Dr.YSR Aarogyasri Health Care Trust
Towards achievement of universal health coverage for BPL families whether defined in terms of financial protection or access to and effective use of health care, Government of Andhra Pradesh is implementing state sponsored Dr.YSR Aarogyasri Health Insurance Scheme. This scheme certainly counts to be one of the pioneers in terms of achieving equity and providing accountable and evidence-based good-quality health-care services in the state to assist poor families from catastrophic health expenditure. The aim of the Government is to provide Universal Health Coverage to BPL families. The scheme is a unique PPP model in the field of Health Insurance, tailor made to the health needs of poor patients and provides end-to-end cashless services for identified diseases under secondary and tertiary care through a network of service providers from Government and private sector.
Origin Of The Trust
In order to facilitate the effective implementation of the scheme, the State Government set up the Dr.YSR Aarogyasri Health Care Trust, under the chairmanship of the Honorable Chief Minister. The Trust is administered by a Chief Executive Officer who is an IPS Officer. The trust, in consultation with the specialists in the field of insurance and healthcare, runs the scheme. The Trust being an independent body and single purpose unit is able to achieve universal health coverage to poor families in the state at a faster rate. Some of its activities could include governing, organizing and monitoring the scheme, capacity building of the stakeholders and negotiating with the providers.
Functioning of the Trust
Hospitals having a minimum of 50 hospital beds with requisite infrastructure and expertise within the states of Andhra Pradesh and Telangana are eligible to be empanelled under the scheme for providing services.In respect of single speciality hospitals like ENT, Ophthalmology etc 20 bedded hospitals are eligible.
To bring in quality and transparency into the system of empanelment, online empanelment procedure is adopted. Hospitals while applying have to upload their application along with entire details of the hospital such as Infrastructure, availability of Specialists, Equipment, Lab facilities with documentary and photographic evidence. Once the online application is registered these hospitals are inspected by team of doctors from the Empanelment and Disciplinary Committee (EDC) and based on the report and evidence the Empanelment and Disciplinary Committee analyse the hospital and thereafter accept/reject the empanelment application. The hospitals whose applications are accepted are thereafter inducted into the scheme after a work shop and signing of MOU.
An empanelled health care provider shall be referred as a network hospital-Are listed in website: www.ysraarogyasri.ap.gov.in
- Disciplinary action
The EDC shall initiate disciplinary proceedings against erring NWHs for the following reasons:
Man power deficiencies
Violation of service contract agreement
- Medical Audit
The success of the scheme rests on ensuring that all the stakeholders adhere to the highest level of medical ethics.
Monitoring of quality of medical care.
Framing guidelines to prevent moral hazard.
Monitoring the trends of utilization of listed therapies across NWHs.
Conduct investigation into allegations of treatment lapses.
Analyze mortality and morbidity under this scheme and recommend corrective measures.
Recommend punitive actions against a medical professional or NWH.
For elective cases the approvals are given within 12 hours and for emergency cases telephonic approvals are given immediately.
All pre-authorisations are being handled through the Trust portal. The pre-authorization is done 24x7x365 days.
- Telephonic approval:
A provision is made in the scheme to ensure timely preauthorization in cases of life saving emergencies through Telephonic Approvals. Provisional approval is given by collecting minimal essential data through call conferencing facility available round the clock between the treating Doctor/Medco, pre-auth executive and pre-auth doctor. The data thus collected through few questions is captured in online format by preauthorization team and a system generated reference number is given to the hospital. The online format thus created is automatically made available in the hospital login to help hospital to use it to send regular pre-authorization.
- Claims settlement
Hospital can raise claim only after 10 days after discharge as post discharge 10 days period is part of package. All the claims processing shall be carried out electronically through the Trust portal. Payments to all the NWHs shall be made through electronic clearance facility of the Trust.
The Claim processing is done on the basis of outcome of treatment and is evidence-based with definite post treatment indication.
- Online workflow
A dedicated real-time online workflow system was designed by the Trust in order to bring dynamism and decentralization of work in a massive scheme like Dr.YSR Aarogyasri This includes total online processing of the cases starting from registration of case at first referral center (health camps or network hospitals or other sources), pre-authorization, up-load of medical and non-medical records electronically, treatment and other services at the hospital, discharge and post treatment follow-up, claim settlement, payments through payment gateway, accounting system, TDS deductions till the end. Any inputs for improvement of the system will be taken from all the stake holders from time to time. A dedicated data center is being maintained by Trust for this purpose. Analytical tools including BI (Business Intelligence or Service Intelligence)
- Information Education and Communication (IEC)
The Trust undertakes IEC activity to create awareness among various stakeholders through awareness campaigns, Health camps, Publicity through pamphlets and posters, Publicity through electronic media, Training and orientation
- Capacity Building
Workshops or training sessions for capacity building of the their beneficiaries, representatives and other stakeholders in respect of the scheme and their roles at each district is organized by the Trust. The following training programmes are organized for stakeholders
Empanelment training programme
Network Hospital training programme at hospital
Network hospital reorientation programme
PHC Vaidyamithras training programme
raining Programme for Field functionaries
Soft & Communication skills training programme
Any other training and orientation programme designed by the Trust
- Cochlear Implant Program
Financial assistance is provided to the children of BPL families born totally deaf and dumb to undergo cochlear implantation surgery and Audio-Verbal therapy under Dr.YSR Aarogyasri Health Insurance scheme.
- Cochlear Implant Program
Dr.YSR Aarogyasri is the flag ship scheme of the state government and the aim is to achieve "Universal Health Care " to poor people in Andhra Pradesh, and the benefit in the primary care is addressed through health camps as part of scheme implementation. Health Camps are main source of mobilizing the Beneficiaries. The important role played by the health camps includes conducting IEC activity, screening, counselling , treatment of common ailments and refer the patients to Government and Corporate Network Hospitals for treatment under Dr.YSR Aarogyasri