Document Revision Control

Revision Number / Date / Revision Author / Description
1.0 / 19/10/05 / Lisa Chote (PSTG) / Draft developed
1.1 / 19/10/05 / D. Belmonte (PSTG) / Edits
1.2 / 27/10/05 / I. Brunskill (PSTG) / Amendments
1.3 / 30/10/05 / L. Chote (PSTG) / Amendments guided by input from Infotech
1.4 / 30/10/05 / D. Belmonte (PSTG) / Edits

Table of Contents

Document Revision Control

Table of Contents

1.0 Introduction

2.0 Enrollment Strategy Objectives

3.0 Enrollment Design Considerations

4.0 Enrollment Options & Analysis

5.0 Summary and Next Steps

1.0 Introduction

In order for the Chronic Disease Assistance Programme (CDAP) Smart Card Solution to be successful, National Insurance Property Development Company (NIPDEC) must ensure that the smart card tokens (tokens) are distributed to patients and that patients use them to access the system.

NIPDEC must endeavour to provide tokens in a timely manner and to ensure that all CDAP patients receive a token. NIPDEC must also set rules to govern the programme to ensure that all programme partners are required to use the smart cards to dispense and receive medication.

A successful enrollment process will be measured by the following:

  • Ease of channel accessibility – partners, customers, and NIPDEC;
  • Target 0% turn away rate;
  • Respond to new programmes quickly, seamlessly and with minimal cost;
  • Zero tolerance for fraud;
  • Clear accountabilities established;
  • Established control points and audit trail to ensure operational integrity and confidence;
  • The majority of clients requiring/accessing health services are registered; and,
  • Service delivery and operational metrics established and management system in place to monitor performance.

Several workshop sessions were held with key stakeholders to solicit input to designing a successful enrolment strategy. This document represents that input and provides solutions which are representative of those requirements.

This document servesto provide options for enrollment as well as the analysis required at the various decision points. The document also speaks to the advantages and disadvantages of each option and suggests next steps to be actioned by NIPDEC and the Ministry of Health.

2.0 Enrollment StrategyObjectives

The business of CDAP enrollment includes registering clients for health programmes, maintaining their personal information, and providing health programme information. CDAP enrollment also plays a critical role in the delivery of other services, including Health Care providers’ claims payment and access to client health information and programme enrollment information.

The enrollment process will be guided by the following principles:

  • The process must be easy to access and take into account unique user needs;
  • CDAP smart card must be simple to use and not seen as a barrier to access in the first instance;
  • The period of time between enrollment and receipt of card must be seen to be reasonable by the patients;
  • An equitable provision of service must be maintained; and,
  • Process must ensure that clients always get the drugs to which they are entitled.

The objectives of the enrollment strategy are to:

  1. Register and enroll all clients of CDAP health services in a standardised, secure way;
  2. Determine client eligibility in CDAP and other health programmes as required;
  3. Reduce and prevent service fraud, abuse and misuse;
  4. Assure the privacy of health client information is maintained;
  5. Improve customer service levels by expanding client accessibility and availability to CDAP Services; and,
  6. Manage the transition associated with moving towards a new operating environment, in a manner which minimises any disruptions to the delivery of CDAP services.

3.0 Enrollment Design Considerations

CDAP Programme:

The CDAP Programme is available to all citizens of Trinidad & Tobago who are suffering from a chronic disease as defined by the Ministry of Health. Eligible citizens have access to drugs at no cost, as identified by the government.

There are no age restrictions to accessing the programme and eligibility is determined by prescribing doctors at private and public institutions. Patients whose prescriptions contain a CDAP drug line item also access the programme, once their prescription is written on a CDAP prescription pad.

At the end of September 2005, approximately 155,000 patients were enrolled in the CDAP Programme.

At present, NIPDEC has no direct relationship with CDAP patients. The introduction of the smart card solution will establish a new relationship to enroll patients, determine their eligibility for the purpose of issuing a smart card and respond to enquiries on card status.

32% of the CDAP population is over 70 years of age. 29% are between the ages of 60 and 69.Seniors therefore account for over 60% of the CDAP population, and their unique needs must guide the process.

The statistics show that no one under the age of 16 accesses the programme.However, as there is no tracking of patients at the public pharmacies, this may be misleading.

There is an almost even geographical spread of CDAP users across the four regions in Trinidad, with some 3,500 unique patients in Tobago. Approximately 70,000 patients are patrons of the first 50 pilot pharmacies.

The registration and enrollment strategy will focus on three key items:

  1. Customer / Stakeholder Service Delivery Needs:
    Access and Reach – (Where)
    Availability (time/place) – (When)
  2. Delivery Timeframe and Order of Magnitude (Transaction Volume) – (What)Currently there are 149,000 persons registered; patients are geographically dispersed (e.g., client concentration by pharmacy location); understanding the ongoing management and delivery of services once registration is complete;
  3. Service Delivery Channel Strategy – (How)
    This involves determining what services over which channels; identifying constraints; determining the level of interdependencies and dependences among delivery organisations; determining the applications which will run on the cards;

The enrollment strategy must address several key areas as illustrated in the diagram to the right: CDAP patient needs, the process to enroll and establish authentication credentials, and the identification of the appropriate distribution channels. The strategy will be supported by a communications strategy to ensure that messages are clear and actionable.

Various constraints to a successful enrollment process have been identified as follows:

Budget – costs of enrollment and logistics;

Timing – pilot rollout and full rollout of terminals;

Timing – adequate card supply to meet the growth of the programme;

The need to run parallel systems until such time the system is fully operational;

Patient awareness and understanding of new programme requirements;

Ability to reach the patient – geographic, bed-ridden, and other groups with special needs;

Level of effort required by patient to produce pieces of information required to apply for a card, e.g. photograph, new birth certificate; and,

Time from the receipt of an application by NIPDEC to the receipt of a card by the patient.

In addition, we anticipate that the following factors will affect the process and timing of the enrollment process:

Number of enrolled CDAP users, broken down by geographic location and profile group;

Potential CDAP programme expansion, timing and forecast number of users;

Potential for other applications being added to the card, such as e-food hampers

CDAP Programme Card Requirements – what is actually printed on the card;

CDAP enrollment information requirements – biometrics, signature, foundation documents;

Number and type of service locations;

Time associated with enrolling an existing or new CDAP patient – future process;

Implementation timing of full CDAP system and the mandatory use of cards to access CDAP drugs; and,

Length of time and simplicity of patients getting new birth certificates. This is a concern as currently 87% of the CDAP users access the programme with their ID cards only.

Enrollment Requirements and Decision Points:

The following diagram illustrates the decisions that must be made by NIPDEC to design the appropriate enrollment process. This process was used to produce the options for enrollment identified further in the report.

4.0 Enrollment Options & Analysis

Two options for enrollment are examined below. Each option is presented and its advantages, disadvantages and decisions required will be outlined.

For each option the foundation document required for programme enrolment will be the new birth certificate which contains the Population Registry Number as the unique identifier for the proposed CDAP system.

Presentation of the birth certificate will satisfy identification criteria, ensuring that the person is in fact a uniquelyidentified individual. Only nationals of Trinidad and Tobagocan apply for a new birth certificate, ensuring that only those eligible to access the CDAP programme can register to receive a smart card token. A Population Registry System (PRS) number is assigned to each birth certificate/national, and this number will act as the unique identifier.

The CDAP prescription will be used to confirm the person’s eligibility.

The authentication credential for the process will be the smart card token which will allow the individual to access the service involved on a recurring basis. It presumes the existence of the birth certificate and the prescription, without which it cannot operate.

Option A focuses on using the smart card for CDAP access only. The point for applications, registration and card distribution is at the private and public pharmacies only. This option would be managed by NIPDEC and will involve the use of third party service providers in the areas of data entry and card production.

Option B presents a wider network for receiving applications, which in turn would require biometric patient information. This option is better suited to using the card as a ‘universal’ card to access multiple government services. Under Option B, NIPDEC could potentially outsource the entire enrolment process to a third party vendor(s), from enrollment right through to card delivery.

Option A – CDAP Focused Enrollment Process - Analysis

Success Factor / Impact
Cost /
  • The cost to NIPDEC is minimal, as Pharmacists will accept completed and signed forms, and verify these against a copy of the new birth certificate.
  • Forms will be sent to NIPDEC using the existing mechanism for claims submission.
  • Delivery of the cards will take place at the pharmacies, using the existing drug delivery mechanism of TTPost.
  • Low communication and awareness costs as the message will be delivered only at pharmacies.

CDAP clients /
  • Patients must go through the process of getting a new birth certificate to apply for a card. This process takes place at 5 locations nationwide, which may be inconvenient to many users of the system.
  • Patients must provide a photocopy of the birth certificate to attach to their forms.
  • Illiterate patients may require assistance to complete the forms.
  • Using the pharmacists to introduce the concept of the smart card will provide a degree of comfort for those patients who do not understand why they are required to get cards to access the programme.
  • Elderly and infirm patients will not be required to physically present themselves at the pharmacies to complete their applications.

Level of management required /
  • Clear procedures must be put into place to ensure that completed application forms are submitted to NIPDEC by the pharmacies on a timely basis.
  • Pharmacists must be trained to ensure that forms are completed accurately and legibly, as this will impact the number of cards which may be unusable due to the input of incorrect patient information.
  • Minimal communication collateral requirements as the point of interface is singular.

Level of security /
  • Verification is done on the back-end of the system, as there is no biometric data on the card. There may be a perception of increased potential for fraud.

Time for delivery /
  • Delivery time of the cards will be dependent on the timely receipt of applications by NIPDEC.

Stakeholder reactions /
  • Pharmacists are willing to assist in collecting application forms as they see this process as fundamental to building relationships with their regular customers.

Time to implement and set-up /
  • This process is relatively simple to implement with few infrastructural requirements.

Option B – Enhanced Enrollment Capability – Analysis

Success Factor / Impact
Cost /
  • The cost to NIPDEC is higher, as other application centres will require a fee for accepting applications.
  • NIPDEC must invest in biometric data capture equipment – digital cameras, and / or fingerprint capture machines.
  • Cost of producing the cards and consumables will increase as there is more to be printed on the card.
  • If scanning photos, there is an up to threefold increase in data entry costs.
  • Back-end technology requirements will increase and the cost will grow to store and manage photo images.
  • Cards will be renewed at required intervals as patient’s appearance changes, thereby creating an additional cost to produce new cards.
  • Resources at application centres will require training to reduce the rate of error.
  • Promotion and awareness costs will be high to convey the message to the national public.
  • If cards are to be directly delivered to patients, there will be additional delivery costs.
  • Should the card be used to access more than one programme, other GoRTT partners can share the costs of expanding the patient enrollment process

CDAP clients /
  • Patients must go through the process of getting a new birth certificate to apply for a card. This process takes place at 5 locations nationwide, which may be inconvenient to many users of the system.
  • Patients must provide a photocopy of the birth certificate to attach to their forms.
  • Patients may need to purchase photographs to include on their applications. The CDAP patient profile is that of an economically disadvantaged person, and this may be an additional cost which is unwelcome.
  • Illiterate patients may require additional assistance to complete a more complex application process.
  • Elderly and infirm patients will be required to physically present themselves at the pharmacies and other locations to complete their applications. This will present a barrier to acquiring and using a card.
  • The level of comfort from using a primary health care provider to walk clients through the process is absent.
  • CDAP patients must go to pharmacies to fill their prescriptions. However, they will be required to go to another location which may be inconvenient.
  • Patients may view the biometric data requirements as an infringement of their personal privacy.

Level of management required /
  • Management of this enrollment process is complex and will require additional staffing at NIPDEC.
  • NIPDEC will be required to establish service level agreements and performance standards for each of the service providers being used to accept applications and produce cards. Close attention must be paid to the new partners to ensure that the applications are completed accurately and remitted to NIPDEC at required intervals.
  • There is potential for the card producers to be overwhelmed by large numbers of applications in the first phase of card rollout.

Level of security /
  • Biometric data capture makes the smart card seen to be more secure.
  • The card may be viewed as more acceptable for other applications such as e-food hampers if it contains a photo or other biometrics. There would be less of a perception of fraudulent use.

Time for delivery /
  • The infrastructure to capture biometric data was not included in project estimates. Additional time will be required to create these arrangements.
  • Delivery of cards may be faster, as there will be many more outlets at which patients can receive their cards or have their cards delivered to them.

Stakeholder reactions /
  • NIPDEC will run the risk of incurring negative feedback from the Pharmacists, who may view the use of other service locations as an infringement on their relationship with their patients.
  • The process may be viewed by regulators as more secure and less open to fraudulent use.
  • If the registration process can take place at more outlets, this will make card acquisition easier with regard to expanded use of the card for other programmes.

Time to implement and set-up /
  • The acquisition of the supporting biometric capture infrastructure will lengthen the process of beginning enrollment.
  • NIPDEC will require time to set up new service agreements with additional partners.
  • Time will be needed to educate the general public on the new process and change their behaviour.

Comparative Assessment of the Enrollment Options

A comparative assessment of both enrollment options against the selected success factors is provided in the table below.

Success Factor / Option A – CDAP Application / Option B – Multi Government Purpose
Cost / (+) less costly to implement when compared with option B; can leverage existing pharmacy delivery network; / (-) additional cost to implement and manage given enhanced card requirements;
CDAP Clients / (+) relatively less intrusive when compared with option B – will have impact in that clients must now possess a card; / (-) more impact on clients when compared to option A – additional requirements from the client is needed;
Level of Management Required / (+) less management effort in A compared to option B – Option A is less complex; / (-) Option B is additionally more complex to manage – e.g., more service delivery partners; enhanced technology; etc.
Level of Security / (-) verification of patients will be done during the back end processing, less secure when compared with Option B / (+) highly secured card and authentication of individual through the use of biometric, secure delivery channels, etc.
Time for Delivery / (neutral) dependent on timely receipt and processing of applications received by NIPDEC / (neutral) additional need for infrastructure offset by the additional number of outlets available to clients for enrollment
Stakeholder Reactions / (neutral) pharmacists willing participants to help in enrollment and use of delivery network for card distribution / (neutral) although pharmacists may view the use of other service locations as an infringement on their client relationships, this is offset by positive view from regulators; (secure process)
(+)more registration and enrollment centres ensures higher uptake of the smart card token and increased access to service
Time to implement & set-up / (+) relatively simple to implement when compared to Option B / (-) more complex to set-up and deliver, e.g., investment in additional infrastructure; service agreements with new delivery partners, etc.

To summarise the relative strengths and challenges associated with Options A and B: