Improving hospital-based processes for effective implementation of Government funded health insurance schemes: evidence from early implementation of PM-JAY in India

Abstract

Background Government-sponsored health insurance schemes (GSHIS) aim to improve access to and utilization of healthcare services and offer financial protection to the population. India’s Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) is one such GSHIS. This paper aims to understand how the processes put in place to manage hospital-based transactions, from the time a beneficiary arrives at the hospital to discharge are being implemented in PM-JAY and how to improve them to strengthen the scheme’s operation. Methods Guidelines were reviewed for the processes associated with hospital-based transactions, namely, beneficiary authentication, treatment package selection, preauthorization, discharge, and claims payments. Across 14 hospitals in Gujarat and Madhya Pradesh states, the above-mentioned processes were observed, and using a semi-structured interview guide fifty-three respondents were interviewed. The study was carried out from March 2019 to August 2019. Results Average turn-around time for claim reimbursement is two to six times higher than that proposed in guidelines and tender. As opposed to the guidelines, beneficiaries are incurring out-of-pocket expenditure while availing healthcare services. The training provided to the front-line workers is software-centric. Hospital-based processes are relatively more efficient in hospitals where frontline workers have a medical/paramedical/managerial background. Conclusions There is a need to broaden capacity-building efforts from enabling frontline staff to operate the scheme’s IT platform to developing the technical, managerial, and leadership skills required for them. At the hospital level, an empowered frontline worker is the key to efficient hospital-based processes. There is a need to streamline back-end processes to eliminate the causes for delay in the processing of claim payment requests. For policymakers, the most important and urgent need is to reduce out-of-pocket expenses. To that end, there is a need to both revisit and streamline the existing guidelines and ensure adherence to the guidelines.

Experiences and challenges in accessing hospitalization in a government-funded health insurance scheme: Evidence from early implementation of Pradhan Mantri Jan Aarogya Yojana (PM-JAY) in India

“…Time taken for ‘pre-authorization approval’ can be high if (a) at hospital level AM is submitting incomplete ‘admission and pre-authorization request’ resulting in repeated queries from the insurer, (b) the insurer lacks the capacity to process the received ‘admission and pre-authorization request’ on time. It has been suggested that the time required for completing hospital-based processes that involve AMs can be reduced by investing in capacity-building efforts for AMs [ 15 ]. The results of the present study highlight a need to focus on capacity-building initiatives for AMs in Madhya Pradesh as compared to Gujarat, and within Madhya Pradesh to prioritize such initiatives for AMs working in private hospitals.…”

“…This was found to be more relevant for patients with conditions, like cancer, that require treatment by a team of doctors using multiple treatment modalities. It has also been reported that the patients are asked to pay for the difference of costs between the treatment preferred by the healthcare providers (for example, medicine or an implant for treatment of a cardiovascular condition) and that covered under the scheme [ 15 ]. Irrespective of the reasons, OOP payments affect the financial and physical coverage of the GSHIS scheme and negatively affect user satisfaction.…”

“…PM-JAY is a recent initiative and there is limited literature on it. In the existing literature, a need to study beneficiaries’ perspectives on PM-JAY processes has also been stated [ 15 ]. By attempting to understand responsiveness, financial burden, and patient satisfaction and its determinants, this study seeks to enrich the existing literature and provides useful insights to the policymakers and program managers to strengthen the scheme.…”

The African Health Initiative’s Role in Advancing the Use of Embedded Implementation Research for Health Systems Strengthening

“…During the last 10 years, EIR has been used successfully to improve the use of knowledge in decision making at different levels within health systems, resulting in tangible outcomes that have been documented in numerous publications. [8][9][10][11][12] The EIR approach, as demonstrated by the AHI, has shown its potential for strengthening the learning capacity of health systems and improving health systems' performance. While further evaluations of the EIR approach are needed, there is clearly strong support for this approach to contribute significantly to improving policy and program implementation.…”

“…In these instances, workshops focused on the interpretation and dissemination of the research findings, which have been critical in helping to adapt and improve program delivery. [9][10][11] In Argentina, EIR resulted in the development of new monitoring indicators to improve the implementation of the perinatal health policy. In Chile, research findings led to the establishment of a training program on reproductive rights that targeted municipal health facilities.…”