Interview with A. Babu, CEO of Arogyasri Trust, Hyderabad
Duration: 01:00:14; Aspect Ratio: 1.778:1; Hue: 25.272; Saturation: 0.086; Lightness: 0.482; Volume: 0.321; Cuts per Minute: 0.066; Words per Minute: 122.174
Over the past three years we have conducted numerous field visits in seven Indian states.These visits include numerous video-conversations, some short and others very long, with a diverse number of those who were involved with this entire process of participating in the emergence of a digital ecosystem of governance. These are interviews with people being enrolled into the Aadhaar programme, with district-level Panchayat and other officials, with numerous State government bureaucrats, with private enrollment representatives, representatives of various governmental services, with operators and other members of this digital workforce. Conversations are often long, spontaneous and deliberately unstructured: and the focus is mainly on a vérité style using amateur video.
Some key issues that we shortlisted for detailed inquiry were issues of migrants, both domestic and across international borders, homelessness in cities, and the financially excluded. Each of these areas was discussed in considerable detail at major public consultations held in Delhi, Kolkata, Hyderabad and Bangalore, in partnership with the CSDS, the Mahanirban Calcutta Research Group, and the Urban Research and Policy Programme Initiative of the National Institute of Advanced Studies, Bangalore. All videos of all presentations made at these events are also available here.
CSCS also has an extensive text archives of material on the field as a whole, available on http://eprints.cscsarchives.org
Interview with the CEO of Arogyasri Trust, Mr. A. Babu. The CEO explains in considerable detail the way the health care programme of the Andhra Pradesh state works, and the kind of data they are able to generate with the digitization of the entire programme. The extent of data available on each beneficiary leads to major questions about individual privacy.
The Identity project emerged as a result of our dissatisfaction at the nature of the debate that was emerging on the area of digital governance in India.
INTERVIEWER:This is a research study.
Speaker: What do you plan to do? You plan to take it in detail, further, or or is this a kind of familiarization stage?
INTERVIEWER: This is a familiarization phase. We are planning to cover eight states across the country, and we have made some initial visits. We visited Jharkhand, we are now here, we will go to Karnataka, Tamil Nadu, Himachal, but the most interesting data we are finding is here.
Speaker: The reason is, we have been working on this much before the UID process. Though not 100% perfect, in the sense that, if you take the biometrics and other things, and iris and other thing
Speaker: In 2005-06, a massive exercise was done, for one and a half years, where what we called DPL Centres, Digital Photo Lamination Centres, and these were established in almost all villages - I knew this only from out outside, when I gave the cards in one particular sub-division, in Madanapalle district, which was one of the largest revenue divisions with seven taluks.
Speaker: What we did was a socio-economic survey before establishing these Centres, and all the Departments were engaged, and parameters were fixed, like how to define a person above and below poverty line. We didn't go by the Planning Commission parameters which are now under a lot of criticism: the other day the Supreme Court also questioned them.
We went for a different parameter, like whether the person owns a motor-cycle, a pucca house, so many parameters were put.
And then an income parameter was put there, of Rs 25,000, in rural areas and 35,000 in urban areas annual income - in 2008 this was increased to Rs 65,000 and 75,000 to bring more people under the umbrella of coverage of various schemes.
From 2004, there is a saturation approach. Before that there was a targeted approach in this state - you selectively fixed a certain percentage for this section of people - but from 2004 there was a saturation approach in four or five sectors, pensions, housing, health, education, wherein whoever doesn't have these things in a village, let us give them - that was the idea.
To undertake that kind of exercise, we would require a massive database - you know that, and that is why this project was initiated: let us go for an identification mechanism. So a socio-economic survey was done, the surtvey data was collected, and we gave dates to the family members in the villages, to come to this Centre, so this database will be there, which is already fed, their photos are taken, their iris biometrics are taken, and it was used.
The only mistake done at that time was, the iris biometric was not used for real-time basis for cross-checking. When you take a biometric today, if it is getting your centralized data system, and tomorrow somebody else is trying to get the same thing, there can be a de-duplication, and that was not done
It is now being done in Aadhaar, I think it is being done in Bangalore as of now, and it gets de-duplicated there, and then only they issue the number which comes by Speed Post or Registered Post. This exercise was done then and 2.3 crore families were given these cards. Out of them, around 20 million families were given white cards, and around 30 lakh people were given pink cards, that means 80% of the population was considered BPL, whereas even the Planning Commission as per the Tendulkar Committee stays at 29.9%. So the idea was saturation.
Let us cover the middle class also. For example, take our scheme. There were a lot of studies which proved that people were falling from the middle-class to the Below Poverty Line, because of escalating welfare costs. So the idea of saturation was done, the cards were done, and then we started all these schemes - housing, pensions, scholarship, which had a lot of financial implications, but were carried forward, one way or the other. But this database was limited, I would say. Inferences were there. But still this database prevented a lot... And in our scheme, particularly, there was a lot of control we could have done... We have the numbers of people we are going to cover in this scheme, so so, we are not going to allow people from say Tamil Nadu or Orissa or Kerala or some others coming. Because two lakh rupees coverage we are giving, in a year for a family, meant people were ready tocome even on Kingfisher Airlines to Hyderabad, to take treatment and go. But this prevented that: this identification mechanism.
And that has also helped us in controlling the prices: at $ 10 per family we are giving a premium of $ 4,200, for a family for a year. That means around Rs 460 or 470 average premium we are paying for a family, we are getting a coverage of Rs 2 lakhs which is one of the cheapest... You would have studied about the Rashtyiya Swasthya Bima Yojana (RSBY) where they are going with the smart card. There the premium is around Rs 700 and the coverage they are giving is Rs 30,000, whereas we are giving Rs 2 lakhs.
The reasons are many, control mechanism: one is this card - I'll just get into the online system for a moment - Before that, these aspects have been explained, I think, I'll just run through this - if you have any doubt then you can ask me.
So this was the situation before the scheme - 75% of the people either were borrowing or selling their assets
for health care costs, and in 2004, as researchers you will be knowing, in 2004, farmers' suicides reached a peak, and there was a Commission which went into the study of them, the Jayati Ghosh Commission, you would have read that Commission report also. It is interesting, please read that report. She cited that the second most important reason for suicides was health care costs. People were mortgaging their assets and falling into debt traps.
At the same time we had a Chief Minister, coincidentally, who was a Doctor by qualification- Dr YSR - and people started pouncing on him, 300 or 400 people would come to him every day for health care assistance alone. He used to collect their requests, their bills, the test reports and other things, and every night he used to sit and sanction some amount, say 30% or 40% of what was needed. That went on for almost three or four years in which 1.25 lakh people were givien 450 crores as assistance from Chief Minister's Relief Fund (CMRF) for health alone.
Then he told us, this is not the way that we have to move forward. The reasons are that you are only touching upon a percentage; you are not giving full coverage. Second, only people who are approaching him are getting support, so it is not saturation. The third thing is all the moral hazards, there is no transaction system, no check to see if the procedure is being done or not. So he told us to bring a scheme which covers 80-82% of the population, through this card. Three things he told us: saturation, cashless treatment, quality of treatment.
Then he gave us a challenge to do this as a scheme. So many bureaucrats studied this scheme for one to one and a half years, how to go about it. We studied other states' schemes, other countries' schemes, and we did not find any success models anywhere, let me be clear: health financing models even in developed countries is not a success. One month back you would have read what happened in the USA, mediclaim, in two states there was 265 million US dollars of fraud with phantom clinics, phantom doctors, phantom treatment, phantom patients: one patient was shown going to hospital 4000 times. And claims were made for all those. With 265 million dollars I could have run three Arogyasris. Only fraud money.
When we looked all around, we were seeing... If we purely go by insurance, we found failures in Assam, in Maharashtra, and so we proposed this model. This was accepted in 2007. The Trust was formed as a regulator, planner and implementer, and insurance companies would be selected continuously on a year-to-year basis and a phase-to-phase basis keeping control on prices and other things
A network of hospitals, service providers both from government and private, then we wanted to be very inclusive, the Arogyamitra concept, health camps. Then the entire thing was integrated thorugh a technology solution that was developed and maintained in-house.
This is the only scheme which goes to the people, screens them and takes them. When we are covering this massive number of people, especially rural, we have to keep one thing in mind. People are suffering, but they don't know what they are suffering from. So we have to go to them. We cannot wait in the hospitals for them to come. One classic example: we find that every year there are around 1,20,000 fresh cancer cases coming in this state.
And 70% are in the rural areas, which is contradictory to the normal thinking that cancer is more urban in nature. A further 70% of this are women, in rural areas, suffering from cervical cancer, breast cancer and other things. And many of them suffer without knowing that this is cancer.
And you know, early detection is the cure in cancer treatment. So if we wait in the hospital they will come only at the end-stages, and then you can only have a palliative approach.
We have to go to them, screen them, massive screening - how to do that? This is our methodology. So, I can show you...
Then we went for a careful selection of procedure. This is a card, which we give. I can show you the online system. Then we gave the patient an option. See, you are going for such a massive scheme, where 70 million people are covered, we have 350 or 375 hospitals, we have to distribute the load, and at the same time we have to give a choice of selection of institution to the patient, unlike the NHS system you are given a hospital, and have to wait till your time comes
Now here we wanted to give a choice, then only competition will be there, the choice can be either Government or private: the Government (hospitals) also have to attract the patients. You cannot sit and say, we are Government, come here, you have to give the facilities, the reception. So we have to have a pool, where the centralized database is there. We should act as a centralized reception centre.
You see a patient is calling from a village to our call centre, we should be able to give him an informed choice. Look, near your place so many hospitals are there, so many specialities, so many beds, you can go on so-and-so day. Or if it is an emergency you can go now itself.
That choice we are giving through all these mechanisms. And you can see 45% of them are coming through these health camps, who would otherwise not have come to hospitals. And today I can very firmly and strongly say that that 60% of the people whom we have treated in the last four years would never have undergone treatment but for this scheme.
40% would have somehow adjusted, they would have begged, borrowed or stolen, but 60% would never have come. That is what our studies have proved.
And then the implementation mechanism. Unique nature. Looks very complex but the complexity is taken over by us, and the solution - for a man out there, it is just this card, flash this card, finished.
The referral system you are seeing, the green one, he comes to the hospital, his preliminary verification, the out-patient, this is done, the complete database is brought to us. Verification is done at our level, at two levels, at the time of pre-authorization and at the time of claim, the procedure is done, after the pre-authorization is given, the complete data (comes) to us, the patient gets discharged, and only on the 11th day of discharge a claim can be raised, and on the day of discharge we do something unique - a social auditing tool.
On the day of discharge, a letter gets printed, like this, at our Centre. Now this letter is in the name of the Chief Minister, with a feedback letter. You know, the Reader's Digest concept, where the postage we pay. So sometimes when the patient reaches the house, after getting discharged, this letter will be there.
We are asking for the feedback. And within these ten days we get a feedback, if anything negative is there. And this is put into a claim processing system.
And if anything negative is there, we don't pay the claim. So this is acting as a very important tool to get the feedback.
And then it is outcome-based. The claim processing is outcome-based. What is the outcome of the treatment? And then only the payment is done. The complete thing is done, including the follow-up. And at the bottom you are seeing the data: what kind of data is available.
We have also put in there a service intelligence tool - you may have heard about a business-intelligence tool like SAS, SPSS< IBN+M and other things - we have converted the SAS into a semi-single (unclear) tool, I can show you online, and this tool is helping us to identify the outliers, the abnormal behaviours, for operational purposes. It is also helping us do research analysis.
At the top are the stakeholders. And the manpower details. The various department works, including (unclear), field operations, claims, all these things. We have around 4,929 people working for this scheme, in various departments - all these are linked through this online system. You would have been told about the responsibilities of the hospitals, what they do. One camp in a week, (unclear) reception, free food, they have to give a coordinator.
And we also do some targeted approaches in camps. Like for example, for two-three months we concentrate only on tribal areas. So far we have done around more than 25,000.
And our call centres - we have so far attended to around 43 lakh calls. And the training programmes are very crucial, because this is a new thing. You need a lot of change management, patient management in the hospital, administration in the hospital.
Lot of new things have to be done by the doctors. These kind of online systems have failed even in developed countries like the UK and Germany. They have developed a lot of health IT. They created many things but it was not used. Because they dumped everything on the doctors. In our system a patient undergoes a work flow which is handled by 18 people. The 18 people include, the Arogyamitra in the village till the chief minister of the state.
We have only given clinical parameters to the treating doctors. He has to sit in front of the computer only for a short time. He has to be with the patients, he shouldn’t just sit in front of the computer. So we have sub-divided the work. These 18 people include the Arogyamitra, the paramedics in the hospitals, nursing staff, lab technicians,doctors and treating doctors. Then from our side the pre-organising doctors, the executives and the claim doctors.
At the same time we have ensured that there is data security. You know it is patient-related data. We cannot open it up to 200 people. Only authorised doctors can look at it. We have very clearly separated that aspect. It is one of the reasons developed countries are very stringent with the security. They think of too much security but nothing is implemented. If you carefully split it up where the medical data is seen only by the doctors and the socio-economic data which can be seen by others. Hand holding data is there where you can trace and follow up with the patient. This training programme has helped us to spread this message. 9500 people have been trained.
This is our module. We started with 3 modules of registration, pre-organisation and claims. Now it is running with around 25 modules including all solutions. Without this module it would have been... If you cut IT from the scheme if fails the same day. Because it runs 24 hours. Concurrent usage is around 2000. And I can show you the web-statistics of a single day. The entire office automation is done across the project office of the insurer and the trust. Again everything is online; you can see no files here.
Here the office systems are also on an online platform called the E-Office. You can see the central node. Very crucial data. 65% of the cases who are treated are below 45 years of age. The productivity of the scheme... Normally you take insurers think that the older you are, you will have more problems. It is not true either In India or anywhere in the world. The diseases are so multifarious that it is spreading across. If you take 55 years of age the percentage will be around 78%. So 78% of the people are below 55 years. So the productivity of the scheme, the usage of the scheme is highlighted.
The share now is 20% is done by government hospitals and 80% is done by private hospitals. When we started it was 6% (government) and 94% (private). As usual there is no inertia for the government system to react. The same packages we are paying the government hospitals. If I am paying Rs.95, 000 for a by-pass surgery to Apollo I will pay the same amount a government hospital. Now there is sharing in government hospitals. 65% goes to the treatment and hospital development and infrastructure etc. 35% goes to the team from the surgeon to the treating doctor till the ward boy.
As an incentive, in addition to their salary. It is one of the bold decisions that the government took. I think in Karnataka also there is a small scheme called the Vajpayee Arogyasri which they have started. In fact they copied our name, concept but they did not copy the features. So there are a lot of issues there. Even there they are not paying the government hospitals. And they do not have any incentive mechanisms.
I was told that they are going to start. This incentive mechanism is making the government doctors work. At least some and not all because it takes some time. Many of them are having traditional habits of going to private institutions and treating. It takes lot of time to pull them back. But in at least in 25-30 hospitals we are seeing that people are staying back and doing more number of cases in government hospitals. Operation theatres are working even on Sundays.
Some doctors are earning 2-3 lakhs every month in addition to their salaries, as an incentive. That is also helping in bringing up the efficiency. The growth of the scheme every month. It started with a few districts and few procedures. Now all districts and around 9,900 procedures. Average cost is coming down because of additional procedures and control mechanisms. And the premium factors per number of procedures are also coming down. So we are having a control on the prices with less and less increase in the outlay. We can cover more and more procedures. That means that we can now move towards the universalization of healthcare. Tomorrow I can even cover outpatient care with this system.
I can cover all the deliveries, which is not being covered now. Normal deliveries and only the C-section are not being covered now. But in the future I can cover them also. About 12 lakh deliveries, maybe at the cost of 400 crores. That is what we estimate. The government of India is spending a lot of money through the NRHM. The success rate is low, as you know. It has a potential for growth. We have a scheme expansion policy which is a kind of a hybrid model where the disease load analysis is done.
Speaker 2: As sir explained, when the scheme began went by the CM Relief (Fund) data and the general performances in government hospitals. The statistical data related to these surgeries and we studied the disease rate. Based on that we took the expert opinion on what should be the package for the disease coverage for that. And as I said we started with 163 procedures and we expanded it to 339 procedures in 6 systems. Subsequently, a further study was done. Initally we concentrated on tertiary care. The analysis has revealed that even at the secondary level in government hospitals or existing health centres are not able to meet the full demand of the public.
So based on that another 600 procedures were identified. The same committee that I mentioned earlier. The doctors sitting together they identified the diseases and out of that we identified those that are which are not freely available in government centres and also which have a lot of cost inputs. Coming into that particular criteria that we laid down and we identified another 600 procedures. The total package was extended to 942. Now it is 938 because 4 procedures were taken out for redundancy. So basically it was 938 procedures. Further, as you have seen, when we started the programme on insurance mode but when we identified another 600 procedures it was in the middle if the policy.
The disease node was not really known by that time, and we did not really know what is the premium code for those things. So to overcome the problem the trust started it as self funding scheme. Funded from the CM’s Relief Fund. We started implementing it on our own under the same package model. Everything is the same. The same cashless treatment for the patient for these identified procedures. The front of the scheme was Arogyamitras and everything was utilised from the existing insurance companies. The front end was utilised and this was done. It was a hybrid model.
One was the insurance and the other was the trust implemented scheme. But gradually as the scheme... the cost of the pre-existing load came down. We shifted them to the insurance model. Because the premium was coming down and with the same premium or marginal hike we were able to shift all the procedures to the insurance model.
Speaker1: It is like this, what he is saying is that if we are going in for more coverage now. Initially for one or two years. We can run it ourselves and create a database of the load and then project it out so that we have control. Normally, what we do is call all the insurers. We give the data, we tell them that this is the data from the past one or two years. These are the ups and downs procedures wise. Now we wisely got it done. Because of that we are getting the proper quote. And if someone over quotes even by bidding. Even if the guy quoting the lowest has high rates we can say that it is too much. There is a control in that. That is helping us.
And some of this data has also helped in going for additional PPP models. See when we ran this scheme. For example in one sector we found that the lack of infrastructure even in private hospitals was haemodialysis. Soo many people were coming. We have very few machines.. In government nothing was there and in private hospitals it was limited. So government thought that we should give coverage in this way let us go for the PPP model.
Let us invite some partners with a bidding process. Let us give this space in our government hospitals for them and build up everything. And pay them on a case to case basis from the scheme. The result is somewhat like this- 111 haemodialysis machines where put in 11 hospitals. This is a government hospital. Hardly will people believe that this is a government hospital. This is the Guntur centre. This is Kakinada.
The demand was so huge that we are expanding into 6 more centres with 55 machines. All the haemodialysis is done at half the market rate. We pay them, the partner gets a share and the hospital gets a share. All this that you see here has been put in by the private partners. Not even one rupee is paid by the government. They get the share of the payments. It is a seven year agreement. After seven years they will hand over this model. So, full treatment, anywhere they can get the treatment because they are covered under the scheme. Give the facilities with in the government hospitals. Anyhow the spaces were unutilised within government hospitals.
Similarly, because of the success of this model we are now planning to do it for trauma care and cancer care. Similar PPP models. For example in the government sector we have only on cancer institute for the entire state where threre are facilities. It was to spread out because the load is so tremendous .We are giving that proposal. Many states have studies this scheme. As I told you the WHO thing has also happened. Did you tell them about that?
The World Health Organisation has appreciated this scheme. Especially the Department of Health System Financing. They are taking up a 1.5 year study starting from May this year. What they are doing is that they are conducting a study based on the priority setting, equity and resource allocation. So they are going to prepare a checklist on how this scheme emerged. They are going to publish that checklist for the other counties. They are studying two countries, one is India and the other is Namibia. And in India they are studying the scheme in AP.
We also do social auditing of the various schemes. We did it twice. Once with Rachabanda and the other is Praja Patham where in gram sabhas were conducted in every village and peoples representatives and officials go and analyse various government schemes. One of the schemes that was verified was our scheme. And out of all schemes ours was the best. In terms of appreciation and acceptance. Where patients treated by us narrated their stories. Which made all the other people to accept this.
Toady you go to any household to any remote place in Andhra even in remote tribal villages. Ask them about Arogyasri they know. And you go to any hamlet in Andhra Pradesh you can find a minimum 10-15 households who have benefitted from the scheme. So that is the spread and to achieve that in 4 years is a tremendous thing. I would say that it is 50% of the systems that we have put in. See in all this there are only 5000 people. But for the systems, I would have had to add 25,000 people.
This is Praja Patham. Critical success factors are these.
Top level leadership- Our chairman is the CM, the chairman of the trust. We had three CM's in the past three years. All the three of them have given equal importance. The founder CM used to have our website on his desktop in this camp office and Secretariat. Every day he used to analyse the data. It was a daily reporting force. That is required for such a massive scheme. In fact 21 states have studied this scheme. Hardly anybody could do it. Primarily one key factor is this.
INTERVIEWER: It is intended as a public private partnership. What is the nature of private participation? There are the hospitals.
Speaker: See it’s the costing. We are getting the procedures done at half the market rate. Otherwise it is not viable. For example, bypass surgeries. If you go to Apollo Hospital as a private person you have to pay a minimum of 2 lakh rupees. The same guy for an Arogyashri beneficiary is doing it for Rs.95, 000. And that too in addition to the treatment he is doing the screening, he is doing the out patienting. He is verifying three patients free of cost and all that. So its win-win situation for all. Normally a private partner looks at profit only. Here it is limited but there is an economy of scale. If you take the major groups like Apollo and Care and others, 55% turnover of the Apollo group is from this scheme.
They have made 8-9 hospitals in Andhra Pradesh. Out of which 6 came because of the scheme. If I go to Karimnagar you can find a 150 bed Apollo Hospital here. 90 % of their patients are Arogyashri patients. Narayana Hrudayalaya, Bangalore they approached out CM three years ago. They said that they are in Bangalore and they operate Volvo Buses to Anantapur, Cudapah and Nellore, take patients there and treat them free of cost please add out hospital to your scheme.
We told them no, if you want to come to our state. The result is a 500 bed hospital of Narayana Hrudayalaya in Hyderabad. 99% of their occupancy is Arogyasri. CMC Vellore, they are coming to Chittor.
With this scheme we have seen 6000 new beds being added. New hospitals are coming up in remote places. When we started the scheme we had hospitals in 4-5 major locations. Today we are seeing it in 76 locations. So I would say the private participation is that they have kept aside their greed part.
INTERVIEWER: You also have partnerships with insurance companies. That is the other set of partners.
Speaker: Where can you get coverage of 2 lakh for Rs 440? You go as a private policy holder take the same package coverage, you will have to shell out Rs.12, 000 a year as premium. Another thing is insurance mechanism in the country has not seen a systematic approach. There is no transaction system at all. I will just give you a bird’s eye view of our data. This is what has happened in the past 24 hours in the scheme.
Normally we do around 21-25 health camps in a day. Yesterday only three took place. There was some festival. In three health camps we screened 536 patients.
Almost all the villages we have touched out of which 4 million people were screened. I have the the database of all these 43 lakh people. What they are suffering from and what is their issues and other things. This is out strength.
We are able to analyse at least our screening. I am not saying that it is an epidemiological data covering the entire population. This is a very good sample. 5% of the population has been screened in your camps.
This data we use for our disease load analysis. In the last 24 hours 5646 people came to the hospitals and registered. Outpatients and inpatients. We gave our approval for 1024 cases in the last 24 hours worth 2.76 crores. Here we can see the server time 3:41pm and our time is the same. This is yesterday’s time. The time is 24 hours.
We have processed 12,770 cases. In a minute we have processed around 17 cases. Here we can seen that in the last minute the cases that have come. 340 i.e. 58th second of the 40th minute after 3.00 pm. In that 40th minute around 17 cases. Across hospitals there are different kinds of things.
I will go to one case, for example. This is the case. We can see the patient on the bed here. The social economic parameter of the case is the 16 digit unique number of the health card, that is there. Here this data, this is the family. This guy is lying down in the hospital. Do you know where this photo came from?
It came from the 80 million databases. That is there in the card database. We are clearly establishing the identity here. If this doesn’t come out that fellow isn’t covered under the scheme.
We analyse this, we verify that the person has come and all his details, his registration details, his previous treatment details are available. His referral route, how he came to the hospital. His admission notes. All that you see in a hospital, the management system.His admission notes, his clinical notes, his vitals. Pre-organisation details that deals with the doctor, treatment plan and other things.
We can see the doctor name his here, his qualification is here, his MCI registration number is there. His telephone numbers are there. We are keeping all these things to fix the responsibility and our doctors will speak to the doctor if there is any doubt while giving the approvals. And all this clinical parameters are there, his package is there. In this case, we have previous case also done.
This patient has undergone two dialysis earlier. Now here we can see the previous history and there EMR's. All his EMR's are available here. EMRs are Electronic Medical Records. All kinds of reports, Doppler films.
Now we also have angiograms like this coming into us. All these things x-rays, angiograms, blood analysis reports, colour Doppler’s everything flows to us online. Doctors look at it on our end.
If it is an angiogram, it is looked by a cardiothoracic surgeon or a cardiologist at our end. We see weather indications are there for his treatment for the patient. If that is established we give our approval. So nobody can cheat us in terms of unindicted procedures or other things.
The technology is helping us in analysing this data. We analyse the data and give approvals and then for example... this case... we give our approvals like this. You can see the approval. Dr.Vijaythirumala Reddy and Dr.Srivani. Two doctors are approving it. The approving remarks are there. This is the case has now come claims and account number is verified.
Operation node is available; post treatment state of the patient is available. Discharge summary is taken from the system including his advice for the future and other things. The post discharge data which has to come to us. In this case, it is a colour Doppler that we require.
Then the billing including the taxing and other things and the claim. The claim processing and his payment and other things. We also has discharge photographs coming to us so that we know that the patient has been discharged along with (unclear) and other things.
Looking at all these things you can see that there is a definite route along which the patient moves. And his claim is paid only after all this takes palace. And claim is paid by electronic transfer. No cash no cheque nothing.
We can see what the hospital is doing. What we are processing the hospital can see. No pick and choose of file. If you give pick and choose option in India there is corruption. Move my file get this much percentage.
It is first in, first out. The money falls into the books of accounts. Our books of accounts are also online on a real-time basis. There are no hardcopies or anything. This helps us to develop the fastest transaction system. The moment now a claim is submitted we pay within 7 days.
Now we are paying within 24 hours also. Because 90% of our claim processing is done at the time of discharge itself. So this quick payment mechanism is helping our hospitals to treat our patients at half the market cost. Where the turnovers are important than the actual profit.
You know you take for example CGHS there are many government schemes. Where the transaction itself is 1.5 year long. And the cost and other things escalate because of that. Today we find a very strange phenomenon. If there is only 1 bed in a hospital and 4 patients go. One is a software professional with private insurance, an Arogyasri patient, a CGHS beneficiary or an ESI beneficiary. If there is only one bed then the hospital chooses the Arogyasri beneficiary.
Because he gets the quickest money from the Arogyasri system. Even private insurance guys sometimes when you get discharged from a hospital also pre-authorization doesn’t come. That is the situation.
This transaction model is helping us and then the complete aspect... this is the service signal tool that I was speaking about.
This helps us in analysing the trends, gives us alerts ,reports and other things. The trend analysis and other things. We also have alerts like this- abnormal behaviours, outliers are outlined. Various kinds of procedures. We also have dashboards and other things. These have an implication on the workflow also. Are they moving properly. What is the trend over period of time.
This tool was conceptualised and customised for this particular scheme by us. All our doctors are utilizing this now for their day to day work. Like that we have separate reporting tools. It is all technology.
I will just show you how the people are working now. We have 700 workstations in 4 locations in Hyderabad. All controlled by access control systems and biometric and nobody can come into our system without these security features. And when the doctors are to come in are also decided. What time they have to come it is all flexible.
This is our Banjara Hills centre. There are live pictures. Here we have 140 workstations. You can see the various section of people working. It includes executives and doctors etc.
This is another location in NIMS i.e. Nizams Institute of Medical Sciences. Here also you can see doctors, call centre people and executives working. Here we have around 50 work stations.
We have another centre in Koti in another part of the city. Here also we can see doctores giving approvals as of now. This is our this particular location where 200 work stations are there. So all these people are controlled by this entire technology.
They have to just come in and their work efficiency is decided by the system. For every person there is a KPI common- Key performance Indicator. Part of their salary is paid on their performance. System calculates their performance and their timings attendance etc. So everybody comes does their work and goes.
To understand the scheme totally it needs at least one month.
INTERVIEWER: The Arogyamitras are direct recruits is it?
Speaker: They are on the rolls of the insurance companies. Their cost in also involved in the premium, the Rs.465. The adminstrative cost of the scheme both for the insurers and us is only 5%. Because of the tools and the mechanisms and the reamning 95% goes to the clients claims.
INTERVIEWER: So 5% of the total reveneue goes towards adminstration.
Speker: What we have realised is that there is no shortcut for adminstrating a health financing scheme than by looking at each patient. You have to look at each patient. That vefircaion is requited. Otherwise people make a mokery of it.
INTERVIEWER: You have such a robust system. Why would you need something like UID/Aadhaar? Where does the Aadhaar fit into all this.
Speaker: Here the government of India has decided on the Aadhaar. We also have to comply. In Aadhaar there are two concepts. KYR and KYR Plus you know that right. KYR is an individual based number. It is not a family based card. Whereas we have a family based approach in our card in our card.
We are going for the KYR Plus. We have given certain additional paramentes at the time of collecting Aadhaar data. The indivudual numbers, individual details are calculated: only 4-5 parameters are there. Where do you stay, name, age and other things. In addition to that we are collecting some 7-8 parameters plus the family linking.
So once Aadhaar system comes in, the family linkage will be established and we can access in much more detailed manner. It is coming with total de-duplication, Aadhaar. Our iris data is not fully de-duplicatable. There are issues because there are no cross checks at the time of the collection of the data. There are certian places where people have taken cards in two places. Though the data is only 70% accruate. With Adhaar we feel that we can make it 100% accurate and now even without a card. Once the Adhaar system is integrated a patient need not even have a card. You come and sit in front of the iris camera at a hospital and that is enough.
INTERVIEWER: Now are people that don't belong to a family quite high in your... additional members.
Speaker: Our family are the people in that particular card. Now what I am talking is about is the biometrics. Family aspects are now clear. But the biometric aspect is not 100% accurate. I think with Aadhaar we may acheive that 100% accuracy.
INTERVIEWER: What are the total number of claims that you meet every year?
Speaker: Every year around 4 lakh people.
INTERVIEWER: Would it be possible for us to get a copy of the powerpoint presentation.
Speaker: I will send it to you by mail. All these aspects are there. All the things are there on our homepage. You can go to our homepage and have a detailed look. I can show you the bed occupancy as of now. It is a very interesting stastic.
INTERVIEWER:What is the constraint you face in running the scheme apart from the financial aspects.
Speaker: As of now 15, 150 people are on the beds. Basically I am running a virtual hospital of 15,150 beds as of now. For a government to put in so many beds, in the government sector. One of these beds, other than the land costs, with all the doctors and other things is a 10-12 lakh investment.
And then the maintainace of it. The main isssue with the governement is the manitainence of it. It is very difficult. We basically getting this out of the scheme so it is a very ( unclear).
Other than the finances, the challenges we are facing is that people are now demanding that everything be covered under the scheme. Pople go to the hospital and they get the coverage based on our procedures. Other cases are there where only out patient consulation is given free of cost. The challange for us is to universalize it in terms of coverage.
INTERVIEWER: Running of the shcheme you don't have any difficulty.
Speaker: I don't because I have to put in some more assitance. It is an everyday development for us. We are working on an agile platform. If you see the production deployed in our system, almost evey fortnight we ... one of our evaluators from Harvard told us that every 15 days there is an imprvement in the scheme. So it is a continous exersice. Thats a challenge. The main challange is to cover all people for everything. Now 82% of the population is covered. We have demands for the remaning 18% saying we will pay please cover us also.
So now the government has decided to extend the cover to govenment employees and their families. Which is roughly 40 lakh people. On a co-payment basis. In this case the government is bearing a part and they will also pay a part of the premium.
So with that we will be covering another 8% of the population. So it will be 90% coverage. The people who are left out will be those in unorganised sectors i.e. private employees and others.
There is a lot of political importance. Last time it bought a lot of impact on the elections. He came back and the first department to be appreciated was ours. We had 3 major political parties in the last elections. All of them had this scheme in their manifesto. Only the names were different. One person put it as Rajiv Arogyasri and another as NTR Arogya Padakam.
It has now become a demand driven scheme. I can tell you an example. In a hospital there was an issue for half an hour with registration. The local LAN failed. In half an hour there were dharnas ( protests) and rasta-rokos (road blockages) happened. I think we can control the scheme in terms of its quality. As far as to run the scheme or not is not in anybody's hands it is in the peoples hands