Strengthening Partnerships for Implementation of PM-JAY in Uttar Pradesh: Contribution of the Medical Colleges

On May 31, the State Agency for Comprehensive Health, and Integrated Services (SACHIS), the implementing agency for the Pradhan Mantri Jan Arogya Yojana (PM-JAY), the Department of Medical Education, and ACCESS Health came together to deliberate on increasing the participation of medical colleges in the government-sponsored health insurance scheme. The workshop was attended by the Additional Chief Secretary, Department of Health & Family Welfare, Principal Secretary, Department of Medical Education, Chief Executive Officer, SACHIS, Director General Medical Education and Chief Medical Superintendents, and the PM-JAY Nodal Officers of 51 public and private medical colleges.

The participants deliberated to identify actionable steps for Medical Colleges which would improve access, experience, quality of care and reduced out-of -pocket-expenditure for patients who access care under PM-JAY. The state has a wide network of 51 empanelled medical colleges under PM-JAY, which provides an opportunity to increase the availability of tertiary and specialized care for the state including PM-JAY, which in the last three years has been limited. The scheme provides a prospect of additional financing for the public medical colleges which can help strengthen the teaching institutions in the state.

The key takeaways for improving access at Medical Colleges under PM-JAY included pivotal need in screening beneficiaries of their eligibility status, (as patients are walk-in and may or not be enrolled) through strengthening of the PM-JAY desk and other approaches. Empaneled medical colleges such as King George Medical College and Tirthankara Mahaveer Hospital and Research Centre Moradabad highlighted that they screen all the in-patient cases for their eligibility status under PM-JAY, in all the wards and the departments which helps in reaching out the beneficiary. Ram Manohar Lohia hospital does community outreach through the Department of Community Medicine. Additional strategies included scheme orientation of all levels of staff in medical colleges, incentivizing the staff through the reimbursements, increasing accountability through coordination and monitoring support,which have shown success in the colleges.

The implementation highlights that despite being a cashless scheme the patients incur out-of-pocket expenditure (OOPE). The majority of this expenditure is towards the purchase of medicines, diagnostics, consultation, and then some towards transportation and boarding. The discussion highlighted supply chain issues affecting the availability of medicines. For which use of E-pharmacies has emerged as one of the options, additional bulk purchasing to address supply-related gaps were discussed and suggested. Another cost of OOPE is transport, which is especially very high in cases where the patient is going to another state for treatment. In the last three years, more than 80,000 patients have gone out of the state for the services which are available within the state and in some cases within the districts and mostly for tertiary care. Thus, a key strategy to reduce OOPE will be to increase availability of services nearest to home and medical colleges will have a critical role.

On improving experience and quality of care, the discussion emphasized on strengthening four elements of care- quality of doctors, nursing care, paramedic care, and coordination support to patients, and ability to give feedback. The case of SNMC Medical College Agra was presented, whereby supporting the medical colleges through monitoring, problem resolution, and capacity building the uptake of PM-JAY increased considerably along with improvement in correct and timely submission of the claims. The suggestion of developing Standard Operating Procedures towards building Adarsh Ayushman Kendra in Medical Colleges was made. Further, examples of how hospitals that are accredited and certified in addition to standardizing quality of care have also shown better claims management processes and systems. Additionally, training and being updated on the scheme developments are critical for which SACHIS can devise methods to keep the provider network engaged.

Another element is continuity in post-hospitalization care when the patients get back home. The key vision of the Ayushman Bharat reforms is a continuum of care through gatekeeping, and forward and backward linkages. The implementation highlights at present that most patients are direct walk-in, therefore forward referrals from lower institutions may not be immediately possible, however, how can we initiate backward linkages to provide continuity of care through the Health & Wellness Centre. In this direction, SACHIS and ACCESS Health are working on an integrated application, which aims to establish bi-directional linkages for the patient.

An important health systems issue highlighted by the Principal Secretary Medical Education was the urgent need to shift the thinking towards self-sustainability and innovation for the teaching institutions. PM-JAY for public colleges is an opportunity of additional financing, which along with other innovations and ideas could strengthen the institutions. He urged the medical colleges to introspect and identify actionables.

A major issue voiced by the hospitals is the availability of cash flows due to time taken for claims settlement. A new funding proposal called the Green Channel was shared by SACHIS to encourage greater participation of empaneled hospitals. Under this hospital empaneled with PM-JAY for at least six months with no history of reported malpractice can receive 50 percent of the claim amount at the time of claim submission subject to no trigger for fraud. The partial payment will be released automatically through the system at the time of claim submission while the balance amount will follow the process of adjudication. The proposed idea was welcomed by the participants.

The Medical Colleges also got an opportunity to understand in detail from Dr Shankar Prinja, the Executive Director National Health Authority, on the newly launched Health Benefit Package 2022. The revised HBP aims to bring more clarity in the nomenclatures of the different procedures earlier put under the unspecified packages. It now has new procedures for palliative care, high-end drugs, consumables, and diagnostics that have been unbundled from the per-bed day cost of medical packages, inclusion of daycare packages for mental health, more procedures as cross-specialty, standard specifications for implants. Additionally, prices include outpatient consultation and pre-diagnostic work-up within three days of the procedure, the cost of the procedure, hospitalization following the procedure, and the cost of drugs for 15-days following hospitalization. The introduction of a differential pricing based on the type of city and level of care location will also make the pricing attractive for the hospitals. The Medical Colleges welcomed the new revisions.