{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2024,12,19]],"date-time":"2024-12-19T05:19:23Z","timestamp":1734585563918,"version":"3.30.2"},"reference-count":20,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2024,12,18]],"date-time":"2024-12-18T00:00:00Z","timestamp":1734480000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2024,12,18]],"date-time":"2024-12-18T00:00:00Z","timestamp":1734480000000},"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"],"abstract":"<jats:title>Abstract<\/jats:title><jats:sec>\n                <jats:title>Background<\/jats:title>\n                <jats:p>The effective operation of health insurance requires functioning administrative processes, including appropriate filing for reimbursements. The unlisted palliative care package is one of the most utilized oncology packages within Indian state health insurance schemes. We conducted a clinical audit to evaluate the appropriateness of claims for this package for patients with breast cancer.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Methods<\/jats:title>\n                <jats:p>We obtained documentation submitted to support a random sample of insurance claims for the unlisted palliative care package for 50 patients (total) from one public and one private hospital, cataloged the available records, and assessed the appropriateness of package selection using clinical guidelines from India\u2019s National Cancer Grid. Where sufficient documentation was available, we also assessed the clinical appropriateness of care. We also examined whether these patients received relevant care at other hospitals that participate in the scheme and, for five purposefully selected patients, whether additional documentation had been submitted alongside other claims.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Results<\/jats:title>\n                <jats:p>Claims for 45 of the 50 patients had sufficient documentation to assess whether the selected package was appropriate. Among these 45 claims only 33% were selected in accordance with guidelines; the public hospital had a relatively higher share of appropriate selections. In many cases (21 claims), the palliative care package was selected for adjuvant therapy and targeted therapy. While more than half of the sampled patients had multiple related encounters and sometimes received care from multiple hospitals, reviewing additional claims did not affect our conclusions.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Conclusion<\/jats:title>\n                <jats:p>Claims for the palliative chemotherapy unlisted package often had deficient documentation and were inappropriately selected.<\/jats:p>\n              <\/jats:sec>","DOI":"10.1186\/s12913-024-12018-4","type":"journal-article","created":{"date-parts":[[2024,12,18]],"date-time":"2024-12-18T08:53:18Z","timestamp":1734511998000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Health benefits package selection in oncology: a clinical audit of palliative chemotherapy for breast cancer in an Indian health insurance scheme"],"prefix":"10.1186","volume":"24","author":[{"given":"Sebastian","family":"Bauhoff","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Manju","family":"Sengar","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"C. S.","family":"Pramesh","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Anamika","family":"Dhiman","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Abha","family":"Mehndiratta","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"297","published-online":{"date-parts":[[2024,12,18]]},"reference":[{"key":"12018_CR1","doi-asserted-by":"crossref","unstructured":"Cotlear D, Nagpal S, Smith O, Tandon A, Cortez R. Going universal: how 24 developing countries are implementing universal health coverage from the bottom up. Washington, DC.: World Bank; World Bank Group; 2015. Available from: http:\/\/documents.worldbank.org\/curated\/en\/936881467992465464\/Going-universal-how-24-developing-countries-are-implementing-universal-health-coverage-reforms-from-the-bottom-up.","DOI":"10.1596\/978-1-4648-0610-0"},{"issue":"9845","key":"12018_CR2","doi-asserted-by":"publisher","first-page":"933","DOI":"10.1016\/S0140-6736(12)61147-7","volume":"380","author":"G Lagomarsino","year":"2012","unstructured":"Lagomarsino G, Garabrant A, Adyas A, Muga R, Otoo N. Moving Towards Universal Health Coverage: Health Insurance Reforms in Nine Developing Countries in Africa and Asia. Lancet. 2012;380(9845):933\u201343.","journal-title":"Lancet"},{"key":"12018_CR3","unstructured":"WHO. The World Health Report: Health Systems Financing: The Path to Universal Coverage. World Health Organization; 2010 [cited 2022 Feb 17]. Available from: https:\/\/apps.who.int\/iris\/handle\/10665\/44371"},{"issue":"5","key":"12018_CR4","doi-asserted-by":"publisher","first-page":"e730","DOI":"10.1016\/S2214-109X(20)30104-2","volume":"8","author":"AD Marsh","year":"2020","unstructured":"Marsh AD, Muzigaba M, Diaz T, Requejo J, Jackson D, Chou D, et al. Effective Coverage Measurement in Maternal, Newborn, Child, and Adolescent Health and Nutrition: Progress, Future Prospects, and Implications for Quality Health Systems. Lancet Glob Health. 2020;8(5):e730\u20136.","journal-title":"Lancet Glob Health"},{"key":"12018_CR5","unstructured":"WHO. Tracking Universal Health Coverage: 2021 Global Monitoring Report. World Health Organization; 2021 [cited 2021 Dec 20]. 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Available from: https:\/\/pmjay.gov.in\/sites\/default\/files\/2020-10\/Annual-Report-Final_1.pdf"},{"issue":"1","key":"12018_CR9","doi-asserted-by":"publisher","first-page":"175","DOI":"10.31557\/apjcc.2023.8.1.175-179","volume":"8","author":"SK Sinha","year":"2023","unstructured":"Sinha SK, Singh P, Sinha A. Facilitating Cancer Care Through Ayushman Bharat Scheme (PMJAY) in Rural Places of India: A Narrative Review. Asian Pacific Journal of Cancer Care. 2023;8(1):175\u20139.","journal-title":"Asian Pacific Journal of Cancer Care"},{"issue":"6","key":"12018_CR10","doi-asserted-by":"publisher","first-page":"e223","DOI":"10.1016\/S1470-2045(14)70117-2","volume":"15","author":"CS Pramesh","year":"2014","unstructured":"Pramesh CS, Badwe RA, Borthakur BB, Chandra M, Raj EH, Kannan T, et al. Delivery of affordable and equitable cancer care in India. Lancet Oncol. 2014;15(6):e223\u2013233.","journal-title":"Lancet Oncol"},{"key":"12018_CR11","unstructured":"NHA. PMJAY Standard Treatment Guidelines. National Health Authority; 2021. Available from: https:\/\/pmjay.gov.in\/standard_treatment_guidelines"},{"key":"12018_CR12","unstructured":"Aggarwal DV, Malik S, Arora L, Ruchira D. Analyzing Variation in Breast Cancer Service Utilization, Supply and Underlying Causes Under Pm-Jay. 2021. Available from: https:\/\/pmjay.gov.in\/sites\/default\/files\/2021-05\/WP12_Working-paper.pdf"},{"key":"12018_CR13","doi-asserted-by":"publisher","first-page":"1063","DOI":"10.1200\/GO.20.00122","volume":"6","author":"P Mathur","year":"2020","unstructured":"Mathur P, Sathishkumar K, Chaturvedi M, Das P, Sudarshan KL, Santhappan S, et al. Cancer Statistics, 2020: Report From National Cancer Registry Programme. India JCO Global Oncology. 2020;6:1063\u201375.","journal-title":"India JCO Global Oncology"},{"key":"12018_CR14","unstructured":"Chandrashekar S, Sehgal PK, Khurana R, Naib P, Bhokare S, Chhabra S. 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BMJ Glob Health. 2023;8(Suppl 1):e010726.","journal-title":"BMJ Glob Health"},{"issue":"1","key":"12018_CR20","doi-asserted-by":"publisher","first-page":"60","DOI":"10.1016\/j.jval.2016.01.004","volume":"20","author":"PC Smith","year":"2017","unstructured":"Smith PC, Chalkidou K. Should Countries Set an Explicit Health Benefits Package? The Case of the English National Health Service. Value in Health. 2017;20(1):60\u20136.","journal-title":"Value in Health"}],"container-title":["BMC Health Services Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12913-024-12018-4.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12913-024-12018-4\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12913-024-12018-4.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,12,18]],"date-time":"2024-12-18T09:05:53Z","timestamp":1734512753000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmchealthservres.biomedcentral.com\/articles\/10.1186\/s12913-024-12018-4"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,12,18]]},"references-count":20,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2024,12]]}},"alternative-id":["12018"],"URL":"https:\/\/doi.org\/10.1186\/s12913-024-12018-4","relation":{},"ISSN":["1472-6963"],"issn-type":[{"value":"1472-6963","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,12,18]]},"assertion":[{"value":"8 October 2023","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"27 November 2024","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"18 December 2024","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The study was undertaken as part of scheme operations to improve quality of care and hence local ethics committee approval was not sought. The study was exempt by the Harvard TH Chan School of Public Health institutional review board, IRB21-1438 on November 11, 2021, including a waiver for obtaining informed consent. All study activities were performed in accordance with relevant guidelines and regulations (e.g., Declaration of Helsinki).","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 no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"1591"}}