Saturday, December 1, 2012

First Hurdles : The Rajiv Gandhi Jeevandayi Arogya Yojna (RGJAY) implementation in Maharashtra

Pleas read this Mumbai mirror article first:
Beautifully written by Ms Jyoti, a Journalist.

The Rajiv Gandhi Jeevandayi Arogya Yojna (RGJAY), covering more than 5 million families in Maharashtra,is poised to cover more than 80 million people. Based on the immensely southern success story "Arogyasree" health scheme. Within this scheme patient get cashless surgeries and other treament from empannel private and public hospitals. The state sponsors this at a highly discounted premium with TPAs / insurance companies.

Fall outs:
As mentioned in the story, there are bogus claims, unecessary treaments, and wrong escalated bills.
This was expected, and i did mention this is in one of my previous blogs / articles.

RGJAY does not follow in spirit the entire learnings of Arogyasree scheme.
Arogyasree does not involve any TPA or third party mediation.
The claim process has to be done with 24 hours. Any further delay leads to fraud and wrong claims and manupilation.
All interaction is with the insurance company without any TPA.
There is no variation in pricing and all hospitals have to follow the same pricing.
There are clinical processes and instructions on what tests, medicines and lenghth of stay and preconditions have to be followed mentioned by Arogyasree, which is left to the hospital here.
All centres are linked by common software and mandatory online MIS. You can actually see vacant beds and MIS online in public, making it transparent.
There is a large call centre and support by local health workers on implementation of this scheme.
There is on an avearge 15 day delay in TPA claim submission by hospital which leads to all the manupilations etc.

Way forward:
This work should be given to insurance companies directly without involving TPA.
The hospitals should follow a common cloud based / linked software for MIS and claim processing.
Clinical proccess should be laid down to prevent unnecssary treamtents.
hospitals whose claims have been found to be fraudulent should be banned /licence cancelled as an example.
Arogyasree scheme should be replicated in same essence and operations.

All this is necesary as the faith in medicine, and doctors will soon go away.
Such programs will not see the light of day if bad examples are reffered to.
Ethics Ethic Ethics. All doctors should be made to stand in line and made to read the hippocratic oath again.
Its High Time.

Author is social impact award winner & MD & CEO of EKohealth. Ekohealth has been fighting against referral fees, cut practice and striving to create a transparent health industry with cost comparisons and information to public to make them better informed.
Dr Akash S Rajpal
EKOHEALTH Management Consultants PVT LTD,
Tel: 9820007137
Awardee, Ramanujan Bose Award 2012:!2012-prize
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