is increased from ₹15000 to ₹ 20000 • Grades of Hospitals reduced to 3 (A, B, C) from 7 (A1, A2, B1, B2, C1, C2 and D)

  9. Claim paid amount proportion: Government hospitals: 17 % and Private Hospitals is 83 % • Incentive to Government doctors: 20 % claims amount is given as an incentive to Government doctors and paramedic staff • Migration to cloud: From 10th September 2019, the entire 22000 GB (22 TB) data related to the health insurance schemes has been transferred to cloud and the entire functioning of both the schemes is being done on cloud

  10. Insights from package utilization patterns • Experience of behind the ear hearing aid package: Specialty blocked in few ENT hospitals, procedure reserved and strict protocol developed for empanelment of ENT specialty • One package blocked of Teke Eye Hospital, Sangli: Hospital was doing Cataract operations under ‘Amniotic Membrane Graft’ package (S3B5.7)

  11. Insights from IEC • As per MoUInsurance company was expected to do IEC through 2% of the total annual premium amount • As insurance company was not doing IEC, SHAS has successfully recovered unspent IEC amount of Rs.63.78 crores from insurance company • 2 % IEC amount is deducted while paying the premium from July 2018

  12. Insights from Clinical Protocols • Simple sets of questions to be answered by treating physicians while admitting patients. • Objective: To help the physician to arrive at an appropriate treatment decision • Dynamic and are periodically updated/ revised • Out of 971 procedures, protocols of 872 procedures & 1009 indication wise have been finalized and uploaded on website till date • Packages of Radiation Oncology were misused: • Revised protocols developed with the help of specialists from Tata Memorial Hospital & CamaHospital • National Cancer Grid Guidelines followed • Impact: Substantial reduction in the unnecessary preauths

  13. Insights from ICR State Health Assurance Society

  14. Insights from antifraud measures (Data period: July 2012 to Sept 2019) • Total hospitals de-empanelled: 303 • Total hospitals suspended: 126 • Amount refunded to patients: 5 Crores

  15. Monitoring through Biometric • Compulsory biometric attendance for Office staff, Field staff of SHAS and TPAs • Field staff of SHAS: Movement from one hospital to another hospital is tracked • Biometric mechanism for the patients of Maintenance Haemodialysis and Oncology will be implemented shortly

  16. Insight from grievances (Data Period: July 2012 to Sept 2019) • Grievances: Received-19370, Grievances resolved - 16655 (86 %) , In process - 2715 (14 %) • CM Feedback letter: As a social audit mechanism CM Feedback letter is sent to beneficiary after discharge • CM audio call: • Audio message by Hon. Chief Minister is sent to patients’ registered mobile number once the pre-authis approved • Audio call provides information related to free treatment under the scheme • Impact- Rs.5 crore refunded back to beneficiaries • Call centre: • Beneficiary calls call centre to register grievance or to seek information • Around 2500 inbound calls received and 400 outbound calls are made daily to discharged patients

  17. HON’BLE CHIEF MINISTER’S LETTERS TO BENEFICIARIES Hon CM Feedback

  18. Audio message by Hon’ble Chief Minister

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