Empanelling providers

It is the job of the insurer in each district to empanel health-care providers. They have to identify and contract potential providers, secure, install the RSBY hardware and software at the provider, and train the provider.

Each healthcare provider signs a memorandum of understanding (MoU) with the insurer stating their agreement to fulfil the scheme’s requirements which include providing OP care and dispensing medicines directly through nearby pharmacies at fixed rates. Alternatively, the district health authority can sign the agreement on behalf of all public providers in the district.

RSBY contracts both public and private health-care providers in order to provide care as close to communities as possible. A mapping exercise was carried out to plot the location of facilities and to determine which, and how many providers should be empanelled to provide adequate access throughout the pilot districts.

The response from health-care providers was better than expected in Puri and a network was empanelled relatively quickly (in just 2 and a half months). This was probably because some health-care providers were already participating in another scheme run by ICICI Lombard, and therefore were familiar with cashless schemes and had a level of experience and trust in dealing with the company. The response from public health-care providers was better than that of private health-care providers.

Mehsana is generally a more prosperous district than Puri. As a result, fewer OP providers in Mehasana were willing to participate in the pilot under RSBY, stating that the proposed payment was not high enough.

The provider payments were later increased for both districts. The provider payment in Puri was initially INR 50, and this was increased in April 2013 to INR 100. In Mehsana, the benefit package differed in that it allowed access to specialists for all covered visits. Additionally, provider fees were higher compared to those in Puri. Therefore providers in Mehsana were initially paid INR 75 per visit to a general doctor, and this was also increased to INR 100 in April 2013. For specialized doctors, the payment was INR 150 per visit.

Another approach taken to increase the number of participating OP providers was to recruit registered homeopathic doctors. This effort resulted in the addition of 6 providers in Puri, who were trusted and often used by the clients.

Please find more details here.

Training providers

All the empanelled providers are trained by ICICI Lombard on the scheme, its benefits, the technology, and the claims and reimbursement processes. The training is on-going and is conducted at several levels:

• Initial training, carried out by the technology partner, FINO, and ICICI Lombard’s customer service team during installation of RSBY OP technology
• District level workshops once every two months, done by ICICI Lombard and FINO. ICICI Lombard develops the content on the benefits package and FINO demonstrates the operation of the RSBY hardware and software
• Practitioner-to-practitioner learning, conducted occasionally, in which a health-care provider is invited to learn by observing the operations at another health-care provider nearby under the guidance of FINO and ICICI Lombard

After the scheme had been running for a few months, it became clear that some providers were struggling to use the technology to register patients and to submit claims. It was therefore decided to conduct refresher training. Teams with representatives of each partner visited each provider, investigated the difficulties they were experiencing and addressed them with training.

Subsequently, it was decided to train each provider at least 2-3 times during the life of the project. Training visits were also available on demand for providers who were new to the technology. In addition, a team from FINO visits providers once a week to address any technical issues.

Enrolling clients

Under RSBY, the insurer is responsible for enrolment, but is supported by the SNA in each state. The SNA creates and maintains the population eligibility data for those who are BPL in an electronic format specified by the national government. Before the enrolment, the SNA provides a list of eligible clients, which is displayed in prominent locations in the village. Information is also provided to each household.

During enrolment a smart cards is issued to each enrolled household. The insurer must reach each household member who is to be included, and authenticate their identity, register them, and issue them a card. The government then pays the insurer premiums based on the number enrolled in this way.

On a scheduled day, the insurer staffs an enrolment centre at a village. The enrolment process takes about ten minutes per household. Up to five family members provide fingerprints and have their photos taken and each household pays the standard INR 30 annual registration fee. Although modest, this fee is thought to increase a sense of ownership among clients.

One biometric smart card is provided to each newly enrolled household either on the spot or the day after registration. Clients must use this smart card to access healthcare through RSBY. This ensures that an eligible client receives services, limiting fraud and improving efficiency by providing the real-time, paperless encounter data. Along with the smart card, the client is given a booklet giving details of the scheme, benefits, available hospitals, key contacts, including the insurer’s call centre, and the complaints process.

An extra smart card can be created for migrant workers. In this case the coverage is split between this card and the household’s main card, and the migrant worker can access services using his or her card across India.

Enrolment in Puri began in June 2011, but was delayed due to the inaccuracy of the list of eligible clients provided by the SNA. As a result of this and further delays due to flooding in the district, enrolment was not finished in Puri until November 2011. Around 132,000 households were enrolled, representing 53 per cent of eligible households.

FINO deployed 50-60 staff with 30 enrolment kits in each block. On average it took the team 15 days to enrol a block.

Enrolment in Mehsana followed that of Puri.  Commencing in September 2011 and running for the designated 3 months, around 78,000 households were enrolled, representing 64 per cent of eligible households.

Re-enrolling clients

Policy renewals were delayed in both districts. In Puri this was a result of problems experienced by the state government when preparing the enrolment data. In Mehsana it was a result of delays in the SNA administering the insurance companies’ tenders, as well as the need to wait until after an election at the end of 2012. As a result, the existing policies had to be extended to cover clients until re-enrolment could be completed. The duration of the policy had initially been set at 1 year, with the option to change it at the discretion of MoLE, and with agreement of the SNA and the insurer. In the end the total policy period was extended to 37 months in Puri and 29 months in Mehsana.

Renewals began almost a year late in May 2013 in Puri. The problems with inaccurate data continued. Nonetheless, enrolment conversion rates in Puri showed a promising trend. ICICI Lombard was able to enrol 60 per cent of potential beneficiaries, compared to 53 per cent previously. This was partly because the SNA incentivized the Field Key Officers to participate by providing an incentive of INR 2 per family enrolled. In addition, the enrolment effort was better planned, with blocks most severely affected by rains enrolled before the monsoon season.

In Mehsana enrolment started in January 2013 and finished at the end of April 2013. Again outdated and inaccurate data hindered enrolment. In Mehsana the conversion rate was around 60 per cent, compared to around 64 per cent previously. This lower result was partly due to the introduction of new sources of beneficiary data, which overlapped with data already recorded for many existing beneficiaries.

The numbers of clients enrolled during each round of enrolments are below:

Please find more details here.

Client Awareness

Creating awareness among clients about the benefits and how they can access them is vital to ensure that they take advantage of them. Awareness campaigns were carried out by ICICI Lombard during the enrolment process to inform clients about the scheme.

Several approaches were tried in each area to see what worked best with each client population. There are considerable differences between the socio-economic backgrounds of Mehsana and Puri. Therefore, different awareness and literacy activities were planned for each district. In Puri dance and folk art were used in village centres and market areas, as well as posters and other displays in prominent areas. In Mehsana the awareness campaign included a radio jingle, dance nights during a festival season, displays, banners, a campaign vehicle, and kites (to coincide with a kite flying festival). Newspaper advertisements were also used, since, unlike in Puri, the majority of the population of Mehsana is literate.

As the pilot progressed, clients were not using the services as much as expected. In addition, feedback from the monitoring teams suggested that the awareness campaigns during enrolment were not sufficient. Therefore, the team carried out further awareness campaigns. These included celebration events at the health-care provider facilities, a vehicle specially designed to promote the scheme (see picture below), and information events and meetings.

However, even after these subsequent campaigns, the partners did not feel sure that awareness of the scheme, including the availability of OP benefits, was sufficient to achieve desired utilization levels.

Please find more details here.

Claims

The health-care provider receives a negotiated payment of INR 50-150 for each outpatient visit, depending on the district, and whether the health-care provider is a primary care doctor or a specialist. The rates were increased in both districts in order to persuade more health-care providers to become empanelled in RSBY provider network.

RSBY uses a smart card technology platform to deliver paperless, cashless transactions. When a visit takes place, a client’s identity is verified and the details of the visit are entered into the system. These details include patient demographics, diagnosis and treatment, and any follow-up required.

When these data are uploaded to the RSBY central system, the insurer is notified to pay the claim. Initially it was possible to upload health-care provider claims in two main ways. Where there is an internet connection, the information is uploaded in real time, when the transaction takes place. Where the internet connection is intermittent, transactions are temporarily stored and uploaded later when there is a connection. If a facility has no internet connection at all, a representative of FINO collects the data in person on a data card. A mobile phone application was tested in August 2012 in Puri, allowing data to be transferred without an internet connection.

Once the data have been uploaded to the central system, FINO performs an initial data check. From this point, ICICI Lombard takes over to verify and process the claims. All OP claims are processed in house by ICICI Lombard; a third party administrator is not used.

Claims are settled with health-care providers through electronic fund transfer (EFT). It is mandatory to pay 95 per cent of the payments via EFT; the remainder can be made through cheques. The payment cycle usually takes 15 days once the claims data are received by ICICI Lombard. However, if ICICI Lombard suspects an error or possible fraud the health-care provider has 15 days to verify and resolve the claim.

Valid claims must be paid within 21 working days from the time the health-care provider enters the details of the encounter. There were some difficulties to achieve this because of problems with the data such as the bank details of the health-care providers. However, the vast majority are now processed within this time period.

Please find more details here.

Technology

Technology enables delivery of the insurance, and allows the scheme to operate on a completely cash-less, paper-less basis. When clients enrol, their biometric data are recorded and they are issued smart cards. Each OP provider authenticates the identity of the RSBY client using a single hardware unit, which contains a biometric card reader, a scanner, and a printer.. The provider also uses a laptop installed with specific OP software, and records the details of the client’s visit here.

Each transaction on this platform  documents that the service has been delivered to the client. The data are uploaded and synchronised with the central technology server, so that the health-care provider is eligible to claim payment for the visit (see section on claims for more detail). The technology partner, FINO, provides troubleshooting in case of technical problems. FINO also manages the central server to record claims upon receipt.

Below is an illustration of the technology-enabled process:

Over time, some adaptations to this core process were necessary. One change was to carry out the fingerprint matching only once, compared to twice initially, because the process was proving too time-consuming for clients. The single check now takes place after the data is entered into the OP software.

When the technology was installed at each provider, there were some problems. The biggest problem was that the providers struggled with unreliable or no internet connection. Data cards were used to help improve the internet connectivity, but issues with connectivity and with electricity persisted, slowing implementation. In addition, some of the devices stopped functioning after a few months, and required reactivation. While devices malfunctioned, claims had to be processed manually. This led to delays in claims payment, ultimately causing some providers to simply turn clients away. This led to a reduction in claims, and a loss of trust among those clients and health-care providers who were affected.

A mobile phone supported claims solution was later introduced, to help sidestep problems of limited internet connectivity. Seven health-care providers tested the mobile phone enabled system, with Bluetooth devices introduced in their clinics. These mobile devices provided a useful alternative to submit claims, and were appreciated by providers. The extended battery life of the mobile and the Bluetooth enabled devices (10-12 hours compared to 3-4 hours for a laptop) allows providers to submit claims from more distant locations, which lack internet or power connectivity. Providers preferred the mobile phone method to the point of service (PoS) alternative and were able to increase OP claims to 3,100 transactions per month, up from 387 transactions per month (with PoS devices).

Please find more details here.

Change in biometric cards

The government was concerned that there was not sufficient space on the biometric cards to store all the data that might be required in the future, particularly to potentially accommodate multiple government schemes using the cards distributed originally for RSBY. It therefore decided to enhance the memory capacity of the cards from 32KB to 64KB.

However, this caused many problems for the OP pilot. The technology for IP RSBY comprises three devices and a laptop, whereas for the OP pilot integrated devices were installed in stand-alone OP clinics. The 64KB cards that were introduced were not compatible with these integrated devices. As a result, freestanding OP clinics could not access the RSBY technology platform. In the end it became clear that the hardware would have to be replaced, yet finalising the new software and installing it in the clinics took months. In the meantime, most private empanelled facilities, which are often the closest and most accessible for clients, simply began turning RSBY clients away or asking them to pay for services out-of-pocket. Freestanding public OP clinics could continue to provide consultations to clients for free, as they did before the scheme. But they were not able to offer medicines free of charge through RSBY, unless these were already available through other government provisions.

Considerable momentum and interest in the scheme had been built up through awareness activities and the experiences of clients. This disruption in service delivery has eroded the trust of clients, which may take significant effort to rebuild once the technology is operational again.

Action Research

Baseline research was conducted for Mehsana in September 2011. For Puri the first round of the research study was conducted in October 2012. For both the pilot locations end-line research will be conducted after the end of the policy period in each district.

Quantitative analysis of preliminary baseline data findings

An overwhelming majority of clients (more than 94 per cent in each district) were aware of RSBY from health-care providers and almost all (about 98 per cent in each district) knew about the cost of enrolment. On the contrary, the awareness about the benefits of the scheme was not as high. Less than half of the respondents (34.8 per cent in Mehsana) knew about hospitalization benefits. The majority of the household respondents did not know whether medical diagnostics (75.7 per cent in Mehsana) and medicines and drugs (59.9 per cent in Mehsana) expenses during hospitalization were covered.

Nearly all clients in Mehsana (93.9 per cent) incurred at least some health-care expenditure. A breakdown of out-of-pocket expenditure for treatment showed that the majority of out-of-pocket costs was for medicines (Mehsana - 89.9 per cent), transport (Mehsana - 60.6 per cent), and diagnostics (Mehsana - 50.2 per cent).

In order to pay for out-of-pocket costs of OP treatment during the reference period, 32.6 per cent of households in Mehsana had to borrow money or take a loan.

Knowledge about how to access benefits was poor (only 18 per cent of clients understood the process in Mehsana). Lack of complete knowledge of how to access benefits was mentioned during in-depth interviews and in focus group discussions (discussed below). ICICI Lombard suspects that it may be the main reason for poor utilization of the OP benefits.

In-depth interviews and focus group discussions

Qualitative data were collected through in-depth interviews of key stakeholders and focus group discussions (FGD) with eligible clients to generate insight into the need for and perceptions of OP insurance.

All the participants in the FGDs were very positive about the expansion of the RSBY scheme to cover OP treatment along with IP treatment. In order to increase use of the scheme, the participants suggested:

• Detailed information about the scheme should be provided, preferably through Gramsabha (group meetings) separately for males and females (this was suggested by the female participants of Mehsana) and through public announcements
• Proper health-care facilities with qualified doctors in nearby health centres are important. The distance to facilities was brought up in particular in Mehsana
• The medicines prescribed by the doctors should be freely available in the health-care centres

Research into low IP claims

Since the start of the policy in Mehsana in November 2011, until February 2012, around 3,500 claims were submitted for IP benefits, compared to only 650 for OP benefits, contrary to the evidence that shows that OP services are accessed much more frequently than are IP services. Experience in the field suggested that this unexpected result was due to low awareness of OP benefits. IP was launched earlier, so there had been more time to build awareness and experience of IP benefits. It is also possible that fewer OP claims were recorded by public OP clinics than actual services delivered, since public clinics already offer free (cashless) OP services to beneficiaries, and may not therefore have recorded encounters on the RSBY system.

To understand why OP benefits were being underutilized a randomly chosen group of 50 clients were interviewed. Although the sample was limited, it yielded some interesting results. Around 87 per cent of those interviewed were aware of the IP benefits, compared to just 13 per cent who were aware of the OP benefits. Additionally, almost two thirds of those aware of OP benefits did not realize that medicines were included as part of the benefits offered for OP care. And among those aware of OP benefits, none of them had actually used them. They gave the following reasons:

• 40 per cent did not have any episode of illness requiring OP care
• 60 per cent went to doctors outside of the empanelled network, since they either did not know which doctors were empanelled or preferred to visit non-empanelled providers who might be more convenient or otherwise preferred.

In summary, it appeared that the large majority of clients were unaware of the OP benefits. When the team then explained the OP benefits available to interviewees, they were largely enthusiastic to make use of the OP benefits. This strongly suggests a need for a broad-based expanded awareness campaign on OP benefits.

Additional research, including the end-line findings will follow.

Other pilots

The pilot was also expanded to six other districts:

• Bathinda, Ferozepur and Rupnagar in the state of Punjab
• Rangareddy in the state of Andhra Pradesh
• Serchhip in the state of Mizoram
• Dehradoon in the state of Uttrakhand

You can see a summary of the pilots here, and the lessons learnt in them here. 

Next Actions

As of February 2014, around 220,000 clients in Puri and 78,150 clients in Mehsana have used RSBY OP services under the pilot. There are now plans to scale-up OP benefits as part of RSBY. MoLE will make it mandatory for insurers to include OP benefits in the benefit package as districts bid or re-bid in 2014.

In the meantime, the following actions are planned for additional pilot testing under RSBY:

• The government is considering including diagnostic services such as laboratory tests to complement consultations and prescriptions in the OP cover. This could provide additional financial benefits for health-care providers, as well as enhanced healthcare and reduced out-of-pocket expenditure for clients. This has been proposed to the state governments.
• Further development and testing of the mobile application, and wider deployment, to alleviate constraints to access the technology platform
• Experimentation with different provider payment methodologies such as capitation, or use of a “gate-keeper” function whereby clients must access specialist services with a referral from a primary care provider.