International Health Policy Program - Thailand International Health Policy Program -Thailand Determinants of clinical practice variations and influence of provider payment methods: A case study from Thailand Viroj Tangcharoensathien, MD PhD Phusit Prakongsai, MD Supon Limwattananon, PhD Chulaporn Limwattananon, PhD Walaiporn Patcharanarumol, MPH International Health Policy Program (IHPP) Ministry of Public Health, Thailand Presentation to the 6 th IHEA World Congress 10 July 2007, Copenhagen
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Viroj Tangcharoensathien, MD PhD Phusit Prakongsai, MD Supon Limwattananon, PhD
Determinants of clinical practice variations and influence of provider payment methods: A case study from Thailand. Viroj Tangcharoensathien, MD PhD Phusit Prakongsai, MD Supon Limwattananon, PhD Chulaporn Limwattananon, PhD Walaiporn Patcharanarumol, MPH - PowerPoint PPT Presentation
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Determinants of clinical practice variations and influence of provider
payment methods:
A case study from Thailand Viroj Tangcharoensathien, MD PhD
* UC-E: UC members exempted from copay per visit** UC-P: UC members required copay per visit
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Odds of receiving inhaled cortico-steriods
Odds ratio* P-value 95% LL 95% ULUC-E vs. SSS 084. 0026. 072 0.98UC-P vs. SSS 147. 000< .
1124 1.73
CSMBS vs. SSS 151 000< .1
129 1.77ROP vs. SSS 093 0492. 076. 1.14Age 36-49 vs. 18-35 yr 101. 0915 088 1.15Age > 50 vs. 18-35 yr 044. 000< .
1039 0.5
Male vs. Female 089. 0009. 082. 0.97Prior admission due to asthma vs. No admission
3 .00 000< .1
257. 3.5
Prior rescue medication vs. No rescue medication
168 000< .1
152. 1.86
Years 2002 vs. 2001 0.78 0.093 0.58 1.04
* Based on logistic regression, adjusted for indicators of 18 study hospitals
20%
30%
40%
50%
60%
70%
80%
2001 2002 2001 2002
Likelihood of receiving inhaled cortico-steroids
Chronic Asthma Adults (N=6,176)
Patients with history of admission due to asthma (N=489)Patients who ever used rescue medication (N=1,512)
CSMBS
CSMBS
UC-P
UC-P
SSS
SSS
ROP
ROP
UC-E
UC-E
Year
Patients with no asthma admissionnor prior rescue medication (N=4,175)
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landDiscussions 1
– Determinants of clinical practice variations• Very complex relationship, whereas provider payment is
one of the determinants • Multiple determinants
– Structural • District hospitals have less Ob-Gyn specialists and
facilities [blood, anaesthesia] for caesarean section than others
• No haematologist in provincial hospitals to initiate chemotherapy for ANLL
• District staff mostly new graduate MD, whereas internal medicine specialists in provincial hospital – competency in application of inhaled cortico-steroid
– Demand side characteristics • Prior exposure to rescue drugs, admission of asthma and
use of inhaled medicines • Older age pregnancy and higher chance for caesarean
section • Patient preference and self demand for caesarean section
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– Insurance status and provider payment methods • Hospital policy
• Variations in drug list – low cost generic versions for capitation model of SHI and UC,
• Original versions and non-ED for fee for services CSMBS and out-of-pocket payment patients
• Clinician prescribing preference • Non-ED and brand drugs for CSMBS
• Being a “Private patients” in public hospitals • Ob-gyn specialists in Thailand are bound to conduct
delivery, time management usually results in medically non-indicated caesarean section [Tangcharoensathien et al 2002]
• Special payment for high cost care such as chemotherapy
• SHI - fee schedule with ceiling at ~870 USD per year• CSMBS - fee for services• UC – central fund using DRG with global budget
payment, and disease management
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Conclusions– Practice variations:
• Determinants are complex and multiple, provider payment is one of the determinants resulting in cost and outcome variations
• Further detail investigations required for each specific tracer. – Caesarean
• Highest rate among CSMBS, plus confounder of “being a private patient” of OBGYN.
– ANLL • Lower access to chemotherapy, poorer survival outcome
among UC patients and in favour of SHI patients • Provider payment, availability of haematologist and clinical
experiences in induction treatment are complex determinants.
– Use of inhaling cortico-steroid in asthma • Severity of disease is important (using admission and use of
rescue drugs as a proxy indicator)• In favour of CSMBS and self pay before UC and UC-P after UC
scheme launched • Not that expensive and not unaffordable, but perhaps
clinician’s awareness of the use of inhaling cortico-steroid
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Policy Recommendations– Minimize practice variations
• Further expansion the coverage of clinical practice guidelines, and advocate their use, e.g. the use of inhaled cortico-steroid,
• Single-out some key interventions from capitation payment with special additional payment e.g. fee schedule with close monitoring e.g. Chemotherapy or additional payments for high cost care
• Adequate payment for high cost and effective intervention, e.g. some curable cancers.
• Monitor and routine report among peers on practice variations, e.g. Caesarean, self control of unnecessary non-clinically indicated Caesarean.
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Acknowledgements• National Statistical Office of Thailand • Ministry of Public Health (MOPH)• Thailand Research Fund (TRF) and Health Systems Research
Institute (HSRI) for institutional grants • Centre for Health Informatics for the dataset of hospital
admissions • Thai Society of Haematology for Leukaemia registry • 18 regional and provincial hospitals of MOPH