Rajiv Aarogyasri Community Health Insurance Scheme

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Registration Name : eINDIA2011/AN/127
Project Category : eHealth::Best Govt Policy Initiative of the year
Project Name : Rajiv Aarogyasri Community Health Insurance Scheme

Details of Applicant
Name : Vishnu Kumar Gottimukkala
Address : KOHINOOR PARK PLOT 1, JUBILEE GARDEN MAIN ROAD MADHAPUR
City : Hyderabad
State : Andhra Pradesh
Country : INDIA
Zip Code : 500081

Details of Project/Implementing Agency
Name of Organisation : Rajiv Aarogyasri Health Care Trust
Address : Dr. Y. S. R. Bhavan,Opp: Dr. B. R. Ambedkar Open University,Road No. 46, Jubilee Hills
City : Hyderabad
State : Andhra Pradesh
Country : INDIA
Zip Code : 500081
Name of the head of Organisation : Sri N. Srikanth, IAS

Brief description of the
 programme/project/Initiative :
Rajiv Aarogyasri Health Insurance Scheme is a state of the art health initiate of Government of Andhra Pradesh with a mission to improve access of below poverty line (BPL) families to quality medical care for treatment of identified diseases involving hospitalization, surgeries and therapies. Cashless treatment to the patient was envisaged. The package covers the entire cost of treatment of the patient from date of screening at villages/date of reporting at network hospital to his discharge from hospital and 10 days after discharge and any complications while in hospital. The scheme provides to each family financial protection up to Rs. 2.00 lakhs in a year for treatment on a family floater basis. The primary channel through which Aarogyasri Scheme is utilized by the target groups is through its ICT Website (https://www.aarogyasri.org). The Website Portal is a workflow oriented integrated system which takes care of the target groups right from the registrations of a patient to the discharge, claim settlement and then administering of follow up medicine to the patients.

Why was the project started :
There is a felt need in the State to provide financial protection to families living below poverty line for the treatment of major ailments such as cancer, kidney failure, heart and neurosurgical diseases etc., requiring hospitalization and surgery. Government hospitals lack the requisite facility and the specialist pool of doctors to meet the statewide requirement for the treatment of such diseases. Large proportions of people, especially below poverty line borrow money or sell assets to pay for the treatment in private hospitals. Health Insurance could be a way of removing the financial barriers and improving access of poor to quality medical care; of providing financial protection against high medical expenses; and negotiating with the providers for better quality care. Government of Andhra Pradesh has accordingly implemented a Community Health Insurance Scheme by name Rajiv Aarogyasri.

Objective :
To improve access of BPL families to quality medical care for treatment of identified diseases involving hospitalization, surgeries and therapies through identified network of health care providers through a hybrid model consisting of tailor-made policy (serviced by Insurer) and self funded reimbursement mechanism (serviced by Trust) to assist BPL families for their catastrophic health needs without compromising the importance of existing Health Care Delivery system of the Government. However the scheme is designed in such a way that the benefit in the primary care is addressed through free screening and outpatient consultation both in the health camps and in the network hospitals as part of scheme implementation and areas of catastrophic health expenditure is met by the insurance scheme. The scheme combined with existing public health infrastructure together meets the total health needs of people thus providing universal coverage.

Target group :
1.98 Crore BPL Families – of Andhra Pradesh
Geographical reach : 23 Districts of Andhra Pradesh
Date from which the project became operational : 1 April 2007
Is the Project still operational : YES

10 points that make the programme/project innovative?

  1. Scheme provides universal coverage to BPL families in the state irrespective of age, sex, social status and family size for all pre-existing diseases in the identified 942 procedures. The sole criterion to be covered under the scheme is to hold BPL ration card with photo and name. The entire premium required to be paid for a family is borne by the government.
  2. The packages designed by experts group covers the entire treatment process of the beneficiaries starting right from the reporting to the hospital till his discharge and 10 days medication after discharge making the services truly cashless to the beneficiary.
  3. All the network hospitals have to conduct at least one free health camp in identified rural areas to screen the BPL population. Further the hospitals will conduct IEC activity and provide basic treatment facilities for the common ailments for other patients.
  4. Aarogyamithras (Health Facilitator) are stationed at each point of contact of the patients. CUG (Closed User Group) connectivity among Aarogyamithras, RAAMCOs, AAMCOs, Field Officials and officials at Head Office provided for easy and round the clock connectivity.
  5. IT based online processing starting from registration of patient from health camp, referral, registration at the network hospital, pre-authorization, patient clinical details including diagnostic tests, claim monitoring, processing and payment.
  6. 24×7 Call center with Toll free Number
  7. Disciplinary actions against erring hospitals through a dedicated committee with laid down guidelines
  8. Grievance Redress Mechanism through dedicated staff
  9. Online accounting system for Trust office for better financial discipline
  10. Online TDS payment application

List the 5 achievements of the programme/project?

  1. Quality Medicare rendered to the common man at all the Network Hospitals of both Government & Corporate level. End to end cashless package which constitutes screening in health camps, consultation, diagnostics implants, prosthetics, food and cost of transportation
  2. Reduces time frame to process the case of a patient. Provides several verification points at each step involved in the process flow.
  3. Provides scope for all stakeholders to monitor information about the case details, surgeries being performed and payment disbursement to hospitals, irrespective of location
  4. Provides online payment gateway and accounting modules
  5. Provides real-time information about medical camps, people screened, in patients, out patients, surgeries conducted, amount claimed

List the 5 key challenges faced while implementing the programme/project/initiative

  1. Scheme Formulation and standardization: Medical specialist, Insurance experts and so on from all over the state were called and brainstorming was done to formulate and draft the scheme. 31 teams of medical specialists were formed which after iterations arrived at standard processing mechanism of each medical case. Aarogyasri Trust was formed to coordinate with all the stakeholders and form a basic set up to run the scheme.
  2. Change Management: The ICT solution was designed to make it simple and easy for end user to use. Series of workshops were conducted by the Aarogyasri in all district headquarters to empower the users in using the ICT solution. Also a Help Manual Book was released by Trust which contains minute details for end user for using the ICT solution as well as educate about the scheme.
  3. Scheduling of Health camps: The ICT solution has automated the scheduling based on the standards set up by the Trust. This ensured that there is no special bias towards any particular hospital/s as well as eliminated any mistakes caused due to human error.
  4. Hospitals Empanelment: All the hospitals are being empanelled through ICT solution. As a result, a lot of metadata as well as attachments about the hospital were captured. This ensured that all the necessary stakeholders know every minute detail of the hospital and check any malpractice attempts by the hospitals.
  5. Process of Approvals: All the approvals were standardized and automated. This greatly reduced the approval lifecycle and increased the efficiency of the users. At the same time, this made the users more accountable as audit trail is maintained for every action performed on the case by them.

List the 5 points how can the programme serve as a model that can be replicated or adapted by others?

  1. Aarogyasri scheme is a unique first of its kind scheme that has implemented the “Quality Medicare to all” Motto both in word and in spirit. This has been possible only with the unique PPP model in which the scheme is functioning.
  2. All of the Policy related matters are taken care by the trust. The field level and scheme level functioning is taken care by the Insurance Company and the Trust employees in coalition.
  3. A Banker is assigned to take care of all of the Banking needs of the scheme. A Technology partner is chosen to make sure that all the technology related aspects are taken care of. Each partner is an expert in themselves and run the scheme smoothly without issues.
  4. This model is very easy to replicate and easy to understand. As a result of the transparent model, Chief Ministers, Ministers and senior administrators of 22 states of India have visited the Trust to study the scheme.
  5. Karnataka (Vajpayee Aarogyasri) and Tamil Nadu (Chief Minister Kalaigner’s Insurance scheme for Life saving diseases), Maharashtra (Rajiv Gandhi Jeevanadhai Yojana) are well on way of implementation.

List 5 points to elaborate on the scalability of the programme/project/initiative

  1. The scheme has broken the myth that Health Insurance is a costly proposition. With its unique implementation procedure of following up each case in an outcome based frame work the pilferages were cut and the cost was kept under control. The Government is able to provide insurance coverage of up to Rs 2 lakhs per year on a family floater basis for 1.98 crore families at a cost of only Rs 400/- per family per year. This could be achieved by the Government without cutting in to other provisions in the budget for health care. Further the huge disease and patient load could be substantially managed with the implementation model.
  2. Every day, atleast 8000 patients are screened in health camps and PHC’s, around 4000 patients get registered in network hospitals, around 2500 patients are treated as outpatients and 1500 patients get inpatient treatment. The scheme is also bringing in quality medical infrastructure and expertise in to the state. Several new hospitals have come up at the district and sub district levels. Presently on any given day a minimum of 13000 beds are occupied by Aarogyasri beneficiaries across the state. Hence the scheme has stabilized over a period of two years and is financially viable and administratively feasible.
  3. The software used in Aarogyasri has been designed by Tata Consultancy Services. While Aarogyasri Trust provided the domain knowledge, TCS provided the technical design and developed the solution accordingly. The following are technology details of Aarogyasri project.
  4. The Online web portal was developed initially for only 3 districts covering around 94 lakhs BPL people with public private partnership involving the Insurance Company and the trust. However, within few months of time, the software was enhanced to handle 23 districts covering around 6.56 crores BPL population, 450 network hospitals, 942 surgical procedures, 2 different sources of funding namely Insurance Company and CM Relief Fund.
  5. Owing to the criticality of this website it was decided that a comprehensive Disaster recovery plan should be in place. The ICT solution provided by TCS ensures that there is redundancy of all critical components of the software application.
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2 Responses to Rajiv Aarogyasri Community Health Insurance Scheme

  1. M Priya Darshini says:

    This is a good project.

    Thanks & Regards.
    Priya Darshini
    Training dept Asst.Manager
    Aarogyasri Health Care Trust

  2. Joseph Thomas says:

    This scheme on its own can help reduce the debt burden of the poor when they fall sick. It should be made available throughout India.