GOVERNMENT OF ANDHRA PRADESH
Health Medical & Family Welfare Department – Employees Health Scheme – Norms for billing and guidelines for utilizations of amounts received by the Government Hospitals under Employees Health Scheme-Orders-Issued.
HEALTH MEDICAL & FAMILY WELFARE (M2) DEPARTMENT
G.O.Rt.No. 112 Dated:01.02.2014
Read the following:-
1.G.O.Ms.No.134, HM & FW (K2) Dept., dated.01.02.2010.
2.G.O.Ms.No.174, HM & FW (M2) Dept., dt.01.11.2013.
3.From the C.E.O, AHCT, Letter No.193/F.31/EHS/P&C/2013, dated.09.01.2014.
As per the policy of the Government 20% of the package amount paid to the Government Hospitals under Rajiv Aarogyasri Scheme is deducted at source by the Aarogyasri Healthcare Trust for common revolving fund. Out of the balance ( ie., 80%), 45% is earmarked for expenditure related to patient care and rest of 35% shall be utilized for payment of incentives to the staff responsible to provide service to the beneficiaries under the Scheme. In the G.O. 1st read above, orders were issued laying down norms for billing Aarogyasri cases in Government Hospitals and for incurring expenditure under 45% of the amount and also guidelines for utilization of 35% incentive amount under Rajiv Aarogyasri scheme.
In the G.O. 2nd read above, Government have issued orders for implementation of Employees Health Scheme (EHS) for the State Govt. Employees, Pensioners and their dependent family members in order to provide them cashless treatment in empanelled hospitals which will ipso facto replace the existing medical reimbursement system under APIMA Rules, 1972, with additional benefits such as post-operative care and treatment of chronic diseases which do not require hospitalization and treatment in empanelled hospitals.
In his letter 3rd read above, the Chief Executive Officer, Aarogyasri Health Care Trust has stated that in the Employees Health Scheme (EHS) also the empanelled Government hospitals are entitled for the same package amount as is paid to the private Network Hospitals, and that the number of therapies in Rajiv Aaarogyasri Scheme (RAS) is 938 whereas it is 1885 in Employees Health Scheme (EHS) out of which 347 are exclusively earmarked to Government hospitals. He has further stated that the beneficiaries under EHS are employees / pensioners and they are contributing to the scheme from their salaries / pensions, and therefore the demand for quality services in Government network hospitals would be there; and unlike in RAS, the beneficiaries in EHS are entitled for semiprivate / private wards. He has expressed the view that, the Government empanelled hospitals need to be strengthened to meet the above demand.
The Chief Executive Officer, Aarogyasri Health Care Trust has, therefore, proposed that the policy of deducting 20% of the package amount at source by the Aarogyasri Health Care Trust for common revolving fund under EHS, as being done in RAS, may be adopted for Employees Health Scheme so that the Government empanelled hospitals can utilize the amount accrued in the Revolving Fund for purchase of equipment required for treating EHS patients. He has also proposed that, similarly, out of the remaining 80%, 45% may be earmarked for expenditure related to patient care and the rest of 35% to be utilized for payment of incentives to the staff responsible to provide service to the beneficiaries.
The Chief Executive Officer, Aarogyasri Health Care Trust has requested the Government to create a revolving fund with the Aarogaysri Healthcare Trust under Employees Health Scheme, as is being done under Rajiv Aarogysri Scheme, by deducting 20% of package amount payable to Government hospitals for purchasing equipment for treating EHS patients, earmarking the remaining 80% of the amount for expenditure related to patient care (45%) and for incentives to the doctors and other staff (35%), on the lines indicated in para 4 of G.O.Rt. No.134, Health, Medical & Family Welfare (K2) Department., dated.01.02.2010.
Government, after careful examination of the matter, hereby issue the following orders:
1.A common ‘Revolving Fund’ shall be created with the Aarogyasri Healthcare Trust by deducting at source, 20% of the package amount payable to the empanelled Government Hospitals under ‘Employees Health Scheme (EHS)’, which shall be utilized for purchasing equipment for treating the EHS patients.
2.Out of the balance ie., 80% of the package amount, 45% shall be earmarked for expenditure related patient care and the rest of 35% shall be utilized for payment of incentives to the staff responsible to provide service to the EHS beneficiaries under the Scheme.
3.The manner of utilization / billing / distribution of the 45% and 35% of the amount, is specified hereunder:
Norms and guidelines for billing Employees Health Scheme cases in Govt. Hospitals:-
The expenditure for the implementation of scheme in Government hospital out 45% of package amount shall be incurred for the following items:
i. The actual expenditure involved in purchase of consumables, disposables, implants, medicines, blood and blood products etc. for the care of the EHS patients involved (other than those available in hospital under regular budget).
ii. Cost of Data Entry Operators and other staff employed for Employees Scheme full time (includes RAMCO, AMCO, if employed on full time).
iii. Expenditure on computer peripherals and its maintenance.
iv. Special Diet provision.
v. Expenditure if any, on conduct of camps other than the items which are reimbursed by the Trust.
- Tariff for various investigations may be as fixed under Rajiv Aarogyasri Scheme.
- Hospitals to maintain separate indenting system for pharmacy requirement of EHS patients.
- In the hospital pharmacy, specific pharmacists may be designated for EHS and they will issue medicines / material available in the hospital. Those not available will be purchased through EHS funds and supplied. Separate account may be maintained for purpose.
- Separate inventory and stock register shall be maintained for equipment, instruments, implants etc. procured for EHS from EHS funds.
- The equipment, furniture, computers etc. procured under EHS funds shall be utilized only for the EHS programme in the concerned department.
- The treatment of patient shall be primary aim of the hospital and sufficient funds shall be made available from the package amount to treat the patient completely. In case the 45% funds allocated out of package amount is not sufficient to meet the treatment cost, the additional amount shall be met from the other cases where residual funds are available out of 45% funds i.e. through cross subsidy of the cases.
- The Superintendent of the hospital and other administrative staff of the hospital involved in the implementation of scheme be paid an incentive for their indirect involvement in patient care. 1% of the balance after meeting the expenditure mentioned above be paid to the Superintendent and 1% to the administrative staff of the hospital.
- The balance after meeting the above expenditure is deposited into the hospital account for the development of hospital infrastructure and facilities as suggested in earlier circulars of Director of Medical Education.
b) The following guidelines shall be adopted for distribution of 35% incentive amount.
i) 35% of the package amount for each case should be distributed as incentive to the staff of various categories who were involved in the care of the patient directly. These include the treating unit (Medical or Surgical) staff, Anesthetic team, supporting specialty services, diagnostic specialties, nursing. Paramedical staff and Class IV staff of the services of any specialists, are hired for treating the patient, their fee has to be met from this part of the package.
ii) The 35% incentive amount shall be apportioned among the Surgical / Medical, Investigative, Nursing and Class IV staff as per the following ratio:
Surgical/Medical Team … 75%
Investigative … 10%
Nursing Staff … 10%
Class IV … 5%
iii) The 75% share of the Professional Team managing the patient shall be apportioned as follows:
In Surgical cases
55% to surgical team of doctors
20% to Anaesthetist team of doctors (for the cases managed in ICU, the Anaesthetist team shall be given 25%)
In Medical cases
Entire 75% to the team – (In case where Anaesthetist services are utilized upto 25% to be provided to Anaesthetist)
iv) After excluding the 10% distribution to Residents (9%) and RAMCO (1%) the remaining 90% amount has to be distributed on the following ratio:
5% extra incentive to Prof / CSS
3% extra incentive to Prof / CSS
3% as extra incentive to Associate Prof / Dy.CS
The remaining shall be distributed equally amongst the existing faculty members i.e.,
Prof / CSS Associate / Dy.CS and Asst. Prof / CAS
In case the Professor / Associate Professor posts are vacant, the amount shall be equally distributed amongst the existing faculty.
In case there are more than one person in any category, the amount shall be equally apportioned between them.
Share of investigating specialists
The share of investigating specialists involved in patient care is 10%. The amount shall be distributed equally among the specialties involved (viz., Radiology, Pathology, Biochemistry, Microbiology and clinical Lab). Each Department may distribute the amount among the Doctors and Technical staff equally on 50:50 ratio.
Share of other categories
The share of the Nursing Staff involved (Ward, ICU, OT etc) is fixed at 10%; and the share of the Class IV employees involved (Ward, ICU, OT, Casualty) is fixed at 5%. For this purpose, the Class IV employees include MNO, FNO, Theatre Assistant, Thoties etc.
The incentive amount shall be paid on a monthly basis by the 10th of the succeeding month in respect of all the Surgeries / Therapies done during the month.
he Chief Executive Officer, Aarogyasri Health Care Trust, Hyderabad / The Director of Medical Education, A.P.Hyderabad / Commissioner of A.P.Vaidya Vidhana Parishad, Hyderabad shall take necessary further action in the matter.