Phase II SAST-VAS Operational Performance 2013 · The Vajpayee Arogya Shree scheme has been extended to cover all the four divisions ... Vajpayee Arogyashree Medical Co-ordinator

Phase II

SAST-VAS Operational Performance – 2013

The Vajpayee Arogya Shree scheme has been extended to cover all the four divisions

of Karnataka and it has made a remarkable boost to address the tertiary health care

needs of population living Below Poverty Line. It is evident by the trend of increased

number of beneficiaries. To meet the increase in demand and strengthen the services

the Suvarna Arogya Suraksha Trust (SAST), has undertaken several improvement

strategies to operationalize the improvements in its performance such that it caters to

the health requirements of the beneficiary on time.

SAST introduced the online system for pre-authorization request submission in 2011.

However, the rest of the process involving claims submission and approval was done

manually.

A full-fledged online system for both pre-authorization and claims submission was

launched in November, 2012.

SAST encountered certain system delays while switching on to the online system for

pre-authorization and claims submission and approvals.

To streamline these, series of improvement measures were taken to improve the

operationalization of the scheme.

which are enlisted below:

1. Strengthening the online systems by building the technical assistance team at

SAST

2. Sensitization of the network hospitals on the procedures and the related

documentation by training the nodal person in the NWHs - Vajpayee

Arogyashree Medical Co-ordinator (VAMCO)

3. Since the beginning of the year 2013, the focus is on strengthening the pace of

approval of pre-authorization. A plan for ensuring no pendency of

pre-authorization requests, on daily basis for speedy approval of the requests

and reducing the Turn Around Time (TAT) for pre-auth approvals was worked

out

With all these measures a marked improvement is seen in pre-authorisation

procedures in the financial year 2013-14.

4. for the process of claims settlement strict timelines are set for claim submission

by Network Work Hospitals with penalty for delayed submission. The claims

by network hospitals need to be submitted within 15 days of the discharge of

the patient. A period of 7 days is allotted to address the queries raised by ISA

and another 7 days for the network hospitals to re submit the revised claims.

Thus, inclusive of all these, a period of 30 days is the total time allowed for

submission of claims. Penalties are imposed for submissions after 30 days.

Claim submissions within 30 to 45 days are subject to a penalty of 5 per cent,

submissions within 45 to 60 days involves a penalty a 10 per cent, submissions

within 60 to 90 days involves a penalty of 30 per cent and submissions above

90 days involves penalty of 50 per cent.

5. SAST has also increased the spread and network of hospitals by identifying and

empanelling about 97 hospitals across the State and also appropriate hospitals

(23 hospitals) in states like Andhra Pradesh and Maharashtra that are bordering

Karnataka, Where the people seek service due to access availability and

shorter distance. This totals to about 120 empanelled network hospitals under

the VAS scheme at present.

6. SAST has widened the scope by increasing number of procedures under the

scheme. The scheme at present covers about 447 procedures.

7. The benefit rates/packages for these procedures are also revised on a timely

basis as per the recommendations of the Executive Committee.

8. Series of compartmentalized consultations with different specialty groups were

conducted to assess and understand the nitty-gritties of actual problems

encountered on field and incorporating suggestions given by them wherever

feasible to strengthen and improve the program (medicated stunt, tumor board

etc...).

Following a continuous, multiple programme strengthening strategies during the

financial year 2013-14 the SAST has provided financial support for treatment of

26000 cases approximately under the Vajpayee Arogya Shree scheme.

To assess the operational performance of VAS scheme for the year 2013, the claims

settled cases by SAST during the period April to December 2013 was considered.

Among the total of 17,922 settled cases during this period, a sample of 3738 was

chosen for the analysis using a systematic random sampling technique.

Regional Distribution

The beneficiaries under the scheme saw a four-fold increase during the year 2013.

While assessing the regional distribution of the beneficiaries, it is found that there is a

fairly better spread as compared to the period starting 2009 to 2012. In the sample

analysed, the top 20 districts’ claims were 80 per cent of the total claims. Of this, the

beneficiaries from the Belgaum and Gulbarga divisions were about 53 per cent and

those from the Bangalore and Mysore divisions were 47 per cent. Thus, there is fairly

good utilisation of the scheme by the beneficiaries across the State. The district-wise

claims of the top 20 districts are shown in the table below. And the map shows the

regional distribution of beneficiaries.

Patient District No. of Claims Claimed Amount % of claims

Belgaum 257 14402720 6.88

Mysore 231 14739468 6.18

Gulbarga 194 11294659 5.19

Raichur 178 9743719 4.76

Shimoga 173 11429933 4.63

Hassan 168 10332189 4.49

Bangalore (U) 166 11335608 4.44

Mandya 163 10816912 4.36

Bellary 153 10018576 4.09

Bijapur 149 9494555 3.99

Bagalkot 148 9606992 3.96

Davangere 147 10000807 3.93

Tumkur 146 10010484 3.91

Chitradurga 135 9288087 3.61

Haveri 120 7505851 3.21

Uttara Kannada 112 9406495 3.00

Koppal 109 6134943 2.92

Bidar 106 5978286 2.84

Yadgiri 101 5915036 2.70

Dakshina Kannada 98 7960469 2.62

Grand Total 3054 195415789

Top 20 Network Hospitals

Markedly visible improvements are observed in the year 2013 with respect to the

spread and services provided by network hospitals. It is encouraging to note that there

is decongestion of the Bangalore based network hospitals, where in NWH in other

districts are also being utilised by the beneficiaries residing near to those NWH.

Among the top 20 network hospitals accessed by beneficiaries, 8 of them are in

Bangalore and about 60 per cent of the claims are from these hospitals. Four of the top

hospitals are in Mysore and 14 per cent of the claims are from the hospitals in Mysore.

The remaining 25 per cent of the claims are from 2 hospitals in Belgaum, 2 hospitals

in Mangalore, 2 hospitals in Shimoga, 1 in Udupi and 1 in Dharwad. The number of

claims and the total amount claimed by each of the 20 hospitals are presented in the

table below.

Hospital name Claims Claims

Amount

%

claims

%

Amount

Narayana Hrudayalaya Private Limited, Bangalore 489 32536500 17.00 17.20

Kidwai Memorial Institute of Oncology, Bangalore 282 14195507 9.80 7.51

SJICR, Bangalore 278 20340000 9.66 10.75

Vydehi Hospital, Bangalore 188 12462490 6.53 6.59

KLES Dr Prabhakar Kore Hospital and MRC, Belgaum 181 10836103 6.29 5.73

Vikram Hospital Private Limited, Mysore 148 12320000 5.14 6.51

Sagar Hospitals, Bangalore 142 8100000 4.94 4.28

BGS Global Hospital, Bangalore 138 7912600 4.80 4.18

Father Muller Medical College Hospital, Mangalore 111 9055886 3.86 4.79

Apollo BGS Hospital, Mysore 99 6315000 3.44 3.34

Belgaum Cancer Hospital Pvt Ltd, Belgaum 95 4215233 3.30 2.23

Trinity Hospital and Heart Foundation, Bangalore 93 8505000 3.23 4.50

Sapthagiri Super-specialty Hospital, Bangalore 90 5270000 3.13 2.79

Cauvery Hospital, Mysore 85 6550000 2.95 3.46

SDM Narayana Hrudayalaya, Dharwad 82 6240000 2.85 3.30

Sahyadri Narayana Hrudayalaya, Shimoga 79 5295000 2.75 2.80

Bharath Hospital Institute of Oncology, Mysore 76 3430844 2.64 1.81

Justice KS Hegde Charitable Hospital, Mangalore 76 5221339 2.64 2.76

Kasturba Hospital, Udupi 75 5212500 2.61 2.76

Nanjappa Life Care, Shimoga 70 5124000 2.43 2.71

Grand Total 2877 189138002

Districts of Origin of Patients in the top Network Hospitals

There is considerable dispersion in the utilisation of the network hospitals as

compared to the previous years. The increase in the utilisation of the hospitals outside

Bangalore conveys a positive note on the capacity to absorb larger number of

beneficiaries under the scheme thus, widening the scope of the scheme. The districts

of origin of the patients accessing services in the top six network hospitals are

presented in the below table. The origin of patients for the top 20 hospitals is also

shown in map below.

Hospital Name Patient district Claims Claims Amt

Narayana Hrudayalaya Private Limited

RAICHUR 62 3512500

GULBARGA 59 3838500

BELLARY 51 3148500

BIJAPUR 44 3222500

YADGIRI 32 1972000

BANGALORE - URBAN 25 1735000

BAGLAKOT 20 1312500

CHITRADURGA 20 1140000

BIDAR 18 1230000

DAVANGERE 18 1230000

Narayana Hrudayalaya Private Limited Total 349 22341500

Kidwai Memorial Institute of Oncology

TUMKUR 32 1814240

MANDYA 24 1205015


HASSAN 19 735055

CHIKKABALLAPUR 17 717725


RAMANAGAR 17 995680

KOLAR 16 785715

MYSORE 13 700170

BANGALORE - RURAL 11 468705

Kidwai Memorial Institute of Oncology Total 189 9405060

SJICR


TUMKUR 27 2260000

HASSAN 24 1665000

BELLARY 16 1085000



MANDYA 11 905000

MYSORE 10 745000

BANGALORE - RURAL 9 575000

GULBARGA 9 495000

SJICR Total 196 14390000

VYDEHI HOSPITAL

RAICHUR 28 1830280

KOLAR 18 1051012

BAGLAKOT 17 1118369


HAVERI 15 926643

GULBARGA 13 793012

BIDAR 10 711571

BIJAPUR 8 584572

YADGIRI 8 635057


VYDEHI HOSPITAL TOTAL 141 9241912

KLES Dr Prabhakar Kore Hospital and MRC

BELGAUM 117 6184103

BAGLAKOT 25 1545000

BIJAPUR 15 1060000

GADAG 8 400000

DHARWAD 3 175000

GULBARGA 3 160000

KOPPAL 3 100000

UTTARA KANNADA 3 892000

RAICHUR 2 105000

HAVERI 1 120000

KLES Dr Prabhakar Kore Hospital and MRC Total 180 10741103

VIKRAM HOSPITAL PRIVATE LIMITED MYSORE

MYSORE 54 4625000

HASSAN 31 2580000

MANDYA 28 2195000

CHAMARAJANAGAR 15 1165000

CHIKKAMANAGLUR 6 440000

RAICHUR 4 360000

KODAGU 3 255000

BAGLAKOT 2 240000


BELGAUM 1 20000

VIKRAM HOSPITAL PRIVATE LIMITED MYSORE 146 12120000

Specialty-wise claims

Most number of claims is found to be continuing for top five specialities from the

inception of programme to till now.

The top specialties claimed are

Cardiothoracic surgery- 30 per cent,

Cardiology - 26 per cent,

Oncology (surgical, medical & radiation) - 24 per cent.

Genito urinary surgery 11 per cent, and

Neuro surgery it is 9 per cent.

Cardiothoracic surgery

Cardiology Oncology Neuro Surgery Genito Urinary

Surgery

Claims 1090 940 886 380 331

Amount (Rs. in lakhs) 1124.1 575.9 441.5 150.3 83.7

0

200

400

600

800

1000

1200

Top 5 specialty -major claims and amount distributed -2013 (April to Dec)

1090, 30%

940, 26%

886, 24%

380, 11%

331, 9%

Top 5 specialty wise major claims (%) -2013 (April to Dec)

Cardiothoracic surgery

Cardiology

Oncology

Neuro Surgery

Genito Urinary Surgery

Age band Analysis

The majority of the claims were in the age group 41 to 50 years which is about 22.82 per cent

of the total claims from the top 10 districts. The least claims were in the age group 21 to 30

years. However, the claims among the age groups below 40 years taken together stood at 44

per cent which indicates the higher disease burden among the younger age groups.

On the positive note, VAS scheme seems to be utilized appropriately to improve the quality

of life of younger age groups and promoting productive life.

The age band-wise procedures claimed under the scheme are provided in the tables given in

the annexure. An observation that is obvious in these tables is that the majority of claims in

the age group 0 to 20 years is related to cardiothoracic surgery and cardiology. This indicates

the burden of cardiac diseases among the younger age groups. The other age groups have

claims related to varied specialties.

Patient District 0 to 20 % 21 to

30

% 31 to

40

% 41 to

50

% 51 to

60

% 61+ % Grand

Total

%

BANGALORE - URBAN 25 8.12 10 5.03 28 9.30 43 10.29 33 9.40 27 10.59 166 9.06

BELGAUM 39 12.66 27 13.57 39 12.96 52 12.44 54 15.38 46 18.04 257 14.03

BELLARY 42 13.64 18 9.05 24 7.97 32 7.66 21 5.98 16 6.27 153 8.35

BIJAPUR 35 11.36 20 10.05 14 4.65 22 5.26 34 9.69 24 9.41 149 8.13

GULBARGA 46 14.94 18 9.05 29 9.63 44 10.53 33 9.40 24 9.41 194 10.59

HASSAN 10 3.25 14 7.04 22 7.31 46 11.00 38 10.83 38 14.90 168 9.17

MANDYA 21 6.82 20 10.05 34 11.30 31 7.42 34 9.69 23 9.02 163 8.90

MYSORE 32 10.39 27 13.57 46 15.28 68 16.27 38 10.83 20 7.84 231 12.61

RAICHUR 41 13.31 21 10.55 33 10.96 34 8.13 35 9.97 14 5.49 178 9.72

SHIMOGA 17 5.52 24 12.06 32 10.63 46 11.00 31 8.83 23 9.02 173 9.44

Grand Total 308 16.81 199 10.86 301 16.43 418 22.82 351 19.16 255 13.92 1832

Operational Performance – Gap Analysis

The time lags at each level of operation of the scheme were studied using the sample (table

below). The Turn Around Time (TAT) in the pre-authorisation stage, that is, from the time of

request for approval to the approval of pre-authorisation, decreased drastically in the year

2013 as compared to the previous years’ average. The average time taken from the

submission for pre-authorisation to the validation is one day and the time taken from

validation to approval of pre-authorisation is 0.5 day. Thus, the TAT on an average is 1.5

days in the pre-auth stage.

Average Number of Days Taken at Each Stage of Operation under VAS Scheme - 2013

Pre-auth -

Submission to

Validation

Pre-auth -

Validation to

Authorisation

Pre-auth to

Admission

date

Hospitalisation

- Admission to

Discharge

Discharge to

Claim

submission

Claims to

Senior

Validation

Senior

Validation to

Claim

Authorisation

1.02 0.50 0.29 17.40 40.39 8.94 0.83

This reflects the collective impact of the improvement strategies to reduce the time taken

from pre-authorisation process.

The time gap from pre-auth to admission of the patient in the hospital was also a minimum of

0.29 day on an average. On the other hand, a long gap of 40 days is observed in the

submission of claims by the network hospitals after the discharge of the patient.

In the claims settlement stage at SAST, the average time taken for the validation of the claims

is 9 days approximately and the average time taken for the final approval and settlement of

claims is 0.8 days. Thus, the TAT at this stage is approximately 9-10 days. Significant

improvements are observed in the operational performances under the VAS scheme as

compared to the previous years where this gap was nearly 40 days on an average. The whole

of the process from pre-authorization requests to claims settlement is depicted clearly in the

diagram below

To highlight and record the improvement and program strengthening strategies it may be

noted that there is remarkable increase in the reach of the scheme to populations across the

state, by covering fourfold increase in the number of cases under VAS. i.e 25,000 cases were

conducted from inception of the program till 2013 where as in one financial year i.e 2013-14

a total of 26,000 are covered.

1.02 0.50 0.29

17.40

40.39

8.94

0.83

0

5

10

15

20

25

30

35

40

45

PA-submission to validation

PA validation to Auth

PreAuth to Admission date

Hospitalisation - Admission to

Discharge

Discharge to Claim

submission

Claims to Sr.validation

Sr. validation to claim auth

D

a

y

s

2013 (April - December)

Annexure table

Top 10 Procedures in the Age band 0 to 20 years

Main Specialty Procedure name No of Claims Claimed Amount

Cardiothoracic surgery VSD 88 7179403

Cardiothoracic surgery ASD 71 6705099

Cardiothoracic surgery ICR for TOF 65 5227842

Cardiology PDA Device Closure 54 3383452

Cardiothoracic surgery Mitral Valve Replacement 27 3389135

Cardiology ASD Device Closure 26 2113051

Cardiology VSD Device Closure 17 1440000

Cardiothoracic surgery PDA Closure 17 407935

Cardiology Balloon Mitral Valvotomy 16 375549

Cardiothoracic surgery BT Shunt (inclusives of grafts) 13 650000

Grand Total 394 30871466






Genito Urinary Surgery URSL - Single Side 27 729041

Neuro Surgery Discectomy-Lumbar 26 794734

Cardiology PTCA - one stent (non-medicated, elective) 15 911401

Cardiothoracic surgery Double Valve Replacement 13 2067171

Cardiothoracic surgery Aortic Valve Replacement 12 1569275

Cardiology ASD Device Closure 10 800000

Genito Urinary Surgery PCNL (Percutaneous Nephro Lithotomy) 3 70585







Cardiothoracic surgery CABG 34 3426477



Oncology Mastectomy - any type 25 858808

Oncology Radical Treatment with Photons (linear accelarator) 24 1818231

24400

24600

24800

25000

25200

25400

25600

25800

26000

2009 to 2013(till March) -4 years 2013(April to Dec) -1year

Total VAS cases


Cardiology PTCA - 2 stent (non-medicated) 13 1049972











Cardiology PTCA - one stent (non-medicated) 20 1283021

Genito Urinary Surgery

PCNL (Percutaneous Nephro Lithotomy) - Single

Side 18 448536










Genito Urinary Surgery TURP 25 622726


Cardiothoracic surgery CABG with IABP 17 2202485


Oncology Palliative Treatment with Photons (linear accelarator) 17 496362







Genito Urinary Surgery TURP 38 954007


Cardiology

Permanent pacemaker implantation (only VVI)

including Pacemaker value 15 1172253




Oncology

Radical Treatment & Post Operative RT(3DCRT)

Upto 30 fractions in 6 weeks 13 1084380


Documents

Phase II SAST-VAS Operational Performance 2013 · The Vajpayee Arogya Shree scheme has been extended to cover all the four divisions ... Vajpayee Arogyashree Medical Co-ordinator