Dr YSR Aarogyasri Health Care Trust Government of

Dr YSR Aarogyasri Health Care Trust (Government of Andhra Pradesh) “Insight from scheme Data” 30 th September and 1 st October - 2019 “Towards Universal Health Coverage”

Health Schemes under Dr YSR Aarogyasri Health Care Trust S. No 1 2 Name of the Scheme Dr. YSR Aarogyasri(in Lakhs)(BPL) Employees Health Scheme Date of Launching No. of Families (Heads) Population / Enrolled No. of Procedures Covered Financial Limit/year 01. 04. 2007 1. 44 Crores 4. 04 Crores 1059 5 Lakhs per family 05. 12. 2013 5, 78, 344 16, 07, 656 1885 2 Lakh per episode 2, 040 6, 371 3 Working Journalists Health Scheme 4 Amaravathi Residents Health Scheme(CRDA) 09. 01. 2017 37, 569 1, 07, 000 5 Aarogyaraksha (APL) 07. 04. 2017 68, 067 1, 77, 979 9, 289 21, 267 04. 07. 2018 - 30. 12. 2018 55, 30, 825 6 Active cards as on 31. 08. 2019 Amrutha (Scheme for Orphans and Destitute) Aayushman Bharat (SECC Data base-BPL) 21. 03. 2015 Total Population covered : 4. 24 Crs No. of Followups Covered 138 170 1885 2 Lakh per episode 170 1059 5 Lakhs per family 138 1044 2 Lakhs person 138 2, 812 1059 5 Lakh 138 1, 70, 80, 552 1392 5 Lakh --

No of Preauths Approved 51, 253 21, 851 19, 847 19, 434 13, 565 13, 344 13, 076 10, 888 RADIATION ONCOLOGY CARDIOLOGY OPHTHALMOLOGY SURGERY ORTHOPEDIC SURGERY AND PROCEDURES GYNAECOLOGY AND OBSTETRICS SURGERY SURGICAL ONCOLOGY NEUROSURGERY NEUROLOGY ENT SURGERY 4, 439 2, 582 2, 197 2, 049 978 168 117 81 PEDIATRIC SURGERIES PLASTIC SURGERY CRITICAL CARE GENERAL MEDICINE SURGICAL GASTRO ENTEROLOGY ENDOCRINOLOGY COCHLEAR IMPLANT SURGERY RHEUMATOLOGY DERMATOLOGY INFECTIOUS DISEASES ORGAN TRANSPLANTATION SURGERY PROSTHESES 5, 504 GASTROENTEROLOGY 0 1 3 1, 579 7, 114 Name of the Speciality PULMONOLOGY 13, 921 17, 483 23, 480 PEDIATRICS 28, 991 47, 221 75, 450 NEPHROLOGY GENITO URINARY SURGERIES CARDIAC AND CARDIOTHORACIC SURGERY GENERAL SURGERY 77, 956 POLY TRAUMA 90, 196 100, 000 90, 000 80, 000 70, 000 60, 000 50, 000 40, 000 30, 000 20, 000 10, 000 0 MEDICAL ONCOLOGY Disease wise utilisation under the scheme for the FY 2018 -19

Preauth Approved Amount (Rs in Cr. ) 0. 00 Name of the Speciality 20. 66 14. 46 15. 53 15. 55 GASTROENTEROLOGY PEDIATRIC SURGERIES PLASTIC SURGERY CRITICAL CARE 0. 01 INFECTIOUS DISEASES 0. 00 0. 11 0. 22 DERMATOLOGY ORGAN TRANSPLANTATION SURGERY PROSTHESES 0. 35 8. 77 1. 92 8. 86 COCHLEAR IMPLANT SURGERY RHEUMATOLOGY SURGICAL GASTRO ENTEROLOGY ENDOCRINOLOGY 6. 83 22. 30 PULMONOLOGY GENERAL MEDICINE 16. 65 32. 56 67. 88 46. 50 22. 43 42. 99 ENT SURGERY NEUROLOGY NEUROSURGERY 64. 98 82. 98 68. 88 27. 26 50. 00 OPHTHALMOLOGY SURGERY ORTHOPEDIC SURGERY AND PROCEDURES GYNAECOLOGY AND OBSTETRICS SURGERY SURGICAL ONCOLOGY CARDIOLOGY RADIATION ONCOLOGY PEDIATRICS 300. 42 350. 00 87. 67 121. 40 96. 57 200. 00 GENITO URINARY SURGERIES CARDIAC AND CARDIOTHORACIC SURGERY GENERAL SURGERY NEPHROLOGY 250. 00 240. 15 300. 00 POLY TRAUMA 100. 00 67. 98 150. 00 MEDICAL ONCOLOGY Disease wise amount spent by the Government for the FY – 2018 -19

High performing Hospitals during the FY 2018 -2019 Hospital Type Govt. Govt. Total Private Private Total Grand Total Name of Hospital No. of Therapies District Preauthorized Amount (Rs In Cr) Sri Venkateshwara Institute Of Medical Sciences Chittoor 24, 322 59. 00 King George Hospital Government General Hospital, Guntur Govt General Hospital Kurnool Government General Hospital, Kakinada S. V. R. R. Hospital Govt. General Hospital- Vijayawada Rims General Hospital Govt General Hospital Anantapur Vishakhapatnam Guntur Kurnool East Godavari Chittoor Krishna YSR Kadapa Anantapur 14074 13894 13253 10088 6629 5160 5012 4530 39. 89 36. 43 40. 69 23. 41 21. 52 14. 24 11. 60 7. 52 District Hospital - Eluru West Godavari 3136 6. 78 Narayana Medical College Hospital Omega Hospitals A Unit Of Kurnool Institute Of Oncology Pvt Ltd Surya Global Multi Speciality Hospitals And Cancer Research Centre Ms Mahatma Gandhi Cancer Hospital And Research Institute Krishna Institute Of Medical Sciences Bollineni Hospital Nellore Nri Academyof Sciences HCG Pinnacle Cancer Centre GSL Trust Cancer Hospital And Research Centre Hope International Hospital A Unit Of Palaparthi Super Speciality Hospitals Private Limited Queens NRI Hospitals Nellore Kurnool East Godavari Vishakhapatnam Nellore Guntur Vishakhapatnam East Godavari 1, 00, 098 9, 842 9, 310 8, 991 8, 958 8, 258 6, 382 6, 141 5, 942 261. 06 31. 80 16. 29 15. 99 16. 39 30. 36 20. 16 11. 29 8. 11 5, 388 8. 56 5, 281 74, 493 1, 74, 591 11. 42 170. 36 431. 42 East Godavari Vishakhapatnam

District wise Therapies Preauthorized for the FY 2018 -19 # Patient District 1 2 3 4 5 6 7 8 9 10 11 12 13 East Godavari Guntur Krishna West Godavari Kurnool Chittoor Nellore Vishakhapatnam Prakasam YSR Kadapa Anantapur Srikakulam Vizianagaram Grand Total FY 2018 -2019 No. of Therapies Preauthorized 66, 507 63, 142 46, 590 45, 090 44, 847 43, 692 42, 581 42, 043 39, 699 37, 659 36, 481 29, 204 27, 233 5, 64, 768 Therapies Preauthorized Amount (Rs in Cr. ) 167. 05 174. 05 132. 79 120. 53 121. 9 112. 68 115 107. 03 110. 95 101. 6 95. 37 76. 14 67. 73 1502. 82

Cochlear Implantation programme: The scheme has been designed as a special package to provide cashless services to the needy hearing impaired deaf and dumb children with package amount of Rs. 6. 5 lakhs per beneficiary towards Cochlear Implantation Surgery and Audio Verbal Therapy for one year. 513 hearing impaired children are benefited from cochlear implantation programme till date. Patients utilization From 02. 06. 2014 to 31. 08. 2019 No. of Patients Treated No. of Therapies Preauthorized Amount (Rs. in Cr. ) 87 87 4. 52 2015 -2016 -2017 -2018 70 70 3. 64 63 63 3. 28 60 60 3. 12 2018 -2019 168 8. 77 2019 -2020 (Till 31. 08. 2019) 65 65 3. 47 Grand Total 513 26. 80 Financial Year 2014 -2015 (From 02. 06. 2014)

“ Inclusion of Maternal Procedures” The Government of A. P in order to further reduce the Maternal Mortality Rate from 65 to 50 per one lakh live births has launched “Talli Suraksha”. The objective of the scheme is to provide cashless Obstetrics services under Dr. YSR Aarogyasri for BPL beneficiaries on par with CGHS 2014 rates, thereby reducing the burden on Govt. Hospitals. The date of implementation of “Talli Suraksha” is on 15. 01. 2019. New Obstetric (Deliveries) Procedures included under the Dr. YSR Aarogyasri and utilization from 15. 01. 2019 to 31. 08. 2019. Sl. No Name of the Procedure Package Rate No. of Therapies Raised No. of Therapies Approved Amount (Rs in Crores) 1 Normal Delivery Rs. 8, 000/- 22, 477 19, 889 15. 91 2 Caesarean Section Rs. 14, 050/- 28, 329 25, 718 36. 11 Grand Total 50, 806 45, 607 52. 02

Mechanism for identifying frauds committed by the Hospitals 1. Panel doctors & Operations wing - Technical Scrutiny (who are processing the Preauths and Claims) 2. Internal Medical Audit of 1% Claim paid cases. 3. External Clinical audit by the third party Agency. 4. Disciplinary committee Monitoring tools for effective implementation of the schemes 1. Flagging system 2. Biometric Mechanism – For IP registration, Discharge, MEDCO, Dialysis & Oncology sessions. 3. SMS services regarding the status of the case (Preauth and after Claims approval) 4. Online Grievance workflow (from Mithra to GM – Grievance) 5. 104 Toll free call centre (Seva Kendram) & 104 Outbound call services 6. Real Time Governance (RTGS) survey - Evaluation by Third Party (by Govt. ).

Flagging system v There is a provision in online system to raise flag from Vaidya Mithra (field staff) to the Executive officer (Trust) level. 1. Flags due to Complaints – Money Collection, Denial of Treatment, Post OP complication, Incomplete Treatment, Delay treatment, adverse complaints, etc. , 2. flags for want of Technical verification – Verification of genuineness of case like Emergency approvals, enhancements, high end packages, Death cases, Special opinions, Specialist opinions, etc. , v The case with flag for Money Collection will be out of regular claim process and processed in a separate workflow till redressal.

104 (Tollfree) - Inbound and Outbound Services v Inbound Services: The Trust has established a dedicated helpdesk/ helpline “ 104 Seva Kendram” (Health Information Help Line) which functions round the clock (24 x 7) 365 days. This Toll-Free Call Centre provides the following services Ø Health Advice, Ø Counselling Services, Ø Availability of beds and specialty in the Network Hospitals, Ø Information regarding the schemes implemented by the Trust Aarogyasri/EHS/WJHS Ø Any citizen can book a complaint through 104 Tollfree Call Centre and by online mechanism further action will be initiated till redressal. v Out bound Services: The Trust initiated Outbound services in 2013 by calling each & every beneficiary after discharge in a defined format with a questionnaire taking the feedback under Dr YSR Aarogyasri and EHS. The satisfaction % is 94 and complaints will be forwarded to Grievance Section of concerned departments for redressal.

Real Time Governance (RTGS) – Govt. The Government is conducting independent evaluation by third party through Real Time Governance – Satisfaction percentage is 88 % as on November, 2018

Medical Audit Internal Medical Audit: Ø The Trust designed an online workflow for conduct of Medical Audit in the year 2013. Ø 1% of all Claim paid cases will be displayed in the Medical Auditor login for auditing in a defined format. Ø Criteria for 1 % selection of cases – All Death cases, high end procedures, high volume procedures including special cases for audit, etc. Ø Special audit will be conducted for Death cases & others due to negligence of NWHs / Fraudulent cases and Disciplinary action will be initiated by EDC. Ø Interaction with Operations team on Medical audit Observations and updating of Guidelines.

Medical Audit Clinical audit by External Agency: v The Board of the Trust has decided to setup a Medical Audit system by outsourcing through a Third Party Agency during the meeting held in 2008. v As per the agreement with Network Hospitals all the Hospitals shall under go Medical Audit. v The Trust identified Medi Assist Agency for conducting Clinical Audit. As per the MOU Agreement: 1. Appointment of one Clinical Director and one Clinical Auditor for conducting Clinical Audit. 2. 2 % of Claim paid cases are to be audited.

Disciplinary Actions • Reasons for disciplinary action § Infrastructure Deficiencies § Equipment Deficiencies § Manpower deficiencies § Service Deficiencies § Violation of service Contract Agreement(SCA) • With holding of Payments • Levy of Penality • Suspension • De-empanelment • Delisting

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