Creation of AMO Areas in hospitals and referral health centres A case of the National Sickness Insurance Fund

Transcription

1 Good Practices in Social Security Good practice in operation since: 2014 Creation of AMO Areas in hospitals and referral health centres A case of the National Sickness Insurance Fund National Sickness Insurance Fund Mali Published

2 1 Summary In 2010, the government of Mali introduced a compulsory health insurance scheme with thirdparty payment for civil servants and workers to guarantee affordable health care. In 2011, the National Sickness Insurance Fund (Caisse nationale d'assurance maladie (CNAM)) concluded agreements with all public agencies, in particular with hospitals, referral health centres and community health centres. Following complaints from insured persons about access to medical care in hospitals, the CNAM decided to set up an administration service in hospitals with the main objective of facilitating access of insured persons to their guaranteed medical services. This was achieved by opening an administrative services counter in hospitals, called the "AMO Area". The AMO agent verifies the identity of the insured person, completes the administrative part of the care sheet and returns it to the person for presentation to a doctor. All these services were formerly provided by the hospitals at the admissions desk, leading to numerous complaints from insured persons. CRITERIA 1 What was the issue/problem/challenge addressed by your good practice? The main problem to be solved was the difficulty of access to health care in hospitals and referral health centres in Bamako. This situation resulted partly from the time it took for the staff at the admissions desk of the hospital and the referral centre to check insured persons eligibility for health care. They also had to complete the administrative part of the care sheet allowing the insured person access to a doctor so that they could receive the care guaranteed by the CNAM. As this initial procedure took considerable time, it not only took longer for the patient to be dealt with at the admissions counter but also contributed to the creation of a hostile atmosphere among the other patients waiting in the queue. This tarnished the image of the CNAM, as the insured persons were ignored by some staff at the admissions desk in favour of the uninsured due to the extra work involved in processing the insured. In addition, staff at the admissions offices had not received special instructions from the hospital about how to deal with CNAM insured persons. Because, in fact, the hospital felt that this was unfair in terms of patient care they did not want to differentiate between patients and allowed the staff at the admissions offices to manage the CNAM insured as they saw fit. Finally, the fact that the admissions offices closed at 4 pm meant that those insured by the CNAM were denied benefits after that time.

3 2 The main problem to be solved was the difficulty of access to health care in hospitals and referral health centres in Bamako. This situation resulted partly from the time it took for the staff at the admissions desk of the hospital and the referral centre to check insured persons eligibility for health care. They also had to complete the administrative part of the care sheet allowing the insured person access to a doctor so that they could receive the care guaranteed by the CNAM. As this initial procedure took considerable time, it not only took longer for the patient to be dealt with at the admissions counter but also contributed to the creation of a hostile atmosphere among the other patients waiting in the queue. This tarnished the image of the CNAM, as the insured persons were ignored by some staff at the admissions desk in favour of the uninsured due to the extra work involved in processing the insured. In addition, staff at the admissions offices had not received special instructions from the hospital about how to deal with CNAM insured persons. Because, in fact, the hospital felt that this was unfair in terms of patient care they did not want to differentiate between patients and allowed the staff at the admissions offices to manage the CNAM insured as they saw fit. Finally, the fact that the admissions offices closed at 4 pm meant that those insured by the CNAM were denied benefits after that time. CRITERIA 2 What were the main objectives and the expected outcomes? The new measures consist of opening counters to provide the administrative services for compulsory health insurance in the hospitals and referral health centres in Bamako, with the aim of: reducing the time taken to access care; providing the insured and their beneficiaries with sufficient information for coverage; reducing the system of queues in hospitals; reducing fraudulent practices aimed at handling the uninsured; introducing a filtering system at admissions offices; ensuring administrative services 24 hours a day. In addition, the main result expected is the reduction of waiting times which cause more frustration among the AMO insured than among the uninsured.

4 3 CRITERIA 3 What is the innovative approach/strategy followed to achieve the objectives? The CNAM has created an administrative service or AMO Area to deal solely with insured persons. The staff in this service are specially trained in all the laws and regulations affecting the AMO and are located in each hospital or referral health centre in Bamako. The administrative strategy implemented consists of staffing the rooms and giving them reliable databases so they can check the eligibility status of the insured persons automatically. In addition, the care sheets previously held by doctors are now available in the AMO Areas. This policy has succeeded in reducing waiting times and the misuse of care sheets by some prescribers. The creation of the AMO Areas has also helped: to orientate insured persons by providing them with full information on what to do once care sheets have been issued by the AMO Area; to identify and mitigate cases of misuse by third parties in the hospital or referral health centre. Staff in each AMO Area stamp all care sheets without which the sheets are invalid. This unique stamp can only be obtained after registration at an AMO Area; to ensure a permanent presence in the hospital or care centre. The AMO Areas are open 24/7, thereby giving insured persons access to health care at any time. CRITERIA 4 Have the resources and inputs been used in an optimal way to achieve the set objectives and the expected outcomes? Please specify what internal or external evaluations of the practice have taken place and what impact/results have been identified/achieved so far. The implementation of AMO Areas has required many resources, not only in terms of staff but also infrastructure. The CNAM has set up offices and recruited 83 employees in 21 health facilities, especially hospitals and referral health centres. Thanks to the AMO Areas, staff can check and provide completed care sheets in a reasonable time. Verification of identity is now also the responsibility of the AMO Areas. In addition, the proper information is now given to the insured persons so that, among others things, they can obtain an insurance card not only for themselves but also for their beneficiaries. This has succeeded in reducing the time spent by insured persons waiting in queues and also the constant trips to and from the hospital and the CNAM headquarters by insured persons.

5 4 CRITERIA 5 What lessons have been learned? To what extent would your good practice be appropriate for replication by other social security institutions? The CNAM has made a considerable change in its mode of operation, especially in health facilities. In fact, there was no provision for this arrangement in the first technical and institutional installations. Thanks to AMO Areas and higher satisfaction levels, the percentage of insured persons has continued to grow. Moreover, the new arrangement has also contributed to the prevention of fraudulent practices at hospitals and referral health centres. The percentage of services provided in CNAM-contracted hospitals has risen considerably. This practice may be adopted by other social security institutions who seek to provide effective, credible and efficient services. The National Agency for Medical Assistance in Mali (Agence nationale d'assistance médicale du Mali) has already adopted this CNAM policy.