{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,25]],"date-time":"2026-10-25T02:11:07Z","timestamp":1792894267518,"version":"4.5.0"},"reference-count":31,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2022,1,15]],"date-time":"2022-01-15T00:00:00Z","timestamp":1642204800000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2022,1,15]],"date-time":"2022-01-15T00:00:00Z","timestamp":1642204800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["BMC Health Serv Res"],"published-print":{"date-parts":[[2022,12]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec>\n                <jats:title>Background<\/jats:title>\n                <jats:p>Government-sponsored health insurance schemes (GSHIS) aim to improve access to and utilization of healthcare services and offer financial protection to the population. India\u2019s Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) is one such GSHIS. This paper aims to understand how the processes put in place to manage hospital-based transactions, from the time a beneficiary arrives at the hospital to discharge are being implemented in PM-JAY and how to improve them to strengthen the scheme\u2019s operation.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Methods<\/jats:title>\n                <jats:p>Guidelines were reviewed for the processes associated with hospital-based transactions, namely, beneficiary authentication, treatment package selection, preauthorization, discharge, and claims payments. Across 14 hospitals in Gujarat and Madhya Pradesh states, the above-mentioned processes were observed, and using a semi-structured interview guide fifty-three respondents were interviewed. The study was carried out from March 2019 to August 2019.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Results<\/jats:title>\n                <jats:p>Average turn-around time for claim reimbursement is two to six times higher than that proposed in guidelines and tender. As opposed to the guidelines, beneficiaries are incurring out-of-pocket expenditure while availing healthcare services. The training provided to the front-line workers is software-centric. Hospital-based processes are relatively more efficient in hospitals where frontline workers have a medical\/paramedical\/managerial background.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Conclusions<\/jats:title>\n                <jats:p>There is a need to broaden capacity-building efforts from enabling frontline staff to operate the scheme\u2019s IT platform to developing the technical, managerial, and leadership skills required for them. At the hospital level, an empowered frontline worker is the key to efficient hospital-based processes. There is a need to streamline back-end processes to eliminate the causes for delay in the processing of claim payment requests. For policymakers, the most important and urgent need is to reduce out-of-pocket expenses. To that end, there is a need to both revisit and streamline the existing guidelines and ensure adherence to the guidelines.<\/jats:p>\n              <\/jats:sec>","DOI":"10.1186\/s12913-021-07448-3","type":"journal-article","created":{"date-parts":[[2022,1,15]],"date-time":"2022-01-15T02:02:56Z","timestamp":1642212176000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":28,"title":["Improving hospital-based processes for effective implementation of Government funded health insurance schemes: evidence from early implementation of PM-JAY in India"],"prefix":"10.1186","volume":"22","author":[{"given":"Anurag","family":"Saxena","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mayur","family":"Trivedi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zubin Cyrus","family":"Shroff","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Manas","family":"Sharma","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2022,1,15]]},"reference":[{"key":"7448_CR1","doi-asserted-by":"publisher","first-page":"426","DOI":"10.1186\/s12913-018-3249-9","volume":"18","author":"J Okoroh","year":"2018","unstructured":"Okoroh J, Essoun S, Seddoh A, Harris H, Weissman JS, Dsane-Selby L, et al. 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Prior to conducting the interviews during field visits, verbal informed consent was taken from the respondents. The research was approved by the Institutional Ethics Committee at Indian Institute of Public Health Gandhinagar, India via letter TRC-IEC No: 14\/2018\u201319.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare that they have no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"73"}}