Please explain the designing and building of this scheme, with an overview of how IT is being used in building the scheme
The Prime Minister wanted 500 million beneficiaries to avail cashless medical treatment and not be made to pay a single Rupee from day one of the scheme’s launch. Pradhan Mantri – Jan Arogya Yojana (PM-JAY) has been conceptualised keeping in view three key principles of paperless, cashless and transparent treatment. To enforce these principles, IT has been used in all frontiers; be it beneficiary identification, empanelment of hospitals, transactions at hospitals, feedback and grievance redressal, fraud and citizen mobile app, as well as in support services such as anti-fraud measures, information security measures, data privacy measures, infrastructure, etc. The core idea is to build upon existing technology solutions through customisations and integrations, thereby enabling an end-to-end technology enabled suite to provide services to all stakeholders.
National Health Authority (NHA) has helped deliver the three core principles using, for instance, its Beneficiary Identification System (BIS). BIS indexes all the eligible families and using powerful phonetic search technology and helps hospitals find out instantly if a person they are admitting is covered by PM-JAY. Citizens can find out if they are eligible for PM-JAY using the same technology on mera.pmjay.gov.in or by downloading the PM-JAY mobile app on Android devices.
NHA’s claim processing platform, called HTMS (Hospital Technology Management System), is another key technology that helps hospitals raise claims for treatment provided, insurance companies to verify and process these claims and make payments and states to monitor the process – which is completely paperless. Technology enables this to be completely paperless with integrated electronic payments. The transparency enabled by technology on the status of a claim and payment of money has encouraged both, public and private hospitals to participate actively in
Please explain the role of technology in boosting productivity and bringing efficiency in the entire system
PM-JAY is estimated to get over 75 lakh claims, which are expected to increase during the year. Keeping claim processing costs low is the key. The insurance industry today largely uses paper-based processes, wherein both the cost and time to process a claim is pretty high – usually around 45 days. NHA decided to launch the scheme with a fully electronic and paperless claims system. This is already a big boost to efficiency and productivity and is the reason why hospitals can process their claims within 15 days. NHA is now looking at which portions of a claim can be auto approved (auto adjudicated). On the beneficiary identification front, NHA recently introduced an auto approval technology that would provide instant approvals. Auto adjudication for claims is a key area for PM-JAY. When PM-JAY expands to UHC to cover more people and provides OPD coverage (medicines, diagnostics) to reduce out-of-pocket expenditure, the number of claims should explode to 10x the current volume. A significant percentage of claims will need to be verified and approved using technology to keep the cost of claims processing down.
Data is the key towards driving an ecosystem to boost productivity and efficiency. In PM-JAY, detailed dashboards have been developed that monitor key performance indicators (KPIs) with respect to the scheme’s uptake and also highlight the issues and grievances related to service delivery at the field level. At the national level, progress reviews are regularly undertaken with stakeholders based on these dashboards and reports, in order to chart out course corrections, wherever and whenever required.
Could you talk about the IT platform being used to build this scheme? How it is different from the Aadhaar platform?
PM-JAY IT platform is a combination of centralised and federated architecture. Three models are
- States fully onboarded to NHA IT platform;
- States using their own IT systems, but fully integrated with NHA IT platform;
- States that use a combination of the first two i.e. partially using NHA IT platform and partially using their own systems.
PM-JAY utilises the Aadhaar platform during beneficiary identification (non-mandatory). The platform harnesses to power of de-duplication and biometric authentication which minimises the possibilities of frauds under the scheme. PM-JAY has adopted several learnings from the highly successful Aadhaar platform. NHA decided to go completely with an open source stack in alignment with MietY’s open source policy. This has brought significant reduction in the cost of ownership of the PM-JAY IT platform. Like Aadhaar, PM-JAY has several open APIs that provide flexibility to states.
For example, Uttarakhand is covering all residents of the state – anyone with Uttarakhand election/voter card or ration card is included by extending BIS, using our APIs. The open API architecture is also being used to integrate with states which have an existing claims processing software, such as with Tamil Nadu. NHA’s systems are also designed for scale and performance. We currently support over two lakh CSC users, over 15000 Pradhan Mantri Arogya Mitras (PMAMs) and more than 2,000 approvers and state team members who monitor the system.
What are the security postures in place to make this mammoth scheme safe from data breach?
NHA published the data security and privacy policies even before the scheme was launched, demonstrating the importance this plays in the organisation. Our policies were formulated on the basis of recommendations of the upcoming data privacy and controls specified by ISO security standards. The NHA platform itself is hosted within a secure environment that uses some of the best technologies in the ever-evolving world of security. Keeping vigil on security and privacy is an on-going activity. NHA has also put together a security and privacy team which works with our various vendor partners to ensure compliance with our policies. Regular audits, third-party assessments, use of encryption to secure private data, are the measures used to keep the system secure against the possible attacks.
What are IT initiatives planned to further solidify the scheme?
Data analytics, machine learning and several other technologies are the areas being closely looked at by NHA. The first area where we are applying these, is for fraud detection in claims. Today’s technology is really powerful in finding patterns – such as which doctor’s claims have different patterns from their peers across the country. Big data and analytics is the key for effective monitoring and evaluation. NHA is looking at how technology can help in measuring hospital quality, accurate costing of procedures and deeper engagements with beneficiaries. Over the next year, we hope to partner with IRDAI to look at how much of the technology investments that NHA has made can be used to support the overall health insurance industry. Going forward, we intend to strongly build the ‘Voice of Customer (User)’ to continue to improvise our processes, policies and IT. This will be enabled through in-bound and out-bound calls through our call centre and other IT enabled initiatives.
Integrations are key to allow for convergence of PM-JAY with other state schemes for expansion of the beneficiary base. This will be done through an agreed data exchange mechanism and technology enabled gateway. Other strategic initiatives such as mobile-first (mobility as a channel), quality certification to improvise quality of care, are being institutionalised to provide a robust technology enabled platform for the scheme to grow upon.
What best practices have you implemented while building the IT infrastructure?
NHA has adopted the IndEA framework, an enterprise architecture model that provides a comprehensive set of world class processes and practices for government ICT programs. NHA decided to proceed with its cloud based IaaS and PaaS in a Government Community Cloud (GCC) with primarily all open source licenses for hosting the entire PM-JAY ecosystem due to the following factors:
- Availability of CSPs empaneled by Ministry of Electronics and Information Technology (MeitY) with provision of GCC hosting;
- Availability of MeitY guidelines with scope and services for cloud hosting;
- No physical procurement involved as everything is provisioned by the CSP is as service;
- Availability of data centre and disaster recovery location in different seismic zones;
- Provision of IT infrastructure and other software licenses on demand with scalability (both upscale and down scale);
- No requirement for hiring a system integrator for implementation and management of IT infrastructure as these services are provided by the CSP;
- 24/7 services for both implementation and monitoring of IT infrastructure;
- No requirement for purchase of monitoring tools as CSP monitors the entire infrastructure and access of the tool is provided the client;
- Agility and ease of change as the business IT landscape evolves and transactional data volumes start shooting up.
NHA recently won the Presidential award for both enterprise architecture and security at the 2019 Open Group awards.
How IT is helping in ensuring smooth functioning of the scheme, especially in remote areas where internet connections are poor and hospitals lack adequate IT infrastructure?
The ability to monitor most aspects of the scheme is near real-time, which is one of the key benefits of the IT system. NHA has a comprehensive set of KPIs that help understand how a well a state is implementing PM-JAY. NHA regularly reviews these KPIs and is able to support states as-and-when challenges are identified. PM-JAY benefits are mostly for hospitalisation, both secondary and tertiary care. We have found that most of these facilities are in well-connected areas with decent connectivity. There are a few facilities in the North East and some districts in states like Chhattisgarh, where connectivity is still lacking. The healthcare facilities in these locations have been provided with an offline method to identify beneficiaries and process claims. We are continuously working on enhancing our IT outreach to such states through various initiatives currently under PoC, like implementation of CDNs, delayed connectivity features, etc.
Which states have moved the fastest in absorbing the AB-PMJAY? How critical is the role of technology?
PM-JAY was launched with 28 states joining the scheme on September 23, 2018. This would not have been possible without IT being provided to the states in a hosted manner. States like Jharkhand, which did not even have a health insurance scheme, have managed to empanel 600 hospitals and treat 95,000 patients for free within six months of the launch. IT has also provided flexibility; for instance, Jharkhand offers PM-JAY coverage to anyone with a BPL ration card in the state.
The open API approach has ensured that states could rapidly integrate and configure the IT system to meet the states’ needs. Existing states that converged the scheme with PM-JAY like Tamil Nadu and Karnataka have managed to integrate the same in a couple of months. Portability has also been a big benefit brought out by the scheme. Technology has helped people with cancer, cardiac and other tertiary care diseases to seek care outside their states in some of the top medical institutions in the country. This was not possible prior to PM-JAY.
How are you using analytics to make the scheme more sustainable and eliminate frauds?
In the area of fraud analytics, a PoC has been initiated with top global analytics firms and start-ups, including SAS, MFX, Lexis Nexis, Optum and Greenojo, for triggering suspect transactions and entities through rule engines and artificial intelligence layer. The teams have started creating the triggers and results will soon be shared with states on a regular basis.
What kind of IT related training is imparted to the Arogya Mitras in collaboration with National Skill Development Corporation (NSDC)?
Intensive training for Pradhan Mantri Arogya Mitras is done on running the Beneficiary Identification System software to identify and verify the beneficiaries, and Transaction Management System software to carry out treatment at the hospitals. PMAMs are trained intensively for three days on these IT systems. In addition, orientation about the scheme, grievance management system and other soft skills is imparted. Since the launch of the scheme, more than 15,000 PMAMs have been trained and are working in all the empanelled hospitals. These trainings have been done through various channels like direct training by state health agencies, in partnership
with NSDC and other stakeholders.
How many ministries, departments, state agencies and government bodies – both central and states – are involved in operationalising AB-PMJAY?
An independent autonomous body in the form of a National Health Auth ority (NHA) has been set up to implement and manage PM-JAY at the national level. Headed by a full-time CEO, NHA is responsible for implementing the scheme across the country. It is governed by a Governing Board, chaired by the Union Minister of Health & Family Welfare and has 11 members. To implement the scheme at the state level, states have formed State Health Agencies (SHAs) in the form of a society/trust. SHAs have full operational control over implementation of the scheme in the state.
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