phase ii sast-vas operational performance 2013 · the vajpayee arogya shree scheme has been...
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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
BANGALORE - URBAN 23 1140770
HASSAN 19 735055
CHIKKABALLAPUR 17 717725
CHITRADURGA 17 841985
RAMANAGAR 17 995680
KOLAR 16 785715
MYSORE 13 700170
BANGALORE - RURAL 11 468705
Kidwai Memorial Institute of Oncology Total 189 9405060
SJICR
BANGALORE - URBAN 61 4555000
TUMKUR 27 2260000
HASSAN 24 1665000
BELLARY 16 1085000
CHITRADURGA 16 1190000
CHIKKABALLAPUR 13 915000
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
BANGALORE - URBAN 17 1070225
HAVERI 15 926643
GULBARGA 13 793012
BIDAR 10 711571
BIJAPUR 8 584572
YADGIRI 8 635057
CHIKKABALLAPUR 7 521171
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
CHITRADURGA 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
Top 10 Procedures in the Age band 21 to 30 years
Main Specialty Procedure name No of Claims Claimed Amount
Cardiothoracic surgery Mitral Valve Replacement 48 6495371
Cardiology Balloon Mitral Valvotomy 41 821284
Cardiothoracic surgery ASD 35 2958839
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
Grand Total 230 17217701
Top 10 Procedures in the Age band 31 to 40 years
Main Specialty Procedure name No of Claims Claimed Amount
Cardiology PTCA - one stent (non-medicated, elective) 54 3420785
Neuro Surgery Discectomy-Lumbar 54 1347168
Cardiothoracic surgery Mitral Valve Replacement 43 5516014
Cardiothoracic surgery CABG 34 3426477
Genito Urinary Surgery URSL - Single Side 28 669699
Cardiology Balloon Mitral Valvotomy 27 550727
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
Cardiothoracic surgery ASD 15 1241744
Cardiology PTCA - 2 stent (non-medicated) 13 1049972
Grand Total 317 19899625
Top 10 Procedures in the Age band 41 to 50 years
Main Specialty Procedure name No of Claims Claimed Amount
Cardiology PTCA - one stent (non-medicated, elective) 128 8089973
Cardiothoracic surgery CABG 103 10008533
Oncology Radical Treatment with Photons (linear accelarator) 53 4020683
Neuro Surgery Discectomy-Lumbar 44 997979
Cardiology PTCA - 2 stent (non-medicated) 35 2525567
Cardiothoracic surgery Mitral Valve Replacement 28 3394170
Oncology Mastectomy - any type 24 817576
Cardiology PTCA - one stent (non-medicated) 20 1283021
Genito Urinary Surgery
PCNL (Percutaneous Nephro Lithotomy) - Single
Side 18 448536
Genito Urinary Surgery URSL - Single Side 18 461753
Grand Total 471 32047791
Top 10 Procedures in the Age band 51 to 60 years
Main Specialty Procedure name No of Claims Claimed Amount
Cardiology PTCA - one stent (non-medicated, elective) 97 6325347
Cardiothoracic surgery CABG 91 9096579
Cardiology PTCA - 2 stent (non-medicated) 51 4797991
Oncology Radical Treatment with Photons (linear accelarator) 36 2662422
Cardiology PTCA - one stent (non-medicated) 26 1586712
Genito Urinary Surgery TURP 25 622726
Cardiothoracic surgery Mitral Valve Replacement 21 2909969
Cardiothoracic surgery CABG with IABP 17 2202485
Neuro Surgery Discectomy-Lumbar 17 543318
Oncology Palliative Treatment with Photons (linear accelarator) 17 496362
Grand Total 398 31243911
Top 10 Procedures in the Age band 51 to 60 years
Main Specialty Procedure name No of Claims Claimed Amount
Cardiothoracic surgery CABG 89 8771981
Cardiology PTCA - one stent (non-medicated, elective) 65 4028267
Cardiology PTCA - 2 stent (non-medicated) 40 3302384
Genito Urinary Surgery TURP 38 954007
Oncology Radical Treatment with Photons (linear accelarator) 33 1876904
Cardiology
Permanent pacemaker implantation (only VVI)
including Pacemaker value 15 1172253
Neuro Surgery Discectomy-Lumbar 15 342651
Cardiology PTCA - one stent (non-medicated) 13 821343
Oncology Mastectomy - any type 13 481429
Oncology
Radical Treatment & Post Operative RT(3DCRT)
Upto 30 fractions in 6 weeks 13 1084380
Grand Total 334 22835599
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