How did the idea germinate?
| Celebrating RGJAY’s 1st anniversary |
In the 90s, many poor patients approached the then Chief Minister of Maharashtra, Manohar Joshi to seek financial assistance for treating catastrophic illnesses such cancer, kidney and heart diseases. In order to address this, the Government of Maharashtra launched the ‘Jeevandayee Yojana’ in 1997 for covering few catastrophic illnesses among the poor families. However, the scheme had many shortcomings related to the coverage of illnesses, access of medical services and out-of-pocket spending by beneficiaries. Therefore, last year the state embarked on a new scheme, the RGJAY, to improve healthcare access to the people of Maharashtra.
Provisions of the scheme
RGJAY is a unique PPP model health insurance scheme tailor-made to meet the out-of-pocket health expenditure requirements of below poverty line (BPL) yellow card holders and above poverty line (APL) orange card holders families as well as Antyodaya cardholders (families who have income of less than Rs 250/- per capita per month) and Annapurna cardholders (issued to shelterless people) for identified speciality services requiring hospitalisation for surgeries and therapies or consultations through an identified network of healthcare providers. The state government has partnered with private hospitals and National Insurance Company to effictively execute this yojana. It is being implemented throughout the state of Maharashtra in a phased manner for a period of three years. The yojana was introduced with the guiding principle that insurance schemes should be targetted at catastrophic illnesses and the benefits in primary care would be through free screening programmes and outpatient consultations. RGJAY’s implementation is being assisted through effective use of IT-based solutions which help in reaching out to the beneficiaries as well as keep track of its implementations.
The scheme provides coverage up to Rs 1,50,000/- per family per year to meet all expenses related to hospitalisation in any of the empanelled hospital subject to package rates on cashless basis. The benefits are available to each and every member of the family on floater basis i.e. the total annual reimbursement of Rs 1.5 lakhs can be availed by one individual or collectively by all members of the family. Immunosuppressive therapy is required for a period of one year in case of renal transplant surgery. So, the upper ceiling for renal transplant is Rs 2,50,000 per operation as an exceptional package exclusively for this procedure. The premium of Rs 333 per family per year is borne by the state government.
Under this yojana, the beneficiaries would be provided with health cards for identification purpose. Family health cards have been prepared using data from valid yellow or orange ration cards. As an interim measure, till the issuance of health cards, the valid orange/yellow ration card with Aadhaar number or in case of Aadhaar number not being available, any photo ID card of the beneficiary, issued by government agencies (driving license, election ID), to correlate the patient name and photograph is also accepted in lieu of the health card.
How does it work?
According to Dr RM Jotkar, Assistant Director-Health Services, RGJAY Society, Government of Maharashtra, there are multiple stakeholders involved in this yojana, namely: the state, network hospitals, the insurance company, the TPA involved and the beneficiaries. He informed, “In order to streamline the entire procedure and to safeguard the rights and responsibilities of all stakeholders we have established a society called the RGJAY Society. This Society has prepared certain guidelines and protocols that needs to be followed by all stakeholders involved. It also acts as the watchdog to ensure that every stakeholder is observing the rules of the yojana so that none of them can exploit the scenario to their advantage.”
Explaining the procedures involved in detail, Ajay Gulhane, Additional Collector & Deputy CEO, RGJAY Society elaborates, “Firstly, the government provides health cards to the beneficiaries and also conducts health camp with the help of the network hospitals. When patients approach hospitals to seek the benefits under this yojana, they have to first register themselves at the Arogyamitra kiosk which is stationed at every network hospital. The beneficiaries will have to provide the appropriate referral card and health card as well as documents to prove their proper identity. The Arogyamitra at the network hospital will then examine the documents, register the patients and facilitate the beneficiary to undergo specialist consultation, preliminary diagnosis, basic tests and admission process. The information like admission notes, test/s done are then captured in the dedicated database by the medical coordinator of the network hospital as per the requirement of the Society. Afterwards the network hospital, based on the diagnosis, admits the patient and sends e-preauthorisation request to the insurer, same can be reviewed by the Society. So, we had two levels of vigilance done in the pilot stage. If the document and report are clear the insurer and the society send their approval within 12 working hours and immediately in case of emergency wherein e-preauthorisation is marked as EM, we have a system called the Emergency Telephonic Intimation in which an approval can be given within an hour for emergency reasons. After performing the procedure, the network hospital forwards the original bills, diagnostics reports, case sheet, satisfaction letter from patient, discharge summary duly signed by the doctor, acknowledgement of payments of transportation cost and other relevant documents to insurer for settlement of the claim.”
Well, the protocols involved in this yojana may seem very convoluted; nevertheless this makes the system more organised and can be easily audited feels Dr Jotkar. As a matter of fact, this has also been one reason for the successful completion of the first phase of the yojana.
As mentioned above, the RGJAY has been designed to function in phases. Launched on July 2, 2012, the first phase of the RGJAY was introduced in eight districts of Maharashtra: Gadchiroli, Amravati, Nanded, Sholapur, Dhule, Raigad, Mumbai and its suburbs on a pilot basis. The government tied-up with 147 private and government hospitals to provide these services. The insurance coverage in this phase was offered to approximately 49.03 lakh eligible beneficiary families. The yojana provided medical aid for 972 surgeries/therapies/procedures along with 121 follow up packages in 30 identified specialised categories in this phase.
First phase of the journey
The response received in this phase is quite commendable. According to the updates given by the RGJAY society, there are 83,268 surgeries/therapies performed till the afternoon of August 21, 2013 out of which the private hospitals contributed to 56293 surgeries/therapies and the government hospitals 26975 respectively. As on August 21, around Rs 229.29 crores have been infused in this yojana, out of which the private hospitals’ share stands at Rs 149.63 crores and Rs 79.66 crores being the government hospitals’ share.
These enticing figures only prove that the people of Maharashtra are certainly making good use of the available benefits. Also, the government and the network hospitals through their health camps have left no stone unturned to spread the word.
Suresh Shetty Minister for Public Health and Family Welfare, State of Maharashtra |
Expressing his joy on the success of this yojana, Suresh Shetty, Minister for Public Health and Family Welfare, State of Maharashtra, in a public meeting said, “It is our attempt to alleviate the healthcare maladies that this country faces and the RGJAY is a step in the right direction.” Adding to this, Dr K Venkatesh, CEO, RGJAY, during the anniversary celebration, mentioned that the people of Maharashtra started owning the scheme right from the beginning which is one of the biggest advantage he sees. “We have received a very good response from the people. We have also kept a track on the feedbacks by patients and they are happy with our services. We have a call centre that daily receives calls from satisfied patients”, adds Gulhane.
Dattatray More, a patient from Mumbai who underwent a bypass surgery under the RGJAY, testifies his experience and says that he feels very gratified on receiving this aid from the government. He goes on say that with his financial condition he would never have been able to bear the cost of his surgery. Now that he has received medical aid free of cost he can lead a normal life. Shahida Khan, a young girl residing in Mumbai was house bound for 12 years due to an orthopaedic problem which was resolved with the help of this yojana. Her mother vouches for the yojana and calls it a saviour scheme. She says that her daughter can now walk and has taken up a small job to support her family.
Apart from the government officials and beneficiaries of the scheme, the yojana is much appreciated by network hospitals from Maharashtra’s impoverished districts where the yojana was introduced. Dr Vipul Bafna, Dhule, feels that the RGJAY is a revolutionary scheme. He explains why, “In a place like Dhule where the human index is very low and there is not much economic development as well as healthcare facilities are bare minimum, this scheme is a boon. Up till now we have performed more than 600 angioplasties and around 200 dialysis under the yojana. Apart from this, during our health camps we conducted more then 1500 angiographies free of cost.” When asked about how has his hospital benefited from the scheme, Dr Bafna replied that the government has not designed any attractive package for private players in this scheme; however, they have this advantage of earning in volumes.
Dr SM Deshpande from National Insurance Company, is of the opinion that the yojana has taught the insurance company to see healthcare in a different light. He discloses that working on a large social initiative like RGJAY has taught them lot of lessons on the roles and responsibilities of an insurance company.
Chinmaya Padhi Head – Payer, IMS Health |
While stakeholders involved appreciate the yojana and its functions, other industry experts also feel that the scheme is a good initiative. Chinmaya Padhi, Head – Payer, IMS Health find the amount of the coverage more impressive as this element of the scheme acts as a great support to the needy who otherwise may not have access to such expensive treatment”. However, Pramod Lele, CEO, PD Hinduja Hospital, Mumbai, states, “I feel that it’s a good scheme but requires some changes to make it more viable for the participating hospitals. Entire thought process is good viz. to make available healthcare available to poor and needy people below Rs one lakh pa family income. They have covered 900+ categories of illnesses, mostly surgical. It’s a decent coverage, though may not be all encompassing.”
So far, everything seems to be hunky-dory with the scheme. But does it mean there aren’t any loopholes or scope for improvement?
| Parameters | At a glance (Since July 2nd 2012) | |
| Enrollment | Families | 118676 |
| Benificiaries | 225256 | |
| Patients | Screened | 176804 |
| Registered | 190299 | |
| Out Patients | Government | 13007 |
| Private | 30952 | |
| Total | 43959 | |
| In Patients | Government | 31617 |
| Private | 61662 | |
| Total | 93279 | |
| Preauthorisations | Government | 28441 |
| Private | 58584 | |
| Total | 87025 | |
| Surgeries/ Therapies | Government | 27478 |
| Private | 57323 | |
| Total | 84801 | |
| Amount Preauthorised | Government | Rs.81.06 Cr |
| Private | Rs.152.73 Cr | |
| Total | Rs.233.79 Cr |
All that glitters may not be gold!
It is a known fact that any government venture in India has to overcome a lot of bottlenecks. RGJAY is no different. The scheme has been criticised by health activists for being procedure or operation driven.
Padhi warns, “Since the scheme covers invasive procedures, we may see issues related to converting a potential treatment from non-invasive basis to invasive basis. Though invasive basis treatment is covered, follow-up visits which are most common post many surgeries are not covered. Hence, hospitals may not focus on the overall health of the patient, which is the most critical underlying intent of such schemes. Regular audits should be undertaken by using services of firms with expertise in this area. This will ensure usage of quality materials in implant-based surgeries and will help bring down percentage of surgery failures and incidences of repetitive surgeries.”
Pramod Lele Chief Executive Officer, PD Hinduja Hospital, Mumbai |
Apart from the threat of malpractice, another area that the government battles with is roping in private hospitals to partner the scheme. The Health Minister of Maharashtra observes that the leading private hospitals had shied away from coming on board, citing the reason that the rates fixed for treatments would compromise their profitability. “We fixed the rates of the procedures after a thorough discussion, but now it is a question of profitability for private hospitals,” the Minister reveals.
Lele presents his counterviews on the same. “Rates provided for various procedures’ reimbursement are about 40 to 60 per cent below the tariffs of most of the tertiary care hospitals. That is why most of the big hospitals did not opt for the scheme.”
Apart from roping in private hospitals, the government has had a tough time negotiating with charitable hospitals as well. The Health Minister also claims that since Mumbai is the prime healthcare hub for Maharashtra they had approached all charitable hospitals to start this scheme within their hospital premises. However, they declined this offer.
Justifying their side, Lele replies, “Charitable hospitals carry out lot of free/concessional treatment to patients under order of the High Court. In the process, many of our beds are occupied by these concessional patients. It is not possible to provide the expected additional beds under the RGJAY scheme (25 per cent). It would render the whole hospital unviable. Charity hospitals would be able to implement only one scheme – either the existing High court charity scheme or RGJAY (with some modifications). One more aspect that needs to be looked into is the timely payment promised under the RGJAY scheme, it generally never comes on time, putting more strain on the finances of the hospitals.”
In juxtaposition with other schemes
| RGJAY Phase II MoU was signed between Maharashtra government and NIC on 8th August 2013 |
Well, with all its boons and banes, the RGJAY has still earned enough goodwill to its credit. But, how is it faring in comparison to other states’ healthcare schemes like Arogyashree and Yashaswini?
“Most of the features in these schemes, which are totally funded by respective state governments, are similar – for example the base cover under RGJAY and Rajiv Aarogyasri Health Insurance Scheme (RAHIS) is Rs.1.5 lakh per family per year. However, while RAHIS has additional cover of Rs 50000 beyond base cover as buffer, RGJAY has Rs 2.5 lakh extra cover for renal transplantation, while Yashaswini scheme covers only surgical expenses of all rural co-operative society members, members of self help group/Sthree Shakti Group having financial transaction with the cooperative society/banks, members of weavers, beedi workers and fisherman cooperative societies. RAHIS and Yashaswini schemes cover treatment as inpatient, but RGJAY has extension of cover to outpatients also,” analyses Padhi.
Analysts compare the RGJAY with renowned government initiatives present in the country, but does the government do so?
“The RGJAY is a replica of the (RAHIS) of Andhra Pradesh”, admits Dr Jotkar. He informs that the Maharashtra Government haves picked up the same the idea from the from RAHIS but made few changes to suit the people of this state. However, the RAHIS underwent through a very rough patch due to the involvement of a TPA. Additionally, the scheme that was kicked off with a noble idea turned out to be a money-spinner for the corporate hospitals, so why did Maharashtra decide to replicate the same model?
Dr Jotkar expounds, “This is because initially we were not confident of managing it alone but eventually we do have plans to eliminate the TPA just like RAHIS did in order to make the scheme viable. Also, where the question of misconduct by private players are concerned we have tried are best to keep stringent protocols and RGJAY is yet in its infancy, we will surely make this scheme more efficient in the time to come.”
Agreed that the scheme in its nascent stage and the RGJAY Society will leave no stone unturned to make it more viable in the long, but what are the immediate alterations done from the lessons learnt so far?
Tightening loose ends
The first phase is complete and the yojana has entered in its second phase which is supposed to be done on a much larger scale. But, before implementing the second phase, the Society is trying to filter the blunders of the first phase, discloses Dr Jotkar.
“In the first phase we received a very good response; however, we have had certain learning lessons. Based on these lessons we have done some modifications for the second phase in order to improve the scheme.” Explaining the challenges and alterations done so far, he goes on, “We had to work on the vigilance part. Initially, we had two levels of scrutiny of the beneficiary’s documents now we have kept only one level where the TPA would validate the documents and reports and the RGJAY Society will only check the rejected cases. This is to reduce the time taken to give approvals for procedures. Another change which will be implemented in the second phase is that we have kept 132 procedures that covers surgeries such as hysterectomy to be performed at government hospitals only. This is done to avoid malpractices. Also, we have reduced the number of procedures from 972 to 971. We have taken out conservative acute myocardial infarction (AMI ) from the list,” he adds. When asked the reason for deleting this procedure from the list, he replied that this was one of the abused areas.
Looking forward
By and large, the RGJAY Society has a clear vision for the future. That the government has taken efforts to learn from their mistakes and even rectifying the errors is certainly commendable. With the same ardour, the Maharashtra Government signed the MOU with the National Insurance Company, on August 8, 2013, to initiate the second phase. In this phase, the state government plans to step into 27 districts, reaching out to more people of Maharashtra. In future, to make it a more viable model, the government will need to work on efficiently administering claims as well as managing expenses and fraud in the right manner.