Joint Learning Network for Universal Health Coverage

India: Rajiv Aarogyasri

65 million people

Funding

None
None
None

Population Covered

Below Poverty Line

Service delivery system

Both Public & Non-state
98
244

Institutional structure

Centralized
State Government
State Government, Commercial insurers
State Government
Reform summary: 
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The Aarogyasri scheme was developed to improve social protection for the poor and reduce the financial and emotional consequences of indebtedness due to illness. Aarogyasri is state-financed and targets individuals living below the poverty line in Andhra Pradesh. Beneficiaries have access to numerous modern medical facilities and are navigated through the health care system by Aarogya Mithras, or patient advocates, hired to oversee each in-network hospital.

The Aarogyasri scheme was developed to improve social protection for the poor and reduce the financial and emotional consequences of indebtedness due to illness. Aarogyasri is state-financed and targets individuals living below the poverty line in Andhra Pradesh. Beneficiaries have access to numerous modern medical facilities and are navigated through the health care system by Aarogya Mithras, or patient advocates, hired to oversee each in-network hospital.

The Aarogyasri scheme was developed to improve social protection for the poor and reduce the financial and emotional consequences of indebtedness due to illness. Impetus for Reform: In 2004, the Congress Party came to power in Andhra Pradesh. Dr. Rajashekar Reddy was the Chief Minister and a medical doctor by training. Dr. Reddy came to power with health as one of the three main priorities in his party’s manifesto. Chief Minister Reddy turned to PK Agarwal, then Principle Secretary at 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 Principle Secretary was asked to spend three days listening to the problems of the poor who were coming to government facilities with requests related to health. The outcome was the Aarogyasri Community Health Insurance Scheme.

Objective of scheme: According to PK Agarwal, the objective of the scheme is “social protection, addressing healthcare problems that cause indebtedness and often bring people into devastating financial and physical distress.” Farmer suicides have been common in Andhra Pradesh and the main reason is financial stress often caused by hospital expenditures and associated indebtedness.

Development: 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.

Scheme Summary: Aarogyasri was introduced after a pilot study period and then was slowly implemented in a phased manner, with additional regions of the state covered in each phase. The state government finances 100% of the premiums for state residents who fall below the poverty level. Catastrophic (inpatient) care is provided primarily by private providers (the network does include some public facilities, but the majority of the network providers remain private facilities), and administrative services are provided by a private insurer. Aarogyasri beneficiaries have access to facilities they would not otherwise be able to utilize due to the financial barriers to access. For example, Apollo Hospitals are one of the leading high‐end hospital chains in India. The Apollo Hospital in Hyderabad is a member of the Aarogyasri network and provides care to hundreds of Aarogyasri members each month. In fact, one third of the hospital’s volumes are comprised of below‐poverty‐line Aarogyasri members. So, even though network eligibility requirements are somewhat stringent, the benefits of being a network provider are many. Additional patient volumes (and thus revenues) alone are an attractive enough proposition for both public and private hospitals to improve their operating procedures to align with the eligibility requirements for Aarogyasri.

Key Success Factors: There have been several attempts to introduce similar schemes in other states but Andhra Pradesh has been one of the only states to successfully roll out the scheme. Some key innovations and success factors in launching Aarogyasri were:

  • Not collecting a premium – Collecting a premium would have required tremendous administrative costs (likely outweighing the amount of the premium itself); moreover, the cost of the premium would have prevented many of the poorest from enrolling even if the amount were nominal
  • A collaborative private sector – The private sector in Andhra Pradesh agreed to low reimbursement rates for services provided and agreed to conduct compulsory health camps where thousands of rural people would be screened every day
  • “White Cards” – White Cards, or ration cards, were an existing targeting mechanism utilized by the state to identify the poorest. Since the poorest already carried these cards, there was a mechanism already in place that would help Aarogyasri identify eligible families.
  • The use of technology – The technology utilized by Aarogyasri facilitates end-to-end cashless claims processing, from pre-authorization to provider payment; the technology also facilitates a robust monitoring mechanism
  • Health camps – All empaneled hospitals are required to conduct free health camps in rural areas to screen patients, identify undetected illness, and refer patients to in-network hospitals as needed
  • Community representation – Aarogya Mithras are patient advocates employed by Aarogyasri to oversee each in‐network hospital and serve as representatives of the insured to help them navigate the system of care, receive quality care, prevent fraud, and conduct reviews and evaluations of service provision

The priorities of this scheme have been criticized in India and internationally. The main criticism has been about the benefits package that focuses on alleviating the financial distress associated with catastrophic illness and ignores health problems faced by the majority of the poor such as fever and gastrointestinal disorders. The two main reasons for the chosen focus of Aarogyasri are: (1) the purpose of addressing indebtedness due to health care costs; and (2) the challenges with monitoring treatment of ailments without hospitalization.

While Aarogyasri has yet to be fully evaluated, some results to date include:

  • The scheme currently covers 85% of below-the-poverty line households in the state—this totals 65 million people.
  • The scheme started with 330 procedures covered and has been gradually extended to 942 procedures.
  • The majority of beneficiaries utilizing the scheme are illiterate and have a rural address.
  • Cardiac, cancer, and neurological interventions make up 65% of all treatments administered by the scheme.
  • Anecdotal evidence suggests that the scheme has had an impact on reducing the financial barriers to accessing care and utilization of services has increased.
Funding: 
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Aarogyasri is funded through general tax revenues generated by the state of Andhra Pradesh and the cost of premiums is fully subsidized for each beneficiary.

Aarogyasri is funded through general tax revenues generated by the state of Andhra Pradesh and the cost of premiums is fully subsidized for each beneficiary.

The state chose to fully cover the cost of insurance premiums 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 be deterred from enrolling even if the premium to be paid out-of-pocket was nominal.

Population covered: 
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Aarogyasri covers all below-the-poverty-line residents of Andrah Pradesh. The scheme has been implemented in all districts in the state. Upon enrollment, beneficiary households receive a Rajiv Aarogyasri Bhima Health Card, a mechanism through which patients are identified and medical records are kept.

Aarogyasri covers all below-the-poverty-line residents of Andrah Pradesh. The scheme has been implemented in all districts in the state. Upon enrollment, beneficiary households receive a Rajiv Aarogyasri Bhima Health Card, a mechanism through which patients are identified and medical records are kept. Aarogyasri covers all below-the-poverty-line residents of Andrah Pradesh. The state already had a mechanism for defining, identifying, and enrolling below-the-poverty-line families. Each eligible family is issued a “White Card” (a ration card) to identify them as below-the-poverty line. Aarogyasri uses the “White Card” as a targeting mechanism for its scheme.

Families in the state who already have “White Cards” are provided with Rajiv Aarogyasri Bhima Health Cards. Everyone in a household can 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. It is presented by beneficiaries when they arrive at a health facility to identify them. The card is also used to store patient visit records and transmit utilization 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 are 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 help to guide beneficiaries through the network of care and inform them about their insurance benefits.

In addition to contacts with Aarogya Mithras, beneficiaries can visit health screening camps that are set up by network providers in rural areas. Under the scheme, all network hospitals are required to undertake a specified number of village health camps in order to maintain their network status. Beneficiaries and potential beneficiaries attend the health camps to be screened for diseases and are provided with preventive care. Those that can be treated at the camp are treated; those that require further treatment are referred to network hospitals where their ailment will be treated free of cost under their Aarogyasri benefits. As of November 2009, there have been more than 15,000 camps and nearly 2.5 million people have been screened.

Benefits package: 
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The Aarogyasri benefits package includes 942 surgical procedures and 144 medical diseases. The system is entirely cashless and there is no deductible or co-payment for seeking care.

The Aarogyasri benefits package includes 942 surgical procedures and 144 medical diseases. The system is entirely cashless and there is no deductible or co-payment for seeking care.

30 groups of doctors from the Government and corporate hospital sectors were consulted to develop the benefits package for Aarogyasri. Through a series of these consultations, Aarogyasri benefits have been agreed upon to include 389 surgical procedures and 144 medical diseases. A list of all benefits and associated reimbursement to hospitals can be found on the Aarogyasri web site.

There is no deductible or co-payment for seeking care, and because the system is entirely cashless patients are admitted, treated, and discharged without exchanging any money. Immediate pre- and post-operative expenditures are included in package rates to minimize the other financial expenses to the patient.

Service delivery system: 
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The Aarogyasri network includes 244 private and 98 public hospitals, all of which must meet specific structural, procedural and pricing requirements. Individuals seeking care approach their nearest in-network health facility, where Aarogya Mithras guide them through the system. If a patient needs further care, they will be given a referral card to the appropriate network hospital(s). Beneficiaries may also seek care and receive referrals at health camps held by in-network hospitals.

The Aarogyasri network includes 244 private and 98 public hospitals, all of which must meet specific structural, procedural and pricing requirements. Individuals seeking care approach their nearest in-network health facility, where Aarogya Mithras guide them through the system. If a patient needs further care, they will be given a referral card to the appropriate network hospital(s). Beneficiaries may also seek care and receive referrals at health camps held by in-network hospitals.

As of January 2010, there were a total of 342 hospitals in the network. The principal reason Aarogyasri Trust decided to work with private providers was the lack of resources in the public system. The government has been unable to attract the needed specialists to public facilities, while the private sector has rapidly expanded high quality healthcare services.

A hospital or nursing home in Andhra Pradesh is eligible to be a part of the Aarogyasri network of care, established for indoor medical care and treatment of disease and injuries. The hospital should comply with the following minimum criteria:

  • Have at least 50 inpatient medical beds
  • Be fully equipped and engaged in providing in-patient medical and surgical facilities along with diagnostic facilities (e.g., pathological tests and X-rays, E.C.G. etc.) for the care and treatment of injured or sick persons
  • Have at least one operation theater of its own where surgical operations are carried out
  • Have fully qualified nursing staff under its employment 24 hours a day
  • Have fully qualified specialist doctor(s) on premises 24 hours a day
  • Maintain complete records as required by Aarogyasri on a daily basis and able to provide necessary insured patients’ records to the insurer or his representative as and when required
  • Have sufficient experience in the specific identified field
  • Agree to deliver the package of services at the rate specified for each identified intervention/surgery as approved by the Trust. The package includes consultation, medicine, diagnostics, implants, food, cost of transportation, and hospital charges, etc. The package price should cover the entire cost of treatment of the patient from date of reporting to discharge from hospital, as well as 10 days after discharge and any complications while in hospital, making the transaction truly cashless to the patient.
  • Include the services of a Radiation Oncologist and Medical Oncologist if it desires to be empaneled for Chemo- and Radio-therapies
  • Include services of trained ENT Surgeon(s) and Auditory Verbal Therapist(s) if it desires to be empanelled for Cochlear Implant Surgery

All hospitals that qualify to be in-network must sign a memorandum of understanding with the insurance company. This Memorandum is subject to the approval of the Trust. A provision is made in the Memorandum for non-compliance/default; all such matters are looked into by the Trust.

From the perspective of beneficiaries, the path to seeking care is made as simple as possible, as indicated in Figure 1.

  • Beneficiaries approach nearby health facility (either public health clinic or area hospital) where an Aarogya Mithra is placed to help beneficiary navigate the health system. Alternatively, the beneficiary can utilize the Aarogyasri 24x7 customer care toll free number (by dialing 1800-474-7788), state’s emergency medical service (by dialing 108), or telemedicine service (by dialing 104) to reach a network hospital. Follow the links for more information on the state’s emergency medical and telemedicine services.
  • Beneficiary is seen and diagnosed by a doctor with the support of an Aarogya Mithra to ensure proper care is delivered.
  • If beneficiary needs to seek care elsewhere, he/she will be given a referral card to the appropriate network hospital(s)—the beneficiary can select which network hospital they would like to visit for the next step of care.
  • Beneficiaries may also attend the Health Camps being conducted by a network hospital in a village and can get the referral card based on the diagnosis done at the Health Camp.

Modalities of receiving care through Aarogyasri

Institutional structures: 
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Aarogyasri is managed by the Aarogyasri Healthcare Trust, a body that is responsible for overseeing the entire insurance program, including certain administrative functions such as setting benefits packages and pricing, managing contracts with insurer(s) and in-network providers, approving claims and monitoring of the scheme.

Aarogyasri is managed by the Aarogyasri Healthcare Trust, a body that is responsible for overseeing the entire insurance program, including certain administrative functions such as setting benefits packages and pricing, managing contracts with insurer(s) and in-network providers, approving claims and monitoring of the scheme.

The administrative structure of Aarogyasri is comprised of four main organizations:

  • Aarogyasri Healthcare Trust: The Trust is responsible for oversight of the entire insurance program as well as some important administrative functions such as setting benefits and pricing, managing contracts with insurer(s) and in-network providers, approving claims, and monitoring.
  • Insurer: The insurer is selected based on a competitive bidding process to bear risk and manage all back-end insurance administration, including claims processing, reimbursements to providers, oversight of hospitals. The Insurer is also responsible for holding health camps in villages to screen, diagnose, treat, and make beneficiaries aware of any health problems they might have; health camps are also used to enroll eligible beneficiaries.
  • Network hospitals: Network hospitals provide care to Aarogyasri beneficiaries.
  • Aarogya Mithras: Aarogya Mithras are patient advocates and assist Aarogyasri beneficiaries to navigate through the system and ensure beneficiaries receive quality care. Aarogya Mithras are also responsible for community outreach.

The table below summarizes the roles and responsibilities of all of the organizations involved in operationalizing Aarogyasri:

Aarogyasri TrustInsurerNetwork HospitalsAarogya Mithras
Oversight of schemeX
Financing schemeX
Setting parameters (benefits package, empanelment criteria, etc.)XX
Hardware specifications (e.g, systems, card, etc.)XX
Contract management with InsurerX
Accreditation/Empanelment of providersXX
EnrollmentXXX
Financial management/planningX
Actuarial analysisXX
Setting rate schedules for services/reimbursement rates X
Claims processing and paymentXX
Outreach, Marketing to beneficiariesXXX
Service deliveryX
Developing clinical information system for monitoring/evalX X
Monitoring utilization and other patient informationXX
Customer serviceXXX
Provider payment mechanisms: 
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Providers are paid on a by-intervention basis, where a specified rate is set by Aarogyasri Trust in consultation with medical experts. For each approved procedure, the payment covers the entire cost of treatment, from the date of admission to discharge, as well as a maximum of 10 days after the discharge and any complications while in the hospital. The package rate includes consultation, medicine, diagnostics, implants, food, cost of transportation, hospital charges, and post-operative hospital stay.

Providers are paid on a by-intervention basis, where a specified rate is set by Aarogyasri Trust in consultation with medical experts. For each approved procedure, the payment covers the entire cost of treatment, from the date of admission to discharge, as well as a maximum of 10 days after the discharge and any complications while in the hospital. The package rate includes consultation, medicine, diagnostics, implants, food, cost of transportation, hospital charges, and post-operative hospital stay.

A comprehensive list of benefits and associated payment pricing can be found on the Aarogyasri web site.

Seeking care is truly cashless for the patient. On the back-end, the provider must submit a pre-authorization to the insurance company (Aarogyasri I procedures) or to Aarogyasri Healthcare Trust (for Aarogyasri II procedures). The insurance company/Trust appoints medical officers who work on pre-authorizations. After pre-authorization and treatment, the insurance company or Trust (depending on which Procedure the beneficiary was enrolled in) will settle claims from hospitals within seven days of receipt of claim, discharge summary, and a satisfaction letter from the patient.

To prevent fraudulent claims, the claim settlement history of each hospital is scrutinized and reviewed by the Trust at regular intervals. In addition, the insurance company recruits specialized doctors, known as vigilance officers, for regular inspection of hospitals. These specialists also attend to complaints from beneficiaries directly or through Arogya Mithras for any deficiency in services reported. The specialists also to ensure proper care and counseling for the patient at network hospitals by coordinating with Aarogya Mithras and hospital authorities.

Monitoring and evaluation: 
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Monitoring of Aarogyasri operations is the responsibility of the insurer and the Aarogyasri Trust, and regular review meetings are held to discuss progress. In-network providers are required to share patient histories, including symptoms and treatment, with the Trust.

Monitoring of Aarogyasri operations is the responsibility of the insurer and the Aarogyasri Trust, and regular review meetings are held to discuss progress. In-network providers are required to share patient histories, including symptoms and treatment, with the Trust.

The insurer is mandated to coordinate and ensure proper implementation of the scheme up to the satisfaction of the Trust, reviewing progress on a daily basis. They are also responsible for implementing suggestions of the Trust for effectively running the scheme.

The most important aspect for the monitoring of the services provided is the technology platform. All hospitals are required to share patient history and detailed information about symptoms and test results for each patient. The dedicated Aarogyasri project office of the insurance company is required to be established at a location that is convenient for the facilitation of coordination between the Trust and the insurer’s administrative offices. The Aarogyasri project office must report to the CEO of the Trust on a daily basis. A dedicated MIS department within the project office is responsible for working with network hospitals and Aarogya Mithras to collect and report data on a real-time basis. This department also has a sub-unit with operators who collect hourly information from the Aarogya Mithras, regional co-coordinators, district coordinators, etc. The most important aspect for the monitoring of the services provided is the technology platform. The insurer’s IT department is also responsible for ensuring that the Aarogyasri website is updated and functional. The website contains all documents relevant to e-pre-authorization, claim settlement, and reimbursement. Through the website, real-time follow-up is maintained between providers, the insurer, and the Trust. The website captures all data collected by the system on a 24-hour basis.

The Trust holds regular review meetings with the insurer and district offices to review progress. Meetings are held once a week. The agenda and issues to be discussed are decided mutually upon in advance. The minutes of the meeting at the district and state level are sent to the Trust.

No formal evaluations of the Aarogyasri program have yet been published.

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