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IESM ECHS Division
Feedback for improvement of ECHS Services
Quarter Ending Mar 10

Part I- Mission and Terms of Reference(No change from earlier Feedbacks)
Introduction
With the increasing cost of healthcare, and depleting income post retirement, issues concerning Health are obvious areas of concern to veterans.
The ECHS, designed on lines of CGHS providing healthcare to Civil Services Government employees are a big help in this regard. However, given the spread of ESM habitations, and the sheer numbers of ESM, certain innovative/ out of box thinking is essential to ensure that this fundamental right of ESM is guarded.
It is assumed that ‘numbers’ should give US a bargaining leverage with reference to private hospitals / establishments, provided we are able to become a ‘commercial possibility’, and are therefore able to drive a bargain to our advantage. Implicit in this statement is the possibility of better rates, at point of usage delivery for health products/ medicines and modernizing of our polyclinics and processes.
Responding to this requirement, the Indian Ex Servicemen Movement (IESM) constituted an ECHS division, as ESM user interface with ECHS. Accordingly Region Liaison Cells (RLC) and Polyclinic Liaison Cells (PLC) have been created, to provide this user interface at all levels. With ‘eyes and ears’ at the grass root level, and with an ESM apex at NCR, it is believed that a reasonable feedback would be available on a continual basis, to the MD ECHS and accordingly to the AG and the DGAFMS, to be able to create the finest healthcare system for the ESM; perhaps surpassing the CGHS

Essentials of ‘The Finest Healthcare System’. (No change from Earlier Feedbacks)

a) Clean, comfortable polyclinics with hygienic facilities for drinking water, toilets and spacious, ventilated waiting areas with adequate seating.
b) Speedy Registration.
c) Empathetic staff and Doctors. ECHS is basically a ‘Service Industry’. The ‘Comfort and Feel Good of the client (patient) comes FIRST – Always and Every time.
d) A Prioritization system for patients in distress/ Senior Veterans and those needing urgent attention.
e) Quick consultation with Doctor and issue of medicine.
f) Expeditious procurement of NA medicines. Intimation to patient about availability.
g) Issued medicines to have sufficient residual shelf life.
h) Simplification of processes to ensure patient is not harassed / made to run around for referrals, approvals etc.
i) Simple processes to ensure empanelled hospitals and not the patient , run around to get approvals/ intimations etc. Polyclinic to be the Single window for all the patient’s requirements.
j) Speedy processing and clearing of hospital bills.
k) Speedy processing and clearance of patient reimbursements.
l) Monitoring and Performance Audit of Empanelled Hospitals.
m) A support system to render advice including legal, to ‘wronged’ veterans to file consumer complaints in case of default/ deficiency in services at any level of the medical chain.
n) In case of any dispute/doubt on what is to be done, the Patients’ convenience and comfort must be the supreme, overriding, deciding factor ALWAYS AND EVERYTIME.
Part II- Review of Previous Feedback Points
Feedback from RLC/ PLC So Far
Major Areas of concern .

(a) TAC. On being issued the Smart Card the ESM were assured that the card would be usable Pan India. In actual practice however, a Temporary Attachment Certificate (TAC) is required when a user wishes to use polyclinic facilities other than his/ her own. It has been opined, both formally and in informal discussions, that the Smart Card MUST be honoured Pan India. Software experts confirm that the present card HAS the potential to be so used. Irrespective of this, a NEW ECHS card is being introduced that as per ECHS authorities, would overcome this problem.THIS POINT IS A CARRY OVER FROM FEEDBACK OF OCT 09.
(b) Emergency Treatment.THE Procedural aspects HAVE BEEN CLARIFIED IN ECHS LETTER NO B/49774/AG/ECHS/Referral DATED 01 Dec 2009. THERE HAVE BEEN IMPLEMENTATION PROBLEMS AT SOME POLYCLINICS, WHICH HAS BEEN BROUGHT TO NOTICE OF ECHS HQ.
(c) Financial Reimbursement in Emergency Admissions. A case has been reported wherein Lt Col Joglekar-a veteran got admitted to an empanelled hospital in Pune in a cardiac emergency. An emergency referral was obtained two days later, but he died in hospital. The officer’s wife was asked to pay which she did. Later, when the ECHS paid the hospital, the latter refunded PART of the payment made by the lady. Question arises
i) If the hospital knew that the officer was an ECHS member, WHY did they ask the widow to pay?
ii) When they got the payment from the ECHS, why was the ENTIRE amount charged from the lady NOT refunded to her? In all fairness, it should have been. AND if the bill was cleared BY THE Polyclinic in parts, why was she not advised how much and why the deductions were being made? Regrettably the local authorities have not responded to her queries in this regard.
BASED ON A FORMAL COMPLAINT LODGED BY MRS JOGLEKAR, ECHS HQ HAS BEEN APPRISED OF THE CASE. DETAILS OF ACTION TAKE BY THEM ARE NOT KNOWN.
(d) Issue of Three Months Medicine. With chronic ailments, medicines are prescribed for long durations and patient asked to report for review in say six months, one year. As medicines continue for the same duration, it would be greatly helpful for the patient to be given (at the doctor’s discretion), medicine for three months. This requirement is pertinent also to patients proceeding abroad for long durations. But more importantly, is relevant to patients in outlying, rural areas, who often need to travel 150-200 km to the polyclinic. Two illustrative cases are attached as Annexure 1. It is strongly recommended that in interests of effective patient care, up to 90 days medicine MUST be permitted to be issued at the doctors’ discretion. THE CASE HAS BEEN FOLLOWED UP AT THE APEX LEVEL. THE PROBLEM IS PERCEPTIONAL, WITH DGAFMS PRINCIPALLY DISAGREEING WITH THE PROPOSAL ON ‘ETHICAL GROUNDS’. THIS HOWEVER RUNS CONTRARY TO GOI LETTER NO MH & FW, O.M. No. S-11011/8/99-CGHS(P), dt 13.10.1999, ISSUED TO CLARIFY A SIMILAR SITUATION IN CONTEXT OF CGHS. THE CASE IS BEING FOLLOWED UP. IN A MEETING WITH AG, IT WAS BROUGHT UP BY US, AND SOME OTHER ESM ORGANIZATIONS WHOSE REPS ALSO ATTENDED THE MEETING.
(e) Dis-empanellment of Quality Hospitals. While initial perspectives envisaged good and reputed hospitals for in house treatment of ESM, the delays in clearing their bills by ECHS has resulted in their gradual weaning away. To correct this - IT IS HEARTENING THAT ECHS HAS SUCCESSFULLY CARRIED OUT TRIALS FOR INTRODUCTION OF TPA METHODOLOGY IN THEIR OPS. IT IS HOPED THAT THIS WOULD OVERCOME THE PROBLEM OF DELAYED PAYMENTS. THIS WAS CONFIRMED DURING OUR MEETING WITH AG (mentioned above).
(f) NA Medicine. While it is appreciated that ‘exact’ brand prescribed by an empanelled hospital OPD may not be immediately available, those prescribed after a hospital admission must be immediately disbursed to the patient. It has been suggested that on discharge, a patient may be issued medicine from the hospital itself for up to one week, and billed for in the hospital bill. As for others, procedures for NA procurements may be refined to expedite its issue. The ECHS division of IESM, is encouraging a system of veteran volunteers to assist ESM patients at polyclinics, and one of their contributions is proposed to be to inform veterans through sms, phone etc that their NA medicine have arrived. ECHS supply chain on its part must plan on ‘Point of Usage’ delivery of medicine, as against stocking and transporting medicine which adds to cost and delays. With an All India network of pharmaceutical companies, this should be negotiated. This would reduce requirements of storage, and guard against medicine going overage. It may even be a good measure to have pharmaceutical companies establish pharmacies on contractual basis/ outsourced in close proximity of polyclinics. IT IS HEARTENING TO LEARN THAT ECHS IS CONTEMPLATING CHANGED LOGISTIC SUPPLY CHAIN MANAGEMENT INCLUDING OUTSOURCING TO OVECOME STOCKING/ SUPPLY PROBLEMS. THIS POINT IS A CARRY OVER SINCE OCT 09.
(g) Pharmacists. Currently pharmacists are not on the establishment of polyclinics, and where posted, are on a lower scale of pay than their counterparts in nursing services. It is felt that their emoluments and aspects of desired retention need careful attention. THIS POINT IS CARRIED FORWARD FROM THE FEEDBACK OF OCT 09.
(h) Dental Care. O P D Dental care is being provided by the ECHS. However, referral facilities for dentures & other specialised requirements are outsourced but are practically non-existent in the E C H S system (there is ONE dental care facility empanelled in NCR- ONE! At Delhi), the rates are fixed in a manner to deter any worthwhile establishment from seeking empanelment. It is recommended that this be reviewed upward. We have volumes and should be able to strike a bargain in rates. THIS POINT IS CARRIED FORWARD FROM THE FEEDBACK OF OCT 09.
(i) Manning/ Organizing for Effectiveness. Present ad-hoc /improvised manning of the Rs 720 crore ECHS, based on offsets is clearly undesirable. Its effect on the Operational effectiveness aside, it deprives the scheme of continuity and growth. It is recommended that GOI approval for a dedicated authorization for the ECHS be taken up. THIS POINT IS CARRIED FORWARD FROM THE FEEDBACK OF OCT 09. IT IS HOWEVER INFORMALLY LEARNT THAT SUCH A COMMITTTEE IS BEING SET UP TO ATTEND TO THIS SERIOUS CONGENITAL ANOMALY.
(j) The Polyclinics. Polyclinics are the ‘delivery points of service’ from the ECHS. It is essential they be well laid out, suitably equipped and efficiently and empathetically manned. Some suggestions in this regard are
i) The layout/ design of Polyclinics should be standardized in consultation with an architect specializing in hospital layouts. Should be adopted Pan India.
ii) It should cater for enough space for comfortable, ventilated, protected from vagaries of weather, waiting areas. Enough rooms for the facilities and provision clean drinking water, sufficient conveniences and storage.
iii) It should lend itself for expansion.
iv) Criteria for selection of OC Polyclinic must include being net savvy, and possessing an understanding of service industry - preferably that of healthcare services.
v) Must have LAN connectivity to ensure optimal smart cards usage, pharmaceutical inventory control and correct demand procedures. This WILL ensure cost effectiveness.
THIS POINT IS CARRIED FORWARD FROM THE FEEDBACK OF OCT 09.
(k) Compensating Military Hospitals for In-house Treatment.
i) Service hospitals (MHs) are authorised & scaled as per the Garrison strength (authorised soldiers only) of the station. ESM are entitled for indoor treatment under specified provisions, as an exception. ECHS was conceived & sanctioned in view of large number of restrictions for treatment of ESM as per the GOI rules vide the RMSAF (Regulations for Medical Services of the Armed Forces).
ii) With gradually increasing number of ECHS patients being admitted to MHs, since inception of the scheme, the load on these units has increased. The staff strength at MHs, particularly the Group D staff is consequently inadequate. All patients invariably complain of poor cleanliness, poor service by safaiwallas, ward boys & ayahs. On the other hand, ECHS has been advised to use the spare capacities of the MHs & rightly so. However in view of the aforesaid problems of staffing/ resourcing, patients do not get the best care which they deserve.
iii) To compensate the MHs ECHS should authorise payment of a nominal amount, say Rs 500/- for each ordinary bed occupied per day to the MH & Rs 1000/- per day for ICU beds. All expensive consumables for eg catheters, stents etc should be paid for by the ECHS. The money paid from ECHS at these nominal rates will bring huge savings to the ECHS in comparison to the Empanelled Civil Hospitals which charge Rs 2000/- to Rs 4000/- per day. At the same time, these funds could be used towards qualitative improvements in patient care and cleanliness.
iv) To improve the facilities of the MH concerned this money should be retained by the MH Commandant, properly accounted for, and utilised only for improvement of facilities for ECHS patients. It could be used for additional hiring of safaiwallas, ward boys and ayahs etc.
THIS POINT IS CARRIED FORWARD FROM THE FEEDBACK OF OCT 09. HOWEVER IT IS UNDERSTOOD THAT THE COMMITTEE REFERRED ABOVE WILL LOOK INTO THIS AND SUCH SOLUTIONS TO MAKE HEALTHCARE AT MIILITARY FACILITIES BETTER.
l) Staffing Pattern at Polyclinics. The present pattern of having type A,B, C and D polyclinics requires a relook. After 5 years the load on polyclinics should be well known. High pressure polyclinics need to have additional staff based on their dependency. Noida , Gurgaon and Chandigarh are in excess of other type A polyclinics. THIS POINT IS CARRIED FORWARD FROM THE FEEDBACK OF OCT 09.
m) OPD Treatment in Off Hours. There is a definite need for permitting empanelled hospitals to undertake OPD treatment after Polyclinic closing hours. An acceptable system (of either having Polyclinic Doctor on Call/ permitting OPD outsourced needs to be put in place. THIS POINT IS CARRIED FORWARD FROM THE FEEDBACK OF OCT 09.
n) Locating Polyclinics. The intricate logistics and difficulty of ‘getting to’ the polyclinics in some stations, eg Mumbai, have been reported by veterans. Apparently the need to utilize existing infrastructure for polyclinics overlooked the ‘convenience’ of users. As the latter becomes more important with age, it is felt that this needs higher priority. In Mumbai for instance, both, the ‘time and space’ aspect of travel, and the road/ rail alignments needed to be borne in mind while firstly, locating polyclinics AND secondly, working out Area dependencies. It is recommended that as a start, this be studied, coopting inputs / assistance from local IESM ECHS Division representatives. THIS POINT IS A CARRY OVER SINCE JAN 10.
o) Tenure and QR of OC Polyclinics. It has been suggested by veterans that a contract of one year is inadequate for OC Polyclinics. By the time he learns the job, its time to move on. It has been recommended that it should be five years. It has also been suggested that OC Polyclinic must be one who is computer savvy, and has had at least two years in the civvies street, before assuming this appointment. This exposure would give him/her, an empathetic understanding of the handling of staff/ clients (ESM). THIS POINT IS A CARRY OVER SINCE JAN 10.

PART III- FRESH FEEDBACK POINTS FOR CURRENT QUARTER

Relocation of Polyclinic Needed. Gahmar in Gazipur distt, UP, is one of the largest villages in Asia. Referred to as the SOLDIERS’ VILLAGE, it has the unique distinction of having 2-3 members of each family in the defence forces of India. There are fair number of World War II veterans..........some as old as 104 years. The nearest polyclinic is at Gazipur, the district Hq, approx 50Km away. It is felt that this needs relocation to Gahmar, considering the village’s substantial contribution to the Defence forces, and the ESM population there.
Loss of ECHS Membership Card. There is a need to evolve a procedure that enables continuous ECHS support even without the card. There is also a requirement to review the current ECHS rules that dictate a ‘cancellation’ of membership when a card is lost the second time. With a photo attached to the card and Biometric checks built in, it is reiterated that such restrictions are not needed.
Integration of Existing Healthcare Services . Neither serving personnel, nor their dependents are eligible for ECHS benefits. In the circumstances, a separated family member has queried as to what does a separated family/dependent family do when the nearest service hospital facilities are over 125 kms from the selected place of residence? There may be an NCC unit located close by and so...even in their case neither servicemen nor their families can avail of the services of the ECHS. That stated, however, they are treated on 'humanitarian grounds.
This anomaly needs to be addressed. Carrying this further, there is a need to explore a nationwide integration with CGHS empanelled facilities if not their clinics.
Upgrade of Hospital Accomodation. A point often projected is regarding upgrades of hospital accommodation beyond the ‘entitled class’. It is understood that this stays a personal adjustment between the ESM patient and the hospital. Currently, hospitals are charging difference between the Full rates between the two rents (ie Full Rental of Room to which upgrading MINUS the rent of accommodation entitled). It is suggested that such contingencies be built into the contract with hospitals and they be required to charge the differential at the contracted rates.
Hospitalization while Abroad. There have been instances of veterans being admitted to hospitals while abroad. Present rules do not permit reimbursement/ coverage for them. It is suggested that a modality be worked out on lines of Non Empanelled hospitalizations, wherein, in such cases at least ECHS rates of local hospitals be reimbursed to them.
Empanelling Hospitals. Very many hospitals are currently empanelled for specific referrals.eg for Cardio only OR Iconology only. It is felt that such contractual agreements of part empanelment deprive ESM of majority of services available with the hospital. At the same time, the hospital benefits in cashing in on the more commercially viable services. It is suggested that a ‘package contract’ specifying rates etc be projected to the hospitals, and a ’package’ be offered to ECHS users. While the hospital would lose out in some services, profit in some and cut even in others, such standardized contracts across the country would immensely benefit ECHS users. We have numbers, which is a marketing cantilever.

PART IV- CASE STUDIES

Case of Cpl Bhandari’s Reimbursement. It will be recalled that following an accident, an AF veteran (Cpl Bhandari) at Jabalpur was admitted to a hospital (empanelled/ Non empanelled stayed a confusion for sometime even for us – the ECHS website does not mention it) by his son’s friends, as the latter is at Dubai. Hospital bill was cleared by the patient on discharge. When his son mailed to the IESM ECHS Division narrating the case, we advised him to submit the bill to the Polyclinic, which was done, wherein we were advised by Polyclinic to submit it to the Hospital who would follow up with them. It was then that we learnt that it is an empanelled hospital which in order to overcome delays in bill clearing has resorted to having patients pay and then claim and reimburse to the patient. Despite constant follow up, the Hospital did not budge from their stand that they would refund ONLY the amount received from the ECHS. Such malpractices by hospitals seem commonplace countrywide, as was earlier witnessed in Mrs Joglekar’s case (see Feedback Oct 09). After being constantly harassed by the Jabalpur hospital , Cpl Bhandari’s family has taken a decision to take the hospital to a consumer court, purely on principles. As per them, though the road would be tough, and even though ‘money’ is not the issue, they would like to do it in larger interest of the ESM community. Our salute to them, and we hope their effort will be backed suitably by the ECHS.
Mrs Joglekar’s Reimbursement. It will be recalled that Mrs Joglekar was made to clear the hospital bill after her husband expired in hospital. After prolonged follow up, while she got the ECHS rates refunded, the full amount paid by her was not refunded to her. At our behest, she took up the case with Station Hq and ECHS. The case is presently stuck up with Region Hq who needs to revert to the ECHS Hq with their comments. (ECHS Hq letter No B/49717-C/AG/ECHS/2767 dated 27 Apr 2010 refers).
Dependency Certificate for absence away from Parent Polyclinic. A veteran pointed out that his mother (herself a military veteran’s wife) faces problems of ECHS support while travelling in NCR, being asked to revert to her dependent polyclinic (BH) even when staying variedly with her sons settled in Noida, Gurgaon and Delhi. It has been clarified by ECHS Hq that such matters can be addressed on Regional basis and the Regional Centre is empowered to issue dependency instructions on a case by case basis.

Conclusion

Excellence is a constant pursuit. While enough ground has been covered in improving ECHS services since inception, creating the “FINEST HEALTHCARE SYSTEM” in the country would still involve constant refinement and respecting client feed back as a challenging opportunity to improve. Question that needs to be asked, to the Armed Forces Health Services hierarchy, to quote
Posted by Indian ExServicemen Movement at 10:56 PM 0 comments
Monday, March 15, 2010
Cpl Bhandari case at Jabalpur
Kuthiala Sir,
This case continues to get deeper into needless issues. WE have been in picture from Day one.
An accident, at the very least with a fracture "would constitute 'emergency'.
On Reporting, there was some confusion about the empanellment. You would recall that till the Polyclinic asked for the documents to be submitted through the hospital, we were thinking we were dealing with a non empanelled hospital. This stage was the first indicator (and we spoke about it in detail) that it was an empanelled hospital with an identical 'pay first, claim and then be reimbursed the ECHS cleared amount' philosophy followed in Mrs Jogelkar's case. While on the issue, you will recall we checked on web and did not find the hospital in the annexure of empanelled hospitals. This deepened the mystery.
Be that as it may, the Hospital had NO business to charge and then reimburse ECHS rates to the veteran. They are ONLY ENTITLED to ECHS rates, including audit deductions if any, and must therefore reimburse the TOTAL amount.
We need to convey to the hospital that there is no getting away from this, and it would be a no holds barred action by us, jointly, to ensure they honor what they are committed to, in being an empanelled hospital.

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