Post on 12-Jan-2016
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!