1 Payment methods of health insurance system in Thailand Samrit Srithamrongsawat Health Insurance System Research Office [email protected].

1

Payment methods of health insurance system in Thailand

Samrit Srithamrongsawat

Health Insurance System Research Office

[email protected]

2

Outline of presentation

Overview of payment methods of the Thai health insurance schemes• Universal Coverage Scheme

• Civil Servant Medical Benefit Scheme

• Social Security Scheme

Effects of payment methods: the Thai experiences

3

1945

2000

2001

Informal exemption

1980

1970

User fees

1-3rd NHP1962-76Provincial hospitals

Health Infrastructure

Thailand: historical development

1975LIC

1990

Establishment of prepayment schemes

Expansion of prepayment schemes

1980CSMBS

1983CHF

1990SSS

4th -5th NHP (1977-86) District hospitalsHealth centers

Universal Coverage

CSMBS

CSMBS

SSS

2001

Universal Coverage

SSS

LIC MWS 1994PVHI

4

Coverage of health insurance: 1991-2003

0

20

40

60

80

100

%

1991 1996 2001 2003

UC

HC

MWS

other

PI

SSS

CSMBS

Source: HWS 1991, 1996, 2001, 2003

5

Age distribution by insurance scheme

0%

20%

40%

60%

80%

100%

UC SSS CSMBS Total pop

60+

15-59

0-14

6

Civil Servant Medical Benefit Scheme (CSMBS)

Nature Fringe benefits, tax-based system

Financing model Public reimbursement model

Beneficiaries Government workers, pensioners and their dependents (5.4 million)

Benefit package Comprehensive package including OP, IP, and private ward in public hospitals

Service providers Free choice of public facilities

Access to private hospitals only in case of emergency

Payment method Retrospective fee-for-services

7

Social Security Scheme (SSS)Nature Social health insurance, compulsory contributions from

employer, employee, and the government

Financing model Public contracted model with both public and private hospitals

Beneficiaries Private employees (8.47 million)

Benefit package Comprehensive package including OP, IP, maternal care, dental care

Service providers Contracted public and private hospitals with 100-bed or above

Payment method Inclusive capitation

Additional payments for utilization rate, chronic conditions, fee schedule for high cost services, and fixed amount for AE, dental care, maternity

8

Universal Coverage Scheme (UCS)Nature Entitlement, tax-based system

Financing model Public contracted model, capitation 1,899 THB in 2007

Beneficiaries Thai citizens uncovered by SSS and CSMBS (47 million)

Benefit package Comprehensive package including prevention and promotion services (PP) and accredited alternative medicines with an exclusion list of some services

Service providers Contracted public and private hospitals and requiring all hospital to establish one primary care unit (PCU) for every 10,000-15,000 registered population

Payment method OP,PP - Capitation

IP - DRG weighted global budget

A/E and HC OP – point system,

AE/HC IP –DRG weighted global budget

9

Historical development: payment methods1991 Inclusive

capitation  Mixed allocation  

1993-4       Global budget

1995 Adjusted utilization

    Fee-schedule: HC

1998     Per capita allocation

1999   Demand side Piloting DRG/ Capitation

DRG system for HC

2000   control     

2001 Adjusted for risks

2002     Capitation and DRG weighted global budget

2005     Age-adjusted capitation

2006   Fee-schedule Performance-based payment

Year SSS CSMBS MWS Health Card Uninsured

10

Aim and objectives of purchasing

To ensure good health

To solve health problems

Response to social expectation

To control cost

Ensuring good quality and efficient services are provided to beneficiaries

Aim

bjectives

11

Payment methods and provider risk

Retrospective Full cost

Discount per diem

Hospital IP DRGs

IP and OP DRGs

Bundled Hospital -MD D

RGs

Full Capitation

Minimum MaximumProvider Risk

Per Discharged

Per member

12

Payment & provider behavior

Prevent health problem

Deliver services

Responsiveness

Contain costs

Line item budget

+/ - - - + /- + + +

Global budget + + - - + /- + + +

Capitation + + + - - + + + + +

DRGs + /- + + + + + +

FFS + /- + + + + + + - - -

WHR 2000

13

Effects of payment methods: the Thai experiences

14

DALYs 1999: 2004Male Female

1999 2004 1999 2004

HIV/AIDS 960,087 641,000 372,974

293,000

Traffic accident 510,907 600,000 114,963

136,000

Stroke 267,567 300,000 280,673

302,000

Liver cancer 248,083 295,000 118,384

141,000

Diabetes 168,372 166,000 267,158

263,000

TB 93,695 89,000 60,643 61,000

Cataract 96,091 41,000

15

Use of ambulatory care

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

0-14 15-59 60+

UC

SSS

CSMBS

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

0-14 15-59 60+

UC

SSS

CSMBS

Use of ill persons Use of ill persons covered by the scheme

Source: 2005 HWS

16

Use of appointed services of patients with chronic conditions

0

0.1

0.2

0.3

0.4

0.5

0.6

0-14 15-59 60+

UC

SSS

CSMBS

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0-14 15-59 60+

UC

SSS

CSMBS

Use services Take-up of benefits

Source: 2005 HWS

17

Hospitalization

0

0.02

0.04

0.06

0.08

0.1

0.12

0.14

0.16

0-14 15-59 60+

UC

SSS

CSMBS

0

1

2

3

4

5

6

7

8

9

0-14 15-59 60+

UC

SSS

CSMBS

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0-14 15-59 60+

UC

SSS

CSMBS

Being admitted

Take-up of benefits

Days of stay

Source: 2005 HWS

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

0-14 15-59 60+

UC

SSS

CSMBS

Number of admission

18

Responsiveness

0255075100

UC SSS CSMBS0255075100

UC SSS CSMBS

0255075100

UC SSS CSMBS0255075100

UC SSS CSMBS

Enabling access Equal treatment

Financial protection Prompt treatment*ABAC (2006)

19

Responsiveness

0255075100

UC SSS CSMBS051015

UC SSS CSMBS

0255075100

UC SSS CSMBS0255075100

UC SSS CSMBS

Equal treatment* Financial difficulties*

Satisfaction ABAC (2006)

Good quality*

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FFS: CSMBS experiences

0

2,000

4,000

6,000

8,000

10,000

12,000

1988

1990

1992

1994

1996

1998

2000

2002

OP IP OP Pensioners IP Pensioners

Cabinet resolution, full pay for non ED, limit ceiling LOS of private R&B and stringent private admission

21

SSS: Per capita expenditures 1998-2005

1,2791,392

1,523 1,5331,597 1,520

1,592

1,896

0

500

1,000

1,500

2,000

1998 1999 2000 2001 2002 2003 2004 2005

22

UCS: approved capitation budget and estimated expenses 2002 - 2006

1202.4

1447

1202.4

1552

1308.5

1670

1396.3

17781659.2

1843.3 1899.7

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

2002 2003 2004 2005 2006 2007

approved estimated expense

23

Conclusions

There were both improving and worsening health problems among Thai populations .

Provider’s bias in service provision was evident by insurance scheme, particularly for chronic conditions and hospitalization. Remaining issues of concern • Quality of medical are

• Outcome of treatment

24

Conclusions

Health insurance systems in Thailand provide fairly responsiveness to their beneficiaries and need further improvement.

Close-end payment methods are more effective in controlling costs than open-end payment method.