Suvarna Arogya Suraksha Trust Integrated Ayushman Bharat – Arogya Karnataka

1. Suvarna Arogya Suraksha TrustIntegrated Ayushman Bharat – Arogya Karnataka CONVERGENCE OF SCHEMES

2. Background of the Health Systems prior to convergence_1 - 2 • The Government of Karnataka had a range of healthcare services through public health institutions • These institutions, hospitals and centers catered to about • 687 lakh patients in a year • providing about 3000 types of treatments. • These services include hospital-based treatment for • 41 lakh in-patients • 2.4 lakh major surgeries • 2.7 lakh minor surgeries • 5.7 lakh child birth deliveries in a year.

3. Background of the health systems prior to convergence_2 - 2 • State Government implemented the following health assurance and health insurance schemes covering about 3.25 lakh cases of secondary and 1.25 lakh cases of tertiary healthcare treatments in a year at a total expenditure of about Rs. 900 Crore per annum.

4. Rationale behind convergence • Significant overlap across schemes in terms of scope and coverage • Sub-optimal utilization of the PHIs • Variations in the treatment rates in private hospitals • The design of some of the schemes had contributed inadvertently to the weakening of the system in terms of service delivery and productivity of the public health system. • The goal of universal, equitable and sustainable healthcare possible, only through a credible, efficient and effective public health system, supplemented by a lightly but credibly regulated private health system • The basic premise of provisioning of UHC is that the available capacities in the public health system are augmented and utilized in full before recourse is made for availing the services from the private providers

5. Major Challenges Towards Convergence (State specific, Steps Specific) _1 - 3 • Distinction needs to be made based on the financial capabilities while providing benefit under the scheme as it is a mater of development policy priorities & programmed to be decided by the Government. Solution:Sum insured Rs. 5 lakh BPL families & Rs. 1.5 lakh to APL families • It would be travesty of public policy to keep the medical capabilities and physical capacities in the PHIs underutilized and at the same time resort to purchase of healthcare services from the private hospitals. Solution:The referral system has been designed from the imperative of utilizing medical capabilities and in the PHIs and to seek the healthcare services from the private

6. Precursor Activities to UHC _2 - 3 • The State Government has invested huge amounts in strengthening and upgrading the PHIs throughout the state • In the past 10 years the State Government has invested nearly Rs. 5575 Crore to strengthen and augment medical infrastructure and equipment in the PHIs • Rs. 9746 Crore invested under the NHM confounded by the Government of India. • 12 new Government medical colleges have been established leading to significant upgradation of capabilities for the healthcare • PHIs at district level and taluka level have the capacity for primary and normal secondary healthcare treatments.

7. Steps taken by the State Towards Convergence (Political, Operational, Risk Pooling, IT, Timelines)_1 - 6 Political: • The Political setup had agreed to implement in NitiAyoga both the State scheme and Central scheme as one integrated scheme with co-branding and arriving on common implementation norms Principle of equity • In the integrated scheme, it would been anomalous if two different sets of benefit packages exist in a single scheme & therefore proposed to enhance the benefit cover under Arogya Karnataka to be on par with Ayushman Bharat viz Rs.5 lakh per family for “Eligible” families, from the 2 lakh per family, per annum Creating a common treatment procedure list • In order to prevent overlapping of the treatments, it was proposed to revise the list of procedures in Arogya Karnataka so as to align with Ayushman Bharat treatment procedures

8. Steps taken by the state towards convergence (Political, Operational, Risk Pooling, IT, Timelines)_2 - 6 • The list of 1349 treatments was adopted in to in the integrated scheme & the combined procedures from both lists was about 1650 • 291 nos. proposed to be reserved only for PHIs 254 were designed to be treated at PHIs based on the capacity and capability and in the event of exceeding this, are to be referred to empanelled private hospital • 900 Tertiary care are to be referred to Private hospitals by PHIs, if the PHIs do not have the capacity and capability to treat • 169 Emergency treatments which the patients could access empanelled private hospitals without a referral. • The operational responsibility of delivery of health services was entrusted to Commissioner of Health and family welfare and the Director of medical education in case of teaching hospitals

9. Steps taken by the state towards convergence (Political, Operational, Risk Pooling, IT, Timelines)_3 - 6 Risk Pooling: • Number of beneficiary availing benefit under the scheme is likely to increase by many folds. There was difficulty in projecting the future year expenditure with the proposition of all the scheme under one • There was no estimate available regarding the likely increase implication of the scheme over the next few years • Assuming the expenditure pattern per family expenditure rate of increase of beneficiary were same for the last few years under different scheme put together • Referral System from a PHI was considered an integral part of the scheme Capability gaps in PHIs was done and filled.

10. Steps taken by the state towards convergence (Political, Operational, Risk Pooling, IT, Timelines)_5 - 6 IT • Secured IT system for patient registration after the one-time enrolment with biometric Aadhar authentication and PDS database confirming eligibility & entitlement. • Online preauth reducing TAT significantly and submission of claims and settlement. • SAST had provided secured access to its IT systems to the empanelled hospitals for patients acquisition based on referrals from the PHI, pre-authorization requests, claim submissions, and patient enrollment in emergency cases. • The PHIs and the empaneled private hospitals requirement of updating information on a daily basis, for disclosure to the public. Timelines : • As the IT system was active in all the major district hospitals, scheme was implemented across the state. • Role out in all THC & CHC in phase manor of 3 months and than in all the PHC.

11. Financial Implications • GoK – outlay of Rs. 950 crores for FY 2019-20 • GoI – [62,09,073 /1,15,00,000] x60%xactual cost of treatment • Expenditure – Rs. 397.23 crores has been paid to hospitals as on 31st Aug 2019. • Amount in lakhs

12. Impacts of converging schemes_ 1 - 5

13. Impacts of Converging Schemes_ 2 - 5 30 6.50 Crore Districts covered across state Beneficiaries covered 2,806 65,25,100 Public & Private Hospitals empanelled Health Cards issued 2.47 Lakhs 694.66 Crore Beneficiaries treated Cost of treatment

14. Impacts of converging schemes_ 3 - 5 Preauth Approved – Month wise Analysis

15. Impacts of converging schemes_ 4 - 5Government & Private Hospitals wise Analysis Amount(in lakhs) Claims Submitted Claims Unsubmitted

16. Impacts of converging schemes_ 5 - 5Top 10 Hospital’s contribution summary • In the top 10 high performing hospitals, 9 are in the PHI sector reaffirming the State’s realization that the Goal of Universal, Equitable and Sustainable Healthcare can be possible through a credible, efficient and effective Public Health System, supplemented by a credibly regulated Private Health System.