On implementation of technology

Keep all partners and implementers involved: The smooth functioning of smartcards implies that all actors involved in the project have sufficient information and resources to use them. In this context, it proved beneficial to hold several events to inform them about the project as well as to conduct several workshops and surveys to collect their input. The input collection, in turn, made it possible to also receive information about the apprehensions and training needs for delivering adequate training.

Demonstrations and “hand holding” lead to better acceptance and adoption: Had the users been reluctant to accept and adopt smartcards, the success of the entire project would be put at risk. To promote better acceptance and adoption, a pre-implementation workshop was held in November 2011, which allowed users to understand and experience the smartcard technology. Again, in August 2012, live demonstrations were given and the healthcare providers were trained. It is believed that these events helped to improve the acceptance and adoption of smartcards.

Providers need repetitive and relevant training: In the second impact assessment survey, 50 per cent of hospitals reported instances of interruptions in the identification process. All these interruptions occurred because desktops were formatted or software files were deleted. This experience highlights that providers need to receive repetitive and relevant training for avoiding such interruptions. 

On use of technology and processes

Smartcard technology is successful in identifying clients: The use of smartcards has facilitated a multi-level verification processes, since demographic details, a photograph and fingerprints of the client are saved on the smartcard. The details stored on the smartcards are verified with those of the patient who seeks treatment. In general, this verification process has worked well, making it possible to identify eligible clients. However, two issues have complicated the verification process in some cases: Firstly, the process of taking the fingerprints of clients needed sometimes to be repeated until they could be successfully read and tallied. This problem occurred due to erosion of skin and fading away of impressions due to manual labour. Secondly, some hospitals formatted their desktops or deleted software files, as a result, the information on the smartcards could not be read. Yet, providing regular technical assistance in the initial stage and training the hospital/clinic staff on re-installing the software has helped avoid these interruptions.

Smartcards minimise fraud: Prior to the introduction of smartcards, health service providers relied only on the name appearing on the plastic card because the card did not display any photograph. They also refrained from asking for a secondary proof of identity, such as driving license or any other government-provided identification. As a result, non-eligible persons could obtain treatment. Given that a photograph and the fingerprints are now stored on the smartcard, frauds attributable to impersonation and assumption of a false identity could be eliminated. Aside from fraud by clients, smartcards have also helped to reduce fraud by health care providers. This has become possible because 95 outpatient treatments and 937 inpatient procedures have been pre-packaged and coded. Hence, smartcards have made it difficult for health care providers to over-bill, although the risk remains that providers may directly ask the client for extra money.

Smartcards make it easier to comply with policy limits: Before the introduction of smartcards, clients frequently overshot their insurance coverage limits as aggregation of utilization at multiple locations took place manually at a central location. In contrast, using smartcards has eliminated this problem. Given that the client’s treatment is recorded on the smartcard as well as on the server, health care service providers always receive up to date information about the balance of sum insured to a client’s credit when they verify the client’s identity.

On client value

Smartcards accelerate the enrolment process: The enrolment process includes the filling up of enrolment forms by the client, data entry by the microinsurance provider and the delivery of insurance cards to the client. Prior to the introduction of smartcards, it took up to 2 months to complete this process, whereas it ideally takes between 15 and 25 minutes in the smartcard regime. Nevertheless, this ideal scenario has not always been feasible because: a) eligible persons did not show up at enrolment camps, b) clients were reluctant to pay their contribution and c) some clients did not agree to be photographed or finger-printed due to religious reasons. To overcome these challenges, clients were visited at their home but it still slowed down the enrolment process, as printers and generators could not be taken to door-to-door visits. 

Smartcards accelerate the authorisation of claims: Smartcards facilitate a real-time logging of claims on the server, so that they can quickly be authorised. Consequently, the authorisation of treatment could be reduced from nearly 12 hours to zero hours for pre-agreed and encoded treatments. This in turn shows that more patients can be treated in the cashless mode. Yet, smartcards cannot accelerate the authorisation of claims which are not pre-agreed and encoded.

Smartcards reduce the waiting time before treatment: Smartcards ease the authentication process and reduce the amount of paper work. These advantages have enabled health care providers to reduce the waiting period of the patient (between seeing a doctor and leaving the facility) from 25 minutes to 13 minutes – a reduction of almost 52 per cent.

Smartcards create a medical history: The patient’s past ten transactions are recorded on the card and a wider history is stored on the server, which allows health care providers to quickly access the patient’s medical history. Consequently, the health care provider finds itself in a better position to diagnose and treat, while clients are no longer required to keep documents about previous treatments. In fact, 90 per cent of the surveyed doctors reported that the availability of the medical history has led to better diagnosis and treatment.

Smartcards inform clients about their credit balances: Given the caps of the benefit package, the insurance policy does not necessarily cover the entire costs of a treatment. Yet, clients do not always understand these caps and they do not always pay attention to them. In fact, 75 per cent of beneficiaries had insufficient credit balances for covering the complete treatment before smartcards were introduced. This, in turn, required them to mobilise additional funds and they, for example, often resorted to borrowing from local money lenders. Although smartcards do not eliminate this problem, they have at least raised the clients’ awareness about their credit balances, since swiping the cards at terminals provides immediate information about credit balances. Consequently, fewer patients have had insufficient credit balances for covering their treatment. 

On business case

Smartcards can reduce enrolment related costs: The introduction of smartcards has fundamentally changed the enrolment process. Enrolment data does no longer need to be pre-printed on forms and sent to actors involved in the enrolment process, such as insurer’s offices and third party administrators. Instead, the enrolment data has been digitised under the smartcard regime, which has, as aforementioned, reduced the enrolment process to 15-25 minutes. This does not only signify an increased client value but it also reduces the supply cost. In fact, the recurring enrolment cost per card has been reduced from USD$ 1.78 to USD$ 1.64, assuming that the enrolment process is completed within 15-25 minutes.However, as above discussed, this ideal scenarios has so far rarely been feasible, which suggests that smartcards may have increased enrolment costs.

Smart cards reduce claims related costs: Smartcards have reduced the insurer’s costs related to medical treatment alone as well as costs related to claims administration. In terms of the former, the pre-agreed treatment charges of a large number of procedures has lowered pure claims costs from USD$ 3 to USD$ 1.9 – a reduction of nearly 35 per cent. Similarly, the above discussed reduction of fraud has also contributed to a reduction of claims. In terms of administrative claims costs, the introduction of smartcards has helped to reduce these costs from 17 per cent to 10 per cent of the premium. This reduction is also attributable to omission of a fee for a third party administrator.

Smartcards reduce a hospital’s operational expenses: Smartcards accelerate the work of hospital staff and they render photocopying, courier charges and phone calls as well as visits to the offices of third party administrators obsolete. This has made it possible for hospitals to reduce their operation expenses between 8 and 15 per cent. 

On network development/enhancement

Smartcards support the development and enhancement of the network: Given that smartcards facilitate the digitisation of data, their use provides statistical input about disease profiles and about the distanced travelled by claimants. This in turn makes it possible to create and identify newer service points and the facilities within them. So far, the analysis of the claimants under the smartcard regime has shown that they travel on average 2.5 kilometres to reach the hospital / clinic. Given that the vast majority of healthcare facilities are located within 5 kilometres from the client’s locations, it becomes evident that most clients have a reasonably easy access to healthcare facilities. Aside from the accessibility of healthcare facilities, the statistical input which is facilitated through smartcards also helps to ensure that the required treatment can be provided by healthcare facilities.