STATE LEVEL WORKSHOP23RD & 24TH MAY, 2014

RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA

DR. V. R. ZARE Deputy Director, Nagpur DR. D. V. PATURKAR Civil Surgeon, Bhandara

STATUS OF RGJAY IN BHANDARA

Maha e seva centres : 127Sangram centres : 542Post offices (since 26th : 002January, 2014)Total no. of health cards distributed : 2,04,117 (82.04%)No. of health camps scheduled in may, 2014 : 07

STATUS OF RGJAY IN BHANDARAAS ON 23RD MAY, 2014

TALUKAAPPROVE

D FAMILIES

APPROVED BENEFICIA

RIES

REJECTED

FAMILIES

REJECTED

BENEFICIARIES

TOTAL FAMIL

IES

TOTAL BENEFICIARIES

SAKOLI 132 341 49 146 181 487

LAKHANDUR 8 234 39 108 127 342

BHANDARA 626 1961 92 286 718 2247

LAKHANI 152 437 40 95 192 532

TUMSAR 153 394 37 93 190 487

MOHADI 238 778 39 155 277 933

PAONI 157 462 42 106 199 568

TOTAL 1546 4607 338 989 1884 5596

STATUS OF RGJAY IN BHANDARAAS ON 23RD MAY, 2014

TYPE OF CARD

APPROVED

FAMILIES

APPROVED BENE

FICIARIES

REJECTED

FAMILIES

REJECTED BENE

FICIARIES

TOTAL FAMILIES

TOTAL BENEFICIARIE

S

ORANGE 812 2478 145 444 957 2922

YELLOW 697 2028 188 533 885 2561

ANTYODAYA 37 101 5 12 42 113

TOTAL 1546 4607 338 989 1884 5596

STATUS OF RGJAY IN BHANDARAAS ON 23RD MAY, 2014

TALUKA

NO. OF BENEFICIARIE

S

APPROVED

IN PROGR

ESS

REJECTED

PENDING

CANCELLED

TOTAL

TOTAL APPROVED AMOUNT

SAKOLI 72 102 0 6 2 9 119 2046145

LAKHANDUR 46 63 0 5 0 5 73 1167450

BHANDARA 161 200 0 22 3 13 238 4655100

LAKHANI 69 75 1 3 2 17 98 1640250

TUMSAR 85 117 1 11 0 11 140 2489100

MOHADI 89 116 0 9 0 7 132 3013650

PAONI 97 121 1 12 0 14 148 2855500

TOTAL 619 794 3 68 7 76 948 17867195

STATUS OF RGJAY IN BHANDARAAS ON 23RD MAY, 2014

TYPE OF HOSPITAL APPROVED CLAIMS

APPROVED AMOUNT PAID CLAIMS PAID

AMOUNT

ALL GOVT 100 1584100 27 287825

ALL PRIVATE 305 6311825 124 2398200

TOTAL 405 7895925 151 2686025

STATUS OF CLAIMSNAGPUR CIRCLE

0

2000

4000

6000

8000

10000

12000

14000

160008614

0

776

48 8

90

10328

3758

2 197

34 7

36

4727

12372

2

973

82

1626

15055

PRIVATEGOVTTOTAL

TOTAL CASE COUNT.STATUS OF CLAIMS

NAGPUR CIRCLE

PRIVATE GOVT0

2000

4000

6000

8000

10000

1200010232

4733

SUM OF PRE AUTH APPR AMOUNTNAGPUR CIRCLE

PRIVATE GOVT0

50000000

100000000

150000000

200000000

250000000

300000000

25,50,03,721

12,91,86,295

CLAIM PAIDNAGPUR CIRCLE

PRIVATE GOVT0

20000000

40000000

60000000

80000000

100000000

120000000

140000000

13,03,70,676

4,50,77,220

PERCENTAGE OF CLAIM NAGPUR CIRCLE

PRIVATE GOVT0

10

20

30

40

50

6051.12

34.89

• ISSUESRESPONSE BY ad@jeevandayee.gov.in

Dist. Hopspital, Bhandara has not been given approval for polytrauma cases despite availability of necessary infra structure.

Our response: polytrauma needs on call neurosurgeon which u have to hire and produce the documents to society. We will take it in Ec and open the polytrauma.

The limit of submission of documents after ETI is given and approved; is 72 hours and needs to be raised to at least 5 working days. The relatives of the patient are frequently unable to produce documents in time due to distance, unavailability of relatives etc. Also frequently; there is need for additional entry in the ration book by tahsildar regarding date of issue which is time consuming.

Our response:  Secretary (2) PHD mam is in process of circulating guidelines to District Collectors to streamline issue date certification process which will reduce the time lag. As per MOU the time relaxation over and above 72 hours appears difficult given the stringent stance taken by Insurer. But will make an attempt.

 Rejection on technical grounds such as advisability of one procedure as against another; evidence of compound nature of fracture in form of photograph, consideration of age factor while approving hysterectomy proposals and its certification by senior doctor with signature/seal are contentious issues which put a question mark on not only the clinical ability and judgement of treating doctors but their integrity as well.

Our response:  We agree that the preauth team should not suggest treatment modalities to treating surgeon/physician. Will take up with NIC and TPA. However, as an interim, ur team may respond quickly to the queries as well as the compliance in case of  documents deficiencies if any.

The seed money of Rs. 5 lakhs needs to be spent for the purposes expressly mentioned in the relevant letter AND also sometimes for other incidental purpose e.g. payment of charges for investigations outsourced; payment of outsourced speciality/super speciality services on event basis, printing of stationery etc.

Our response:   DHS will respond.

Cross speciality work for certain procedures is being routinely done and should be allowed for approval of the proposals. e.g. general surgeon performing lumbar sympathectomy or urological procedures etc.

Our response:   Secretary (2) PHD had set up a committee to review the issue of cross specialty and the committee has furnished the report on 13 Dec 2013. It may be noted that RGJAY aims to have high cost high end low event procedures and hence “can do” may or may not  result in “well done” in instances.

RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA

SWOT ANALYSIS

STRENGTHS Ready availability of infrastructure.

Availability of manpower.

Commitment to make scheme work.

A comprehensive exercise undertaken by the department to put in place the NABH standards

WEAKNESSES

Digitization of the data is an issue.Gaps in the standards of clinical services and

administrative aspects of the system in government sector.

Compulsory multitasking.Present manpower in government sector

lacks in skills required to undertake all procedures reserved for the sector.

WEAKNESSES

Over dependence on procedural and mundane details by preauthorization team; sometimes questioning professional integrity of doctors.

Negative media coverage and inadequate IEC.

Provision of only one way transportation costs .

OPPORTUNITIES

Training and deputation exercise aimed at enhancement and availability of skills.

Use of additional revenue generated towards TQM.

Establish a work culture and good clinical practices.

THREATS

Lack of cooperation by private sector and inclination to use the scheme only when convenient/beneficial.

Umbrella and nature of procedures reserved at present for the government sector resulting in loss to the exchequer.

THREATSAbsence of incentives to government

employees may translate into less enthusiastic approach.

Issue of cross speciality: Stress on “well done” and refusing to allow the fact that “can do” does indeed many a times result into “well done”.

Inordinate and inexplicable delay by NIC in depositing claim amount.

SUGGESTIONSTurn weaknesses into opportunities. Issue of digitization of data of ration cards

can be resolved by special campaign of data entry, considering off-line entry option for health cards, using unique no. of ration cards for search of details etc.

Quality of clinical and administrative performance can be enhanced by training, sensitization/advocacy exercises.

SUGGESTIONS Multitasking in administrative area can be dealt

with by hiring contractual manpower which will increase manpower of the institution.

Training the existing manpower in additional skills such as laparoscopic surgery, oncology, gastro-duodenoscopy, colonoscopy etc, will prove beneficial to the institution and the individuals as well.

The protocol in force for pre authorization etc can do without the some excessively elaborate conditions /riders and details required at present.

SUGGESTIONS Negative media coverage and inadequate IEC are issues

to be resolved with a systematic approach towards faster issue of health cards. The department of revenue and of food and civil supply can achieve this.

IEC can be undertaken from the funds collected under the scheme to project it’s true status and benefits. The scheme needs to provide for both ways

transportation costs as the place of referral is out of district for procedures of super specialization. Also, district hospital at Gadchiroli needs to have an ambulance on rental basis exclusively for this purpose as majority of it’s work is done at Nagpur .

SUGGESTIONS

The strengths and the opportunities mentioned earlier are the obvious avenues to improve the performance. Strengths are already in place and the opportunities are beckoning.

Possibility of engaging expert services on visit/call/surgery basis should be explored

SUGGESTIONS

Efforts are necessary to eliminate/minimise the threats.

The referrals to the private sector can be

routed through monitoring agency and claims regarding issues like waiting list etc need to be verified.

The list of procedures reserved for the government sector can be reviewed and modified.

SUGGESTIONS

The offer of incentives to government employees can dramatically improve the performance of the scheme.

The scheme needs to allow cross speciality work in view of the fact that the “can do “ status of the affairs has worked efficiently so far. This should be at least offered on interim basis till trained manpower is made available.

The delayed payment of claims needs urgent attention.

RAJIV GANDHI JEEVANDAYEE AAROGYA YOJANA

IT CAN WORK EVEN BETTER(IF WE WORK ON IT!)

Thank you!