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

Pleas read this Mumbai mirror article first:
http://www.mumbaimirror.com/index.aspx?page=article&sectid=2&contentid=2012120120121201101329585a34b6329
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.

Reasons:
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.
 
Author:
Dr Akash S Rajpal
MD & CEO,
EKOHEALTH Management Consultants PVT LTD,
Mumbai
Tel: 9820007137
Awardee, Ramanujan Bose Award 2012: http://www.ramanujan-bose-prize.org/#!2012-prize
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Good intention

I was reading a fantastic article by professor Rodwin in New England Journal. Interesting perspective on the conflict of interest by medical practitioners who make investments in place they work. The primary objective logically will be ROI rather than patients interest. (Prof Rodwin's Article : http://bit.ly/U3mlIm)

When I shared this with my students & industry colleagues, some interesting arguments started.

Some practicing clinicians & hospital owners said that (sarcastically of course) that if Prof Rodwin is understood, then practicing medicine for fee itself is a conflict of interest. And I agree to that perspective too without any sarcasm.

Practitioners have been arguing since long time on why patients (consumers) just can't accept art of medicine & healing like any other profession & realize that like any other profession the care provider needs to earn a living too. Almost all surgeons have their own hospitals & physicians their own clinics. So the aspect of ROI (Return on Investment) & a commercial angle to seeing a patient always will arise. Afterall the hospital owners have their bills & salaries to pay. And some argue that offering costlier procedures for increased financial gains though is the norm today, is justified as it "apparently" offers significant advantages over the time tested older cheaper ones. Examples cited were minimally invasive laparoscopic surgery v/s open surgery. And the argument went on further that finally it is market forces which determine ones actions :) (me smiling)

No, I don't mind these responses. Actually, its an interesting argument.

However my concerns:
For first time since last few batches, medical, dental seats are lying vacant to tune of 20 to 35%. 20 to 60 % of doctors & nurses don't clinically practice anymore (many of them are becoming administrators, & even changing industries :) I'm afraid the trend will continue. Fortunately you will see reduction in donation price & fees to fill seats in medical colleges. But over all there is huge competition from other industries like IT, offering better pay packets ( & for ethical work). Youth realize that.
Ethical Work? Yes, youth realise that every investment needs to have a return. The youth spends a fortune & almost a decade in becoming a doctor. With restriction on marketing & publicity, the hierarchy of sorts (of unethical nature) starts to work in healthcare. The hospital pays to family physician a referral fee to influence a patient to visit them. This comes at an ever increasing cost. The ROI will demand naturally more tests, treatment, expensive brands of drugs & so on which may even not be required by a patient. I still remember in disgust how a GP never prescribed antacids (or made patient aware) when prescribing chloroquine. The patient was forced to come back for a second consultation for treatment of acidity. ROI in classic play.

I'm afraid, healthcare is soon going to see a major setback across the globe & in India specially as we will see mass exodus of doctors & nurses to foreign shores for better pay packets. & potential doctors & nurses choosing other professions.

There is a serious introspection needed. This is the time to change & start having a good intention. Intention to see good of patient & sincerely honour hippocratic oath.

My argument on conflict of interest on fee for practice is that in other industries for any harm to an individual there are strict penalties & legal actions imminent (for example life imprisonment for murder, harm), but there is a huge relief given to medical practitioners for such outcomes (death for example) on account of a wrong judgement call. Why? Because we are playing with human lives & trust. The way we honour a soldier for killing in larger interest of the nation, similarly a lot of wrong doing & bad judgement calls are ignored by court of law so that the medical practitioner keeps practising & uses he prior bad experiences to save more lives. Alas that gets lost somewhere in the so called ' fee for practice', right to earn a living.

I remember Dr Naresh Trehan in an exclusive interview on CNBC with my company Ekohealth's Director Nehha Rajpal, said that for success in healthcare the most import thing required is good intention. Else one should choose any other industry. Therefore we have likes of Devi Shetty who come up once in a while as a breather.

If it was for me, I would have made healthcare akin to armed forces. Government spends on it being essential services (Obama trying to do the same exactly for same reason). And there are time tested good examples from past & present. Singapore is worlds most successful public health model followed by NHS. There the citizens prefer to visit a government hospitals, being so good. In such systems, all medicos are hired (there are better opportunities for governance due to low population too, but... Then you can have more centres & resources too) So no conflict of interest arises as patient don't have to pay. India is different, rest of world is different. This discussion is still an interesting argument.

Obviously government can look at a nicely IT enabled nicely monitored PPP delivery at fixed pricing with fixed clinical protocols (like arogyasree)
Obviously more clinical resources like doctors & nurses need to be created by removing red tapes, reasonable nationalistic rules governing medical/nursing colleges (3yr community professional course by govt is a right step. What can you do if doctors won't work even with bonds in villages. & bonds are not efficient & right way to keep doctors where they don't want to be)
OBviously everyone could be insured in the interim to pay for care.
Obviously all treatment should be free as matter of right of better living.

And I hope that day will come.

What is required is just a good intention.

Dr Akash S Rajpal
Author is CEO of Ekohealth (www.ekohealth.in)
He is a ramanujan bose awardee for social impact & is working against fee splitting (referal fee / cut practice)
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