Chapter-III AN OVERVIEW ON THE MANAGEMENT OF AAROGYASRI HEALTH INSURANCE SCHEME, ANDHRA PRADESH

Transcription

1 Chapter-III AN OVERVIEW ON THE MANAGEMENT OF AAROGYASRI HEALTH INSURANCE SCHEME, ANDHRA PRADESH 3.0 INTRODUCTION An attempt is made in this chapter to evaluate the management of Rajiv Aarogyasri Community Health Care Insurance Scheme (RACHI) in the State of Andhra Pradesh. This chapter covers various issues like, nature of the Rajiv Aarogyasri scheme, objectives, vision and goals of the scheme, administrative structure, Board of Trustees, major diseases covered under the scheme. Modalities of receiving care, expansion, financial results, insurance coverage, therapies done by government and corporate hospitals under insurance and trust mode (Aarogyasri-I and II), cochlear implantation programme, pattern of health camps and awareness camps, network hospital empanelment mechanism status, analysis of cost & benefits of the scheme and other peculiarities including recent initiatives of RACHI. 3.1 ABOUT THE STATE OF ANDHRA PRADESH Andhra Pradesh was formed on 1 st November 1956 under the States reorganisation scheme. It is the fifth largest State with an area of 2,76,754 sq.km, accounting for 8.4 per cent of India's territory. The State has the longest coastline (972 km) among all the States in India. Andhra Pradesh is endowed with a variety of physiographic features ranging from high hills, undulating plains to a coastal deltaic environment. 68

2 3.2 DEMOGRAPHIC PROFILE Table 3.1 explains the demographic profile of Andhra Pradesh - at a glance. In 2011, the State of Andhra Pradesh possessed 84,665 thousands of population. The density of population per sq.km was 308, literacy rate was per cent. Table 3.1 Demographic profile of Andhra Pradesh At A Glance Demographic profile of Andhra Pradesh Item Total (In thousands) 35,983 43,503 53,550 66,508 76,210 84,665 Males (In thousands) 18,161 22,009 27,109 33,725 38,527 42,509 Females (In thousands) 17,822 21,494 26,441 32,783 37,683 42,155 Rural (In thousands) 29,709 35,100 41,062 48,621 55,401 56,311 Urban (In thousands) 6,274 8,403 12,488 17,887 20,809 28,353 Scheduled Castes 4,974 5,775 7,962 10,592 12,339 (In thousands) -- Scheduled ribes 1,324 1,658 3,176 4,199 5,024 (In thousands) -- Density of Population (per sq.km) Literacy Rate (%) Per centage of Urban Population Source: Director, Census Operations, A.P. Hyderabad and Directorate of Economics and Statistics, Hyderabad 3.3 NET STATE DOMESTIC PRODUCT The growth of net state domestic product has been continuously increasing. It is evidence from the table 3.2 that the NSD was Rs.1,21,388 in and increased to Rs.4,32,229 at prices. The per capita income of the state however, has consistently been more 69

3 than the Nation s per capita income during the last decade. Sustained efforts made by the state during the late 90s and early years of this century to effectively control the population growth started yielding better results with a lag which has enabled to record higher per capita incomes in the subsequent years. As per the latest available data (Provisional estimates of ) 1, the per capita of Andhra Pradesh stands at Rs. 85,797 compared to India s per capita income of Rs. 74,380. Table 3.2 Net State Domestic product and per capita income of Andhra Pradesh S.No Year State income Per capita income ,21,388 25, ,33,072 28, ,56,646 32, ,90,738 39, ,14,873 44, ,46,936 50, ,82,776 58, ,31,882 66, ,80,367 76, ,32,229 85,797 Source: Directorate of Economics and Statistics, Hyderabad and Central Statistical Office, New Delhi 3.4 PERCENTAGE OF PEOPLE BELOW POVERTY LINE The State is implementing social sector schemes without hindrance keeping in view its commitment to inclusiveness intended to benefit people below the poverty line. According to the table 3.3, the BPL population was per cent in and declined to 9.20 per cent in The rural and urban BPL population was and per cent in and declined to per cent and 5.81 per cent in Interestingly, there is a vast variation between these figures while compared with the BPL estimates to implement the Aarogyasri Scheme. 70

4 Table 3.3 Percentage of People below Poverty Line in Andhra Pradesh Rural Urban Combined * * * * Source: Planning Commission, Government of India. Note: * As per Tendulkar Committee report 3.5 HEALTH INFRASTRUCTURE OF ANDHRA PRADESH The Government of Andhra Pradesh has four systems of medicine, namely Allopathy, Ayurveda, Homeopathy and Unani. As per 2011 statistics, the details of the hospitals that function under each system of medicine are given below 2 : 1. Allopathy: It is the conventional form of medicine using pharmaceuticals and scientific techniques for diagnosis and treatment. There are 332 general hospitals, 39 special hospitals, 1626 PHCs and 319 dispensaries under the government control. 2. Ayurveda: It is one of the ancient systems of medicine being practised till today. Ayurvedic drugs are soft, prepared from natural sources like herbs and minerals. There are 7 hospitals and 551 dispensaries which function under Ayurvedic medicine. 3. Homeopathy: It is a rapidly growing system which is being practised all over the world. Homeopathy came to India in the year 1839 which 71

5 became a household name due to the safety of its pills. The statistics reveal that, there are 6 hospitals and 284 dispensaries in Andhra Pradesh. 4. Unani: In India, Unani medicine was introduced in 1351 A.D by Arabs. There are 5 hospitals and 193 dispensaries in A.P. However, there is a shortfall in the health infrastructure of Andhra Pradesh. It is found from the table 3.4 that about 380 Primary Health Centres are shortage in the state followed by Community Health Centres (220), Health Worker (Male) at Sub Centres (7,914) and Health Assistant (Male) at PHCs (1,624). 3.6 NATURE OF THE RAJIV AAROGYASRI SCHEME Public private partnership in the delivery of health services is recent phenomenon in Andhra Pradesh. The collaborations effectively started during the early 1990s, the period of inception of World Bank projects like India Population Project VIII and Andhra Pradesh First Referral Health Systems Project. Many of these collaborations are adopting various forms like buying and selling of health services, contracting out clinical and non-clinical services, facilitating and promotion of partnerships, pure business partnerships (e.g. telemedicine projects), etc. 72

6 Table 3.4 Health Infrastructure of Andhra Pradesh Particulars Required In position Shortfall Sub-centre Primary Health Centre Community Health Centre Health worker (Female)/ANM at Sub Centres & PHCs Health Worker (Male) at Sub 12, Centres Health Assistant (Female)/LHV at PHCs Health Assistant (Male) at PHCs Doctor at PHCs Obstetricians & Gynecologists at CHCs Pediatricians at CHCs Total specialists at CHCs Radiographers at CHCs Pharmacist at PHCs & CHCs Laboratory Technicians at PHCs & CHCs Nursing Staff at PHCs & CHCs Source: Rural Health Statistics (RHS) Bulletin, March 2012, Ministry of Health & Family Welfare, Government of India Andhra Pradesh is predominantly an agrarian state with a population of cover 7.0 crores population (of undivided Andhra Pradesh). Financing health care of persons living below poverty line (BPL), especially for the treatment of serious ailments such as cancer, kidney failure, heart diseases, is one of the key determinants that affect the poverty levels in Andhra Pradesh. The Honourable Chief Minister addressed a letter to the Union Finance Minister seeking support for State 73

7 Government s effort to which he responded favourably. In 2004, the Congress Party came to power in Andhra Pradesh, Y.S. Rajashekar Reddy, a medical doctor, came to power and he included health as one of the three main priorities in his party s manifesto. Chief Minister Reddy turned to P.K. Agarwal, then the Principal Secretary of the Department of Health, Medical and Family Welfare (DoHMFW) for assistance to develop a strategy for how to effectively improve services for the poor. The Hon ble Minister for Finance and Health, Government of Andhra Pradesh discussed this issue during the first week of May 2006 at Hyderabad. The group of Ministers constituted for working out the details met twice and the Hon ble Chief Minister held a final meeting on The outcome was the Aarogyasri Community Health Insurance Scheme (Rajiv Aarogyasri). The scheme is re-named as Dr. NTR Vaidya Seva Health Insurance Scheme since 2014). It was introduced as a flagship scheme of all health initiatives of the State Government with a mission to provide quality healthcare to all the poor within the overall aim of achieving "Health for All". In order to facilitate effective implementation of the scheme, the State Government set up Aarogyasri Health Care Trust under the Chairmanship of the Chief Minister, and administered by a Chief Executive Officer who is an IAS officer. The scheme is a unique model in the field of health care, tailor made to the hospital needs of poor, providing end-to-end cashless services for identified diseases through a network of service providers from Government and private sectors. The scheme implemented directly by the Trust by entering into contract agreement with network hospitals. It has implementing in to two parts. Aarogyasri-I is operated through Insurance Mode, whereas Aarogyasri-II is BPO mode. Encouraged by the success of Aarogyasri-I 74

8 scheme, Government has launched with effect from 17th July, 2008 Aarogyasri II scheme to include a large number of additional surgical and medical diseases to enable many more BPL people who are suffering from acute ailments to lead a healthy life. Aarogyasri II scheme is an extension of the ongoing Health Insurance Scheme. Together, Aarogyasri I and II cover 938 medical procedures. The scheme provides coverage for meeting expenses of up to Rs.2 lakhs per family per year for hospitalisation and surgical procedures in any of the network hospitals. 3 The insurance coverage is for a period of one year from its commencement date. Primary health care is also provided in the network hospital through free screening, outpatient consultation and health camps. Rajiv Aarogyasri Community Health Insurance Scheme seeks to improve access of BPL families to quality medical care and treatment for identified diseases through a network of healthcare providers. All transactions are cashless for covered procedures. This is a state government scheme privately operated. Under this, the insurance company pays hospital bills of the insured persons. The government pays the premium for insurance company. People do not have to pay anything under this scheme. 3.7 OBJECTIVES OF THE SCHEME The Main Objectives of the scheme are: 1. To improve access to poor families of the Andhra Pradesh State for quality tertiary medical care and treatment of identified diseases involving hospitalization through an identified network of health care providers. 2. To cover catastrophic illnesses, which will have the potential to wipe out a life time savings of poor families. 75

9 3. To provide universal coverage of urban and rural poor of the Andhra Pradesh State. 4. To strengthen the Andhra Pradesh Government Hospitals through demand side financing and; 5. To start Aarogyasri-II scheme run directly under the Trust for additional therapies. 3.8 GOAL OF THE SCHEME Rajiv Aarogyasri Scheme is unique and unparalleled in the country, and having been introduced for the first time in the Andhra Pradesh State, there was no data available to arrive at the disease load and morbidity rates in the Andhra Pradesh State. However, based on historical data from the tertiary care Government hospitals and incidence rates of certain diseases, it was assumed that around 10% of population suffers from ill health, requiring hospitalisation during any year. Out of this 60% would require medical treatment and 40% surgical treatment. Out of the total patients who require surgical treatment 10% might need surgical interventions listed under the scheme. In addition, there is enormous preexisting disease load in the state for which estimations are not available. The scheme besides aiming at elimination of pre-existing disease load in the areas of catastrophic health needs in the long run and extend the depth of coverage aims at universal coverage of the population. 3.9 VISION OF THE SCHEME Rajiv Aarogyasri is the flagship scheme of all health initiatives of the State Government with a mission to provide quality healthcare to the poor. The aim of the Government is to achieve Health for All in Aarogyandhra Pradesh (Healthy Andhra Pradesh state). In order to 76

10 facilitate the effective implementation of the scheme, the State Government has set up the Aarogyasri Health Care Trust. The Trust, in consultation with the specialists in the field of insurance and medical professionals runs the scheme ADMINISTRATIVE STRUCTURE- BOARD OF TRUSTEES In order to facilitate effective implementation of the scheme, the government set up Aarogyasri Health Care Trust under the chairmanship of the Chief Minister of Andhra Pradesh. The Trust - in consultation with specialists in the field of insurance and other medical professionals - devised the tailor made Aarogyasri health insurance scheme. The Trust includes representatives from various government agencies and professional organizations. Aarogyasri Health Care Trust comprises of the Chairman, Vice-Chairman and Trustees nominated by the Government of Andhra Pradesh. The Trustees of the Board include the representatives and experts from Government. The trustees are presented in table 3.5. Table 3.5 Board of trustees of Rajiv Aarogyasri scheme S.No Name of the Trustees Designation 1 Hon ble Chief Minister Chairman 2 Hon ble Minister for Aarogyasri,104,108 Vice Chairman-1 3 Principal Secretary to Govt. HM & FW Dept., Vice Chairman-1 4 Finance(FP) Dept., Trustee 5 Principal Secretary Dept. of Rural Trustee Development 6 Commissioner of Family Welfare Trustee 7 Director of Medical Education Trustee 8 Director of Health Trustee 9 Commission of APVVP Trustee 10 Director of NIMS Trustee 11 Finance Adviser Trustee 12 Chief Executive officer Source: Annual reports of Aarogyasri Health Care Trust 77

11 3.11 MAJOR DISEASES COVERED UNDER THE SCHEME As said above, about 938 identified therapies (Figure 3.1) in 31 categories and 454. Fig. 3.1 Major diseases covered under the RACHI 3.12 MODALITIES OF RECEIVING CARE UNDER THE SCHEME Families in the state who already have White Cards are provided with Rajiv Aarogyasri Bhima Health Cards. Everyone in a household can 78

12 be included in the Rajiv Aarogyasri Health Card. This means the head of the family, spouse, dependent children, and dependent parents. The Health Card captures the family s data and pictures of each family member. Beneficiaries present it when they arrive at a health facility to identify them. The card is also used to store patient visit records and transmit utilisation information. Once enrolled, beneficiaries are guided through the process of seeking care. In order to ensure that beneficiaries know what benefits they are entitled to, and are able to navigate the system of care, Aarogyasri has developed a team of 4,000 Aarogya Mithras. Aarogya Mithras is health workers representing the community of the insured. One Aarogya Mithra sits in each primary health center across the state. These health centers are most often the first points of contact for most families seeking care. In addition, district hospitals and network hospitals also have help desks manned by Aarogya Mithras to facilitate smooth service delivery for Aarogyasri beneficiaries. Aarogya Mithras helps to guide beneficiaries through the network of care and inform them about their insurance benefits (see figure 3.2 modalities of receiving care through Aarogyasri). The administrative structure of Aarogyasri is comprised of the following organisations. It can be seen in figure Aarogyasri Healthcare Trust - The Trust is administered by a Chief Executive Officer who has administrative functions such as formulating packages and pricing, managing contracts with insurer(s) and network hospital providers, approving claims, and monitoring. 79

13 Figure 3.2 Modalities of receiving care through Aarogyasri RAACHIS 2. The Insurance Company - The insurance company is selected through an open bidding process. After selection, the company signs a MoU with the Trust and then goes on to sign MoUs with network hospitals and the Zilla Samkhyas. The insurer manages all front-end and backend insurance administration, including empanelment (registration) 80

14 of hospitals, hiring of staff for scheme facilitation, claims processing, reimbursements to providers, oversight of hospitals, monitoring and feedback mechanisms. 3. Network Hospitals - Network hospitals offer healthcare facilities and treatment to Aarogyasri beneficiaries. 4. District Administration - The district collector is the chairman of the district level monitoring committee. These committees are largely responsible for mobilisation and spreading awareness about the scheme through health camps and campaigns. They review the implementation of the scheme through regular review meetings and oversee the functioning of the field staff. They work in close association with local self-help groups and other field functionaries. 5. Aarogyamithras - Aarogyamithras, Friends of Health, are the health coordinators who assist the patients in registration, admission, evaluation, preauthorisation, treatment, discharge and post-discharge follow-up. 6. Software Company - The entire scheme is processed online - registration of the patient and their details, to empanelment of hospitals, health camp details, preauthorisation, treatment and other services at the hospital. Discharge and post-treatment follow up services, claim settlements, and payments, An online monitoring system and the e-office tool are used for effective tracking of patients and administration. 81

15 Figure-3.3 Aarogyasri Implementation 3.13 MAJOR PERFORMING HIGHLIGHTS OF THE SCHEME The scheme is first of its kind in PPP model adopted wherein professional risk management of Insurance Company is supplemented with administrative capabilities and services of both private and corporate hospitals amalgamated into a unique PPP model of its kind in health insurance and in the country. The scheme is based on process of financial inclusions rather than exclusion (which is a cardinal feature of conventional insurance) as all the pre-existing diseases in the identified procedures are covered from day one. 82

16 Universal coverage of all BPL families in the state irrespective of age, sex, social status and family size. No enrollment process The sole criteria to be covered under the scheme is possession of a BPL ration card. There is no separate enrollment. All BPL families come under coverage from the date of insurance without any separate enrollment process as the entire premium is borne by the Government. End-to-end cashless service through fixed packages The packages designed by experts group cover the entire treatment process of the beneficiaries starting right from reporting in hospital until his discharge and 10 days medication after discharge making the services truly cashless for the beneficiary. Aarogyamithra (Health Facilitator) services are provided at each point of contact to the patients viz., PHC, CHC, Area Hospital, District Hospital and network hospital to register, refer, counsel and facilitate services in these hospitals and are provided with CUG for better communication. IT based online processing starting from registration of patients from health camp, referral, registration at network hospital, preauthorization, patient clinical details including diagnostic tests, claim monitoring, processing and payment Call center The call centre helps beneficiaries and other stake holders obtain information on schemes, regulate patient referrals to hospitals to avoid delay in hospital services, ensure prompt attention to grievances and patient complaints, guide and counsel patients and facilitate coordination between various stake holders. It also provides comprehensive health information and services to Aarogyasri information. 83

17 Coordinators in hospitals for accountability and single point facilitation of hospital services the innovative concept of identifying a responsible officer (Doctor) in the network hospital provide single point solutions to patient services, accountability and better coordination between Insurance / Trust. Camp Coordinators for conducting health camps as per Health Camp Policy - Insistence of a Camp Coordinator at network hospital yielded desired results and improved quality of health camps as health camps are one of the key features of the Scheme. Elaborate empanelment procedure through Empanelment and Disciplinary Committee (EDC) to ensure standard and quality of hospitals as per scheme guidelines and requirements. Clear and well defined guidelines and procedures to ensure clarity and transparency for proper selection of cases and facilitation of timely preauthorisation. Workshops, awareness campaigns and regular training sessions for stake holders to create awareness not only about the scheme but also update them about the regular changes made to the scheme from time to time. Social Auditing through postage paid feedback from beneficiary and mass contact programmes of the Government such as Prajapatham and Rachabanda the beneficiary provides feedback on services in the network hospital through pre postage paid feedback letter. The beneficiaries also participate in mass contact programmes of the Government viz., Rachabanda and Prajapatham and share their experience. Complaints and grievances are also collected by field staff and redressed. Dedicated Medical Audit department for continuous monitoring quality of hospital services. 84

18 Government hospitals treating Aarogyasri patients are entitled to receive the same payment as private and corporate hospitals. 65 % of the revenue goes to hospital development society and remaining 35% to the team of treating doctors and para medics as incentive. Government has decided to retain 20% of the earnings by the Government Hospitals to create revolving fund to regularly assist these hospitals to improve their infrastructure. This system motivates more and more government hospitals to participate in the scheme and utilize the revenue earned to improve facilities, provide quality medical care and bring reforms in tertiary medical care EXPANSION OF THE RAJIV AAROGYASRI SCHEME Population Cover during the year, Rajiv Aarogyasri Health Insurance scheme was extended to the entire state in 5 Phases. The coverage details are given Figure 3.4. Anantapur, Mahabubnagar, Srikakulam covered in Phase I, East Godavari, West Godavari, Chittoor, Nalgonda and Ranga Reddy as Phase II, Medak, Karimnagar, Kadapa, Prakasam and Nellore as Phase III, Hyderabad, Adilabad, Kurnool, Vizianagaram and Visakhapatnam as Phase IV. Government after careful assessment of the scheme has now decided to expand the scheme with some modifications. Accordingly the Fifth phase expansion is planned from July 2008 in five districts viz. Nizamabad, Warangal, Khammam, Guntur and Krishna. 85

19 Figure 3.4 Expansion of the Rajiv Aarogyasri scheme 3.15 FINANCIAL RESULTS FUNDING OF THE AAROGYASRI Aarogyasri is funded by general tax revenue generated by the state of Andhra Pradesh. The state subsidises the full cost of the insurance premium for each beneficiary. The state chose to fully cover this cost as the administrative costs of collecting the premium would outweigh the total cost of the premium itself. In addition, the state wanted to ensure that the benefits of the scheme reached the poorest, who might otherwise deterred from enrolling even if the premium to be paid out-of-pocket was nominal. For rollout of Aarogyasri, the State government engaged in an open, competitive bidding process to select a single insurer to implement the program. The insurer with the lowest premium bid (for the specified benefits package) won the contract to be the insurer for Aarogyasri. For the first phase of Aarogyasri, the premium was set at Rs.210 per household annually, with each household entitled to claim all expenses in relation to a set of pre-specified critical diseases and surgeries upto a maximum of Rs.200,000. The premium is the same across all districts in 86

20 the state and the amount reimbursed per procedure to any network hospital is also the same. Financial performance in percentage share of various heads of Aarogyasri Health Care is presented in table 3.6. The table reveals that the total grants have been continuously increasing from Rs crores in to 1,867 crores in Of which, highest share of grants by per cent in was mobilised from government of Andhra Pradesh (GOAP), followed by per cent in , per cent in , per cent in and per cent in to the total grants respectively. Opening balance was also slightly increased and recorded by 6.94 per cent to per cent during to Chief Minister s Relief Fund (CMRF) has occupied second place in the total grants. CMRF was varied from per cent in to per cent in Meanwhile, NHRM share was stopped from 2011 onwards. Thus, it can be said that majority of the grants to the scheme was allocated by the government and mobilised from CMRF. It is further observed from the table that the grants were spent on Aarogyasri (AS)-I insurance claims, AS II trust claims, cochlear implantation, trauma claims, journalist claims, CMCO claims, printing of health cards, health camps, follow-up services, administrative expenses including 104 scheme and capital assets. Majority of the share was spent for Aarogyasri (AS)-I insurance claims ranged by per cent in to per cent in Expenses on Aarogyasri II trust claims were also significantly recorded by per cent to per cent during the study. But, very meagre fund was spent on health camps which is less than the Administrative Expenses including 104 scheme and Printing of 87

21 Health Cards. Meanwhile, unspent balance was noticed but per cent in and increased to per cent respectively. Table 3.6 Financial performance (percentage share) of various heads of Aarogyasri Health Care Trust (Rs. in crores) Grants from Opening Balance GOAP NHRM CMRF Interest on Fixed deposit Other Income Total (A) Less: Aarogyasri Scheme Expenses AS-I Insurance claims AS II Trust Claims Cochlear Implantation Trauma Claims Journalist Claims CMCO Claims Printing of Health Cards Health Camps Follow up Administrative Expenses including 104 scheme Capital Assets Refund to Government Unspent balance Total (B) INSURANCE COVERAGE UNDER THE SCHEME The insurance coverage of the Aarogyasri is presented in table 3.7. No doubt to say that the scheme become paradigm to other states as 88

22 inspired by many states of India. It is observed from the table that the total number of families was varied from lakhs in to lakhs in Families under BPL were lakhs in and increased to families in But the figure was recorded at lakhs in The Insurance scheme covered lack families out of total across Lack families (87% families covered) residing in 27,138 villages and 1,128 mandals of all districts of the State in five Phases. As said earlier a poor family having a white ration card becomes eligible for the scheme. The benefit on family is on floater basis i.e., the total reimbursement of Rs.2 lakhs (Rs.2.5 lakhs from November 2014) can be availed of individually or collectively by members of the family. An additional sum of Rs.50,000 is provided as buffer to take care of expenses, if it exceeds the original sums i.e., Rs.2.5 lakhs per family. Cost for cochlear Implant Surgery with Auditory Verbal Therapy is paid by the Trust up to a maximum of Rs.6.50 lakhs per case. The beneficiary is identified and authenticated through the online database of the Civil Supplies department of total number of families varied between GoAP. There is no limit on the size of the family. Andhra Pradesh has the advantage of photo ration cards issued to all eligible BPL families by Civil Supplies Department. Taking advantage of this unique foolproof facility, BPL ration cards issued by Civil Supplies Department with family details and photograph were taken as the eligibility card for the scheme. The authentication under the scheme is done through a white ration card. The scheme covers 932 therapies in 29 specialties such as cancer, cardiology, poly-trauma etc. There are 380 network hospitals serving the patients 4. The benefit coverage under the scheme is procedures. 89

23 Sl. No The premium per family Rs.1,122 in and was increased to 2, in , Rs in But it was fallen to Rs.1,058.5 (equaling to %) in Issue 1 Total Families (In lakhs) Table 3.7 Year-wise Coverage under Insurance Year wise Coverage under Insurance BPL Families (In lakhs % to Total Families No. of Procedures NA 4 Premium (Rs.) Per NA Family % growth Source: Annual Reports of Rajiv Health Care Trust, Government of Andhra Pradesh. NA = Not Available The current BPL cards as well as BPL population rounded off in lakhs in the state is given in table 3.8. According to table, about 198 lakhs of Aarogyasri cards was issued to 680 lakhs people in The respective figures were increased to lakhs and lakhs in It is believed that Aarogyasri Scheme has fuelled the demand for possessing a BPL card. This cause along with the GoAP BPL line fixation at Rs.60,000 in rural areas and Rs.75,000 in urban areas could explain the reason for a high number of BPL families in the state. This shows that 86 per cent of the families of the State are BPL (This figure is at large variance with that given by Government of India which is in the range of 40%). 5 90

24 Table 3.8: Phase wise cards and population in the state of Andhra Pradesh (in lakhs) Cards Population Cards Population Cards Population Cards Population 1 phase phase phase phase phase Total Note: Figures are as on the beginning of Policy Period (PP). 91

25 3.17 THERAPIES DONE BY GOVERNMENT AND CORPORATE HOSPITALS The frequency count of surgeries/therapies done for the preauthorisations given during a specified period by government and corporate hospital is presented in table 3.9. The Aarogyasri programme is designed for advanced surgical and medical care. Role of corporate hospitals has prominent place in this scheme. Poor can access corporate hospital treatment. The figures in the table reveal that preauthorised therapies done by Government hospitals were confined to per cent to per cent during to Preauthorisation is a process by which a network hospital obtains written approval for certain medical procedures or treatments to be performed on the patient/beneficiary from Trust/Insurance. Preauthorised therapies done by corporate hospitals were significantly recorded by to per cent in and highest by per cent during In fact therapies reserved for Govt. Hospitals is 133 cases only. Thus, the scope of corporate hospitals commonly extends. In case of preauthorised therapy amount, government hospitals have Rs crores in and it was gradually increased to Rs crores. In others, preauthorised therapy amount of government hospitals varied from per cent to per cent during the study. The remaining share was possessed by the corporate hospitals recorded by Rs.365 crores in and increased to Rs crores in

26 Table 3.9 Therapies done by Government and Corporate hospitals Therapies Government Corporate Government Corporate Government Corporate Government Corporate Preauthorized Therapies (17.68) (82.32) (19.82) (80.18) (79.28) (23.04) (76.96) (20.72) Preauthorised Therapy Amount (Rs.in Crores) (19.29) Therapy Count (17.68) Therapy done Amount (Rs.in Crores) Claim Approved Count (16.17) (13.14) 365 (80.71) (82.32) (83.83) (86.86) (19.82) (18.89) (19.55) (16.07) (80.18) (81.10) (80.45) (83.93) (20.71) (19.92) (10.85) (17.55) (79.29) (80.08) (89.15) (82.45) (23.04) (23.11) (21.44) (23.25) (76.96) (76.89) (78.56) (76.75) Claim Approved Amount (Rs.in Crores) (11.49) (88.51) (14.22) (85.78) (16.03) (83.97) (20.16) (79.84) 93

27 As per the official documents of State of Andhra Pradesh, 6 the cost of pre-authorized was Rs.4, crores from to Therapy count of government hospitals was 24,279 equaling to per cent in and increased to 66,718 equaling to per cent to the total therapy count. The remaining share was possessed by the corporate hospitals. Therapy count of corporate hospitals was 365 equaling to per cent in and increased to 2,21,970 equaling to per cent to the total therapy count in respectively. The frequency count of surgeries/therapies done for the preauthorisations given during a specified period is called therapies done. Therapy done amount such as surgery/therapy done by the Government Hospitals was claimed at Rs crores (16.17% to the total) in It was Rs crores (83.83%) in the same year. It was increased to Rs crores (78.56%) in according to the study. The number of therapies approved for payment out of therapies claim raised. Approved means those approved by Claim Head in case of insurance or CAO in case of Trust. Claim Approved Count was 14,285 (13.14%) in case of government hospitals and 94,457 (86.86%) for corporate hospitals in The percentages of the respective hospitals during were 71,489 (23.25%) and 2,36,003 (76.75%). Claim approved amount (CAM) to the government hospitals was Rs crores (11.49%) and it was Rs crores (88.51%) in case of corporate hospitals during It was drastically increased by Rs crores (20.16%) and Rs crores (79.84%) in

28 It is concluded from the table that the corporate hospitals have done more therapies and therapy done amount than the government hospitals THERAPIES DONE UNDER AS-II BY GOVERNMENT AND CORPORATE HOSPITALS As mentioned earlier, the encouraged by the success of Aarogyasri-I scheme, Government have launched with effect from 17 th July Aarogyasri II scheme to include a large number of additional surgical and medical diseases to enable many more BPL people who are suffering from acute ailments to lead a healthy life. Aarogyasri II scheme is an extension of the ongoing Health Insurance Scheme. The front end of the both the scheme viz., network hospitals, Aarogyamithras, Health Cards etc., remained the same. Pre-authorisation and claim processing for new diseases in Aarogyasri II would however be done by the Trust directly and funded from the Chief Minister Relief fund along with regular budget. To the extent the scope of Aarogyasri I, is enlarged by Aarogyasri-II, it would no longer be permissible for the BPL population to approach the Government for providing relief for medical purposes from the CMRF. The scheme is providing much needed help to poor families for treatment of serious ailments thereby saving them from falling in a debt trap. It is also bringing advanced surgical treatment within the reach of the poor and helping many an invalid young and elderly patients to resume their productive lives. During the year under Aarogyasri II, the following was the progress 7. The Scheme now covers various Surgical and medical procedures for cashless treatment, selected on the basis of the treatment being emergency and lifesaving in nature, requiring specialist doctors / equipment and not ordinarily available at 95

29 district level Government Hospitals. With the launch of Aarogyasri-II, cashless treatment of BPL population for all major diseases has become possible in Government/corporate hospitals. Treatments covered under ongoing Aarogyasri-I and those covered under Aarogyasri-Il are complimentary to the facilities available in Government hospitals and put together substantially meet the hospital requirements of general population. Exclusions from the Scheme are extremely high-end diseases such as hip and knee replacement, bone morrow transplants, heart and liver transplants, gamma-knife procedures in neuro surgery, assisted devices for cardiac failures etc. Therapies done under AS-II by Government & Corporate Hospitals have also considered in the study. It is found from the data that the role of government hospitals was significantly increased in this phase. It is clear from the table 3.10 that pre-authorised therapies count by Government hospitals was recorded by 12,280 (15.27%) in and increased to 51,213 (39.93%) during to Pre-authorised therapies by corporate hospitals were significantly recorded by 68,112 (84.73%) and 77,036 (60.07%) during the said period. 96

30 Aarogyasri-II (Trust Mode) Table 3.10: Therapies done under AS-II by Government and Corporate Hospitals Therapies Govt. Hospitals Corporate Hospitals Govt. Hospitals Corporate Hospitals Govt. Hospitals Corporate Hospitals Govt. Hospitals Corporate Hospitals Preauthorised Therapies Count 12,280 (15.27) 68,112 (84.73) 23,741 (23.29) 78,179 (76.71) 32,045 (32.34) 67,032 (67.66) 51,213 (39.93) 7,7036 (60.07) Preauthorised Therapies Amount (Rs.in Crores) (15.54) Therapy Count 12,078 (15.19) (84.46) 67,449 (84.81) (22.84) 23,459 (23.11) (77.16) 78,050 (76.89) (30.45) 32,355 (32.43) (69.55) 67,409 (67.57) (40.16) 50,283 (39.86) (59.84) 75,862 (60.14) Therapy done Amount (Rs.in Crores) Claim Approved Count (16.95) 4,844 (16.95) (83.05) 23,741 (83.05) (22.75) 13,820 (13.58) (77.25) 87,920 (86.42) (30.49) 30,759 (29.63) (69.51) 73,052 (70.37) (40.04) 41,528 (38.46) (59.96) 66,436 (61.54) Claim Paid Amount (Rs.in Crores) (11.92) (88.08) (12.77) (87.23) (26.49) (73.51) (37.27) (62.73) 97

31 In case of preauthorised therapy amount, government hospitals have Rs crores (15.54%) in and it was gradually increased to Rs.51,213 crores (39.93%). The remaining share was possessed by the corporate hospitals. In case of corporate hospitals, the pre-authorised therapy amount was Rs.68,112 crores (84.73%) in and increased to Rs crores (59.84%) in Therapy count of government hospitals was 12,078 (equaling to per cent in and increased to 50,283 equaling to per cent to the total therapy count. The remaining share was possessed by the corporate hospitals. Therapy count was 67,449 (84.81%) in and increased to 75,862 (60.14%) to the total therapy count in respectively. Therapy done amount such as surgery/therapy by the government hospitals and corporate hospitals was claimed at Rs crores (16.95% to the total) and Rs (83.83%) in It was increased to Rs crores equaling to per cent and Rs crores equaling to per cent in according to the study. Claim Approved Count was 4,844 (16.95%) in case of government hospitals and 23,741 (83.05%) for corporate hospitals in It was increased 41,528 (38.46%) and 66,436 (61.54%) to respective hospitals during Claim approved amount (CAM) to the government hospitals was Rs crores (11.92%) and it was Rs crores (88.08%) in case of corporate hospitals during It was significantly increased by Rs crores (37.27%) and Rs crores (62.73 %) in It is concluded from the table that the corporate hospitals have made done more therapies and therapy done amount than the government hospitals even in Aarogyasri-II (Trust Mode). 98

32 3.19 COCHLEAR IMPLANTATION PROGRAMME 8 Financial assistance is provided to the children of BPL families born totally deaf and dumb to undergo cochlear implantation surgery and Audio-Verbal therapy under Rajiv Aarogyasri Scheme 9. They have to eligible the following Criteria: Deaf children of BPL families Below 2 years of age for pre-lingual deafness Below 12 years of age for post lingual cases Financial Coverage Rs.6.50 lakhs for each child is provided under package. Services covered Cochlear Implant Surgery Audio-Verbal therapy for one year period Pre-Authorization Process Network hospital should follow the regular procedure of admission, evaluation and pre-authorization procedures before sending the patient for committee evaluation. Hospital shall upload all relevant documentation. The preauthorisation obtained will get cancelled automatically after one month period from the date of final approval if surgery is not performed. Hospital shall obtain fresh preauthorisation for such cases by sending them for Cochlear committee evaluation again. 99

33 The progress of cochlear implantation programme is given at table It is observed from the table that the preauthorised therapies Count of government hospitals were 42 only. But preauthorised therapies Count of corporate hospitals were 250 in Meanwhile the therapies count was increased to 5,641 and 12,278 during The percentage share of government hospitals was per cent and the remaining per cent in case of corporate hospitals. The similar variation has also found in case of amount allocation for this treatment. The preauthorised therapy amount obtained by government hospitals was Rs.2.18 crores and Rs crores received by corporate hospitals in The amount was increased to Rs.9.87 crores towards government hospitals and Rs crores received by corporate hospitals in Therapy count of government hospitals was 38 in and increased to 5,441 in The remaining share was possessed by the corporate hospitals. Therapy count was 234 in and increased to 12,213 in respectively. Therapy done amount such as surgery/therapy by the government hospitals and corporate hospitals was claimed at Rs.1.98 crores and Rs in It was increased to Rs.9.64 crores and Rs crores in according to the study. Claim Approved Count was 11 in case of government hospitals and 180 for corporate hospitals in It was increased 5,007and 11,827 to respective hospitals during Claim approved amount to the government hospitals was Rs.0.57 crores and it was Rs.9.36 crores in case of corporate hospitals during Rs.8.36 crores and Rs.8.36 crores in according to the study significantly increased it. 100

34 Table Pattern of Cochlear implantation / Therapies done under CMCO by Government and Corporate Hospitals Therapies Govt. Hospitals Corporate Hospitals Govt. Hospitals Corporate Hospitals Govt. Hospitals Corporate Hospitals Govt. Hospitals Corporate Hospitals Preauthorised ,882 6,565 5,641 12,278 Therapies Count Preauthorised Therapies Amount (Rs.in Crores) Therapy Count ,960 9,467 5,441 12,213 Therapy done Amount (Rs.in Crores) Claim Approved Count Claim Paid Amount (Rs.in Crores) ,518 9,108 5,007 11, Source: Annual reports 101

35 3.20 PATTERN OF HEALTH CAMPS AND AWARENESS CAMPS Awareness camps were held to the stakeholders in all the districts repeatedly, where in people s representatives from village level, self-help groups, Aarogyamithras, Anganwadi workers, ANMs, Para medical staff and Medical Officers. There were made aware of the scheme by explaining the scheme followed by lectures in the local language by Specialist doctors to guide these people in identifying diseases. The scheme was formulated in consultation with specialists from the fields of medicine, healthcare and Insurance in order to address the needs of catastrophic health expenditure of the poor families of the state and at the same time taking care to strengthen the existing infrastructure in government hospitals. Improvement of infrastructure in government hospitals through utilisation of funds earned by implementing the scheme enables them to provide quality care. The scheme is designed in such a way that the primary screening of beneficiaries is done free of charge through a system of health camps conducted at the PHC level and also through free OP screening done by the network hospitals as part of scheme services. The IEC activities conducted during the health camps and OP services in network hospitals supplement the regular primary care provided by Government providers. The health camps also helped in creating awareness and popularising the scheme. The scheme is unique since no other State or Government agency attempted to provide universal health cover to the poor. The choice of hospital for treatment lies with the patient. The entire process from the time of conduct of health camps, OP screening, testing, treatment, follow-up and claim payment is made transparent through an online web based process flow in order to prevent any misuse or fraud. The scheme compliments the 102

36 services rendered by Government hospitals outside the scheme and together attempts to fully meet the hospital needs of the poor. 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 information, education and communication activities, including that of preventive measures and provide basic treatment facilities for the common ailments for other patients. These health camps are providing advanced screening and treatment of common ailments at the doorstep of the patient. Table 3.12 and table 3.13 explains the total and Phase-wise health camps, people screened and referred under RACHI. Table 3.12 Cumulative of health camps, people screened and referred Camps Total Health Camps 6,761 8,263 8,348 7,483 36,394 67,249 Patients 11,76,558 13,90,543 13,37,928 13,28,474 Screened NA 52,33,503 Patients 1,01,687 64,782 43,694 29,546 Referred NA 2,39,709 NA = Not Available It is observed from the table that since the inception of the programme to December 2012, about 30,855 health camps was conducted. Patients Screened campus was made at 52,33,503 and 2,39,709 Patients referred campus conducted. 103

37 Table 3.13 Phase wise health camps, people screened and referred under RACHI Camps Phase - Phase - Phase Phase - Phase Total I II III IV V Health Camps 746 1,660 1,470 1,450 1,435 6,761 Patients 94,121 2,42,057 2,89,587 2,46,599 3,04,194 11,76,558 Screened Patients Referred 7,344 13,569 29,937 21,011 29,826 1,01, Health Camps 1,107 1,792 1,586 1,884 1,894 8,263 Patients Screened 1,64,808 3,18,967 2,69,195 3,10,837 3,26,736 13,90,543 Patients Referred 10,500 13,424 12,482 13,026 15,350 64, Health Camps 1,165 1,806 1,662 1,871 1,844 8,348 Patients 1,70,949 2,95,959 2,76,843 2,92,248 3,01,929 13,37,928 Screened Patients Referred 7,628 8,609 8,463 8,773 10,221 43, Health Camps 785 1,745 1,454 1,761 1,738 7,483 Patients Screened 1,26,520 2,85,770 2,42,165 3,39,979 3,34,040 13,28,474 Patients Referred 2,712 4,654 3,210 8,625 10,345 29,

38 3.21 NETWORK HOSPITAL EMPANELMENT MECHANISM STATUS Hospitals having a minimum of 50 hospital beds with requisite infrastructure and expertise within the state of Andhra Pradesh are eligible to be empanelled under the scheme for providing services. To bring in quality and transparency into the system of empanelment, an online empanelment procedure is adopted where hospitals while applying need to submit their application along with details of infrastructure, equipment, manpower, investigation facilities along with documentary evidence. Once the online application is registered, a team of doctors from the Empanelment and Disciplinary Committee (EDC) inspects the hospitals and based on the report a decision on acceptance or rejection of the empanelment application takes place. The hospitals whose applications are accepted are thereafter inducted into the scheme after a workshop and signing of agreement. Network hospital empanelment status as on 31 st March of the year is presented in table Table 3.14 Network hospital empanelment status Financial Year Government Corporate Total NWH NWH NWH Total

39 Figure 3.5 Network hospital empanelment status It is found from the table that there are 98 Network Hospitals under Government Hospitals (NWH) and 356 corporate Network Hospitals with Beds. Majority of Network Hospitals was empanelled in SCHEME EXPERIENCE: ANALYSIS OF COST AND BENEFITS OF THE SCHEME The scheme experience indicators give a macro level picture of how the scheme has been performing in terms of expenditure ratios and profits. The profitability of an insurance scheme is expressed in terms of claim ratio which is the percentage of amount actually spent by the insurer on paying for treatment out of the total premium received from the Trust. The fund forecasts estimate the amount of fund needed for running a given therapy over a specified period of time in a given area. The key monitoring areas are amounts spent (in terms of premium paid and expenditure, average preauthorise and average claim size), claims (approved and unpaid claims, claims which are in process ), and forecasts of funds under the scheme. Insurance scheme implemented through an identified insurer on payment of premium. Aarogyasri Trust Scheme has implemented 106

40 directly by the Trust by entering into contract agreement with network hospitals. The Trust is administered by a Chief Executive Officer who has administrative functions such as formulating packages and pricing, managing contracts with insurer(s) and network hospital providers, approving claims, and monitoring. Cost Benefit Ratio (CBR): Total claim amount paid to hospitals/total expenditure incurred by Trust. It can useful to compare the efficiency between the two modes of implementation (i.e., trust mode and insurance mode). Table 3.15 reveals the cost and benefits of insurance mode during the period of to It is found that the total Insurance Premium expenditure/cost (premium paid) was Rs.2, crores. Premium paid is the payment of total amount prepaid to the insurer during the policy period including taxes, including payments for any additional cards. Benefit (claims paid), the claims which have been paid by the Bank was Rs.2, crores. The cost benefit ratio during the study period was varied from 71.0 per cent in to 91 per cent in Table 3.15 Analysis of cost and benefits of insurance mode (Rs. in crores) S.No. Year Insurance Premium Expenditure/ Cost (Premium paid) Benefit (claims paid) Cost benefit ratio (%) Total 2, ,

41 Table 3.16 reveals the cost and benefits of Trust Mode/BPO during the period of to It is found that the total Cost (Premium paid) was Rs Crores and Benefit (claims paid), the claims which have been paid by the Bank was Rs crores. The cost benefit ratio during the study period was per cent in and increased to per cent in It was fallen to per cent in The aggregate Cost Benefit Ratio was recorded by per cent during respectively. Table 3.16 Analysis of Cost & Benefits of Trust Mode/BPO S.No. Year Total Trust Expenditure /Cost (Claims paid & Admin) Benefit (Claims paid) (Rs. in crores) Cost Benefit Ratio (%) Nil Total

42 Figure 3.6 Analysis of Cost & Benefits of Insurance & Trust Mode (Rs. in crores) The following table 3.17 reveals the total scheme analysis of cost & benefits of trust mode/bpo during to The extent of benefit package offered gives the depth of health coverage in the scheme. It is clear from the table that the total scheme was Rs.3, crores. Of which, per cent was under BPO/trust mode and per cent under insurance mode. The total Cost Benefit Ratio was per cent whereas it was per cent in Trust Mode and per cent in case of insurance mode. Table 3.17 Total Scheme Analysis of Cost & Benefits of Trust Mode/BPO during to (Rs. in crores) Particulars Total scheme BPO Insurance Cost / Expenditure 3, (24.75) (75.25) Benefit (Claim Paid) 3, (27.25) (72.75) Cost Benefit Ratio (%) Source: Table 3.12 and table

43 Figure 3.7 Total Scheme Analysis of Cost & Benefits of Trust Mode (Rs. in crores) Total Scheme BPO Insurance Cost/Expenditure Benefit Claim paid Cost Benefit Ratio (%) Table 3.18 explains the aggregate expenditure of all the items incurred by Aarogyasri trust till December It is found that the total expenditure was Rs.4, crores. Of which per cent occupied by Government Hospitals and per cent by Private corporate hospitals. Table 3.18: Aggregate expenditure incurred by Aarogyasri trust till December 2013 Year Government Hospitals (Rs. crores) Private Hospitals (Rs. crores) Total (Rs. crores) , , , Total 1, (22.19) 3, (77.81) 4,

44 Figure 3.8 Aggregate expenditure incurred by Aarogyasri 3.23 SCHEME UTILISATION Scheme utilisation can be viewed in terms of absolute numbers and costs incurred on therapies or in terms of rates per unit population covered. The rate of utilisation is a standardised measure of utilisation of a therapy under the scheme. Utilisation rates may be determined by dividing the number of covered individuals who utilised service by the total number of covered individuals. An utilisation rate reveals the trends in the utilisation of therapies or therapy baskets in relation to demographic factors and helps forecast the disease incidence rates. A scheme utilisation review gives us the opportunity to confirm that the health plan provides adequate coverage in terms of population, benefits and finances. The utilisation review of each therapy reveals if any particular therapy is being over utilised or under0-utilised by any hospital or in a district. Based on these historical utilisation rates we can forecast the future utilisation rates for a given period for any district. These forecasts can then be translated into financial terms and the amount of budget needed for implementing a particular therapy can then be assessed. It is a useful tool in detecting fraud by hospitals as well as for forecasting. It also indicates the disease burden in the population. It also helps the 111

45 organisation minimise costs and determine, if the recommended treatment is appropriate. The utilisation of the scheme can be measured from the point of view of number of cards, which used or persons who utilised or the number of uses of therapies. The claim rate gives the actual cost incurred in covering a specified set of therapies per card. The efficiency of scheme at a macro level can be measured under claim experience. Cards Utilised: Cards Utilised means the frequency count of cards which has preauthorisation at least one time for at least one use of any therapy during one or more specified periods (usually policy periods). A card for which preauthorisation is given more than once needs to be counted as a single card utilised. Person Utilisation Rate: The number of persons who utilised a particular [dimension] if one lakh persons are covered over one year period. Persons utilised means the frequency count of persons for which preauthorisation is given for one or more procedures either one or more times during one or more specified periods (usually policy periods). A person which preauthorisation is given more than once needs to be counted as a single person utilised. Table 3.19 gives the details regarding card utilisation rate (CUR) / claims rate (CLR) during the study period. The cumulative card utilisation rate (CUR) was 18,950 and claims rate (CLR) was 7,282. Thus it can be said that the claim rate is less than the card utilisation rate. 112

46 Table 3.19: Card Utilisation Rate (CUR)/claims rate (CLR) in terms of numbers Phase 1 Phase 2 Phase 3 Phase 4 Phase 5 Cumulative Year CUR CLR CUR CLR CUR CLR CUR CLR CUR CLR CUR CLR ,064 2, ,515 2, ,914 2,752 9,012 4,082 7,918 3,460 5,512 2,128 7,235 2,975 36,591 15, ,199 3,374 14,500 5,603 13,094 5,257 13,439 5,278 18,143 6,917 68,375 26, ,782 4,042 15,683 5,959 14,769 5,949 15,664 6,047 17,214 6,825 74,112 28, ,990 5,238 20,614 7,633 18,865 7,433 18,438 7,046 20,336 7,987 92,243 35, ,538 1,287 3,479 1,298 4,252 1,687 3,620 1,418 4,061 1,592 18,950 7,

47 Vital Statistics of the Aarogyasri Scheme since inception in April 2007 till December 2013 is presented in table Since the inception of the programme from April 2007 to December 2013, 36,394 health camps had been held at villages in 23 districts. A total of 7,090,728 people have been screened and of those 4,569,087 treated as outpatients and 2,319,669 treated as inpatients. Table 3.20 Vital Statistics of the Aarogyasri Scheme since Inception in April 2007 till December 2013 S.No Description Provisioning private/public Number of Cases 1 Health Camps 36,394 2 BPL Cards Covered 229 Lakhs 3 Therapies reserved for Govt lakhs Hospitals 4 Population Covered 777 Lakhs 5 Cards utilized Lakhs 6 Therapies Covered Preauthorization Government Private Total Outpatients Government 559,884 Private 4,009,203 Total 4,569,087 9 Inpatients Government 660,468 Private 1,659,201 Total 2,319, Patients Screened 7,090,728 Registered 7,390, Surgeries/Therapies Government 66,718 Private 2,21,970 Total 2,88, Preauthorized cost 4, crores 13 Aggregate expenditure Government (22.19). 1, crores Private (77.81%) 3, crores Total Rs. 4, crores Source: AHCT Annual Reports and website, (accessed 20 January 2013) 114

48 Till date, 2,88,688 surgeries/therapies have been conducted for the patients. In this only underwent surgeries in government hospitals and 2,21,970 underwent surgeries in private hospitals OTHER PECULIARITIES OF R.A.C.H.I. Regulatory effect on Hospitals: The empanelment procedure, defined diagnostic and treatment protocols, capturing of admission notes, daily clinical notes, operation notes, discharge summary and uploading of diagnostic reports including films, webex recording of Angio and Laparoscopic procedures and other photographic evidences have profound regulatory effect on the hospitals. Quality improvement in services: Continued monitoring of the services both online and in the field by the elaborated field mechanism coupled with disciplinary action against erring hospitals is greatly contributing to the quality of treatment under the scheme. Establishing Medical Protocols tailor-made to local situations: Though laid down international diagnostic and treatment protocols are available; the hospitals were not able to follow the protocols due to various reasons like non-availability of infrastructure, affordability of the patients and lack of monitoring by authority. The scheme by taking into consideration of availability of local infrastructure and standard medical practices successfully redefined the medical protocols with the help of senior specialists in each field. Employment Generation: The scheme generated indirect employment potential as the insurance company, network hospital and other stake holders have to employ number of people in different cadres such as Aarogyamithra, RAMCO, AAMCO, duty doctors, para-medical technicians, staff nurses etc. 115

49 Awards to RAHIS RAHIS was awarded Health Insurance Initiative of the Year 2010 in both categories of Jury award and Citizen Choice award through Public Voting where 1,40,000 voters participated throughout the world through online voting. Aarogyasri Health Care Trust also won award in the e- governance G2G category for its 'E-office' initiative through Citizen Choice by public voting. Aarogyasri Health Insurance scheme was awarded The Manthan Award, South Asia 2009 under e-health category that developing the consumer-centred model of health care where stakeholders collaborate, utilising Information Communication Technology, including internet technologies to manage health issues as well as the health care system. Manthan Award is a first of its kind initiative in India to recognise the best practices in e-content and Creativity in South Asia. It was launched on 10 th October 2004, by Digital Empowerment Foundation in partnership with World Summit Award, Department of Information Technology, Government of India. Various other stakeholders like civil society members, media and other similar organisations engaged in promoting digital content inclusiveness in the whole of South Asian nation states for development. Since then it has come to define the very best in e-content for development arena in SAARC countries namely India, Pakistan, Bangladesh, Nepal, Sri Lanka, Maldives, Bhutan and Afghanistan. 116

50 Figure 3.9 The Manthan Award South Asia Follow-up Services Follow-up services are provided for a period of one year through fixed packages to the patients whoever requires long term follow-up therapy in order to get optimum benefit from the procedure and avoid complications. Follow-up package for consultation, investigations, drugs etc., for one year for 125 listed therapies were formulated by Technical committee of the Trust in consultation with specialists and listed in website: RECENT INITIATIVES The Government of Andhra Pradesh has taken some initiatives to strengthening this scheme. The following are some of the recent initiatives. Stabilization of the Scheme: The Trust initiated the following steps to stabilize the scheme during last four years of its implementation. Strengthen pre-authorisation process by updating guidelines from time to time. Strengthening empanelment process. Disciplinary actions against service deficiency and fraud. 117