Analysis of the Pr-Authorization Procedure & Settlement of claims of Vajapayee Arogyashree Scheme
The Vajpayee Arogyashree Scheme introduced by the Government of Karnataka in 2009 was an important policy initiative in the sphere of health financing. Given the resource constraints and the existing scenario of higher catastrophic expenditures on health, the scheme proves as a constructive mechanism in health financing as it fulfills certain major objectives like health assurance to the poor by improving their access of high end medical care and secondly by reducing the catastrophic expenditures among poorer households.
The study intended to perform a comprehensive and objective operational performance review of the SAST-VAS. The study also attempted to identify the potential gaps in implementation and opportunities for improvement covering healthcare and operational parameters. A systematic random sample of 5000 VAS cases (around 20 per cent of the total 25000 cases under VAS) during the period 2009 to 2013 formed the data for the analysis. After data cleaning the final sample consisted of 4838 observations.
During this period, among the top 20 districts with VAS coverage, more than 90 per cent of the VAS beneficiaries were from the backward districts of Gulbarga and Belgaum divisions. This is an obvious finding as the scheme was introduced in these divisions. Of the top 20 widely used network hospitals 14 of them were concentrated in the state capital, Bangalore and 76 per cent of the claims were from these network hospitals in Bangalore. The top 5 specialty that have been claimed under the VAS during this period were cardiothoracic surgery (38%), Cardiology (22%), Medical & radiation oncology (18%), Neuro surgery (11%) and the Genito urinary surgery (11%). The majority of the procedures claimed were in the age group 0-20 years, the second highest claims in the age group 41-50 years and the third highest in the age group 31-40 years. The least number of claims were in the age group above 61 years followed by the age group 21-30 years and then by the age group 51-60 years.
In the overall flow of processes from the request for pre-authorizations to claims approval date under VAS for the period 2010-2012, wider time lags are observed between the claims processing date to claims approval date (40 days), between the treatment bill date to claims received date (31 days) and between the pre-authorization request date to pre-authorization approval (24 days).
With drastic increases in the demand for the scheme, during the year 2013-14, SAST has undertaken several improvement strategies like strengthening the online system with a technical assistance team, sensitization of the network hospitals, speeding up the pace of approval of pre-authorization and also setting strict timelines for claims submission with penalty for delayed submission in order to operationalize the improvements in its performance so that it caters to the health requirements of the beneficiary on time. This called for examining the operational performance improvements during the year 2013.
Phase – II
To fulfill this task 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.
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 analyzed, among the top 20 districts, 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 utilization of the scheme by the beneficiaries across the State.
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. Among the top 20 network hospitals accessed by beneficiaries, only 8 of them were 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 increase in the utilization 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 top five specialties claimed were found to remain constant from the inception of programme till now. The majority of the claims were of the age group 41 to 50 years and the least claims were of 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 has been utilized appropriately to improve the quality of life of younger age groups and promoting productive life.
The Turnaround Time (TAT) in the pre-authorization stage, that is, from the time of request for approval to the approval of pre-authorization, decreased drastically in the year 2013 as compared to the previous years’ average. The average time taken, the TAT, was 1.5 days in the pre-auth stage. This reflects the collective impact of the improvement strategies to reduce the time taken from pre-authorization process.
The time gap from pre-authorization to admission of the patient in the hospital was 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 was 9 days approximately and the average time taken for the final approval and settlement of claims was 0.8 days. Thus, the TAT at this stage was approximately 9-10 days. Significant improvements were observed in the operational performances under the VAS scheme as compared to the previous years.
- VAS scheme has been utilized appropriately to improve the quality of life of younger age groups and promoting productive life.
- The Turn Around Time (TAT) in the pre-authorization stage, that is, from the time of request for approval to the approval of pre-authorization, decreased drastically in the year 2013 as compared to the previous years’ average
- The majority of the claims were of the age group 41 to 50 years and the least claims were of 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.
- 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.