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.. . . : 1. . 2. . 3. . 4.Universal Health Coverage. 5. Health Security. 6. Health Insurance. I. , II. , III. , IV. , V. , VI. , VII. , ISBN

... ... * ..

*

.. (the 8th International Seminar on Health Insurance Development and Implementation in Asian Countries) .. (DSE) . . , .. (.) . , ( (DRG) ). , , . . . (.) . . - (.) (.) ( , , ) .

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B.Sc., B.P.H., M.Sc., M.S. ,

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Master of Economy of Development

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, M.App.Stat ,

.. (), Ph.D., M.B.A., .. ( ) ,

.., .. (), .. (), M.Sc. (Social Policy Finance)

.., M.Sc.

.., .. (). . . ..

.., M.P.H., .. (), .. ()

D.D.S, M.P.H., B.Econ, Diplomate (Dental Public Health), Ph.D.

.., Ph.D., Certificate of Proficiency in Preventive Medicine

.., .

.., Certificate of school of Governance

B.Sc. (Pharm), M.Sc.(Health Development), M.Sc (Social Protection Financing)., PhD.

.. Ph.D.

.., M.Sc., Ph.D. ,

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.., M.P.H. , (),

.., M.Sc, PhD., Certificate of Preventive Medicine

B.Sc., M.P.H.M., Ph.D.

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B.E., M.C., PhD.

B.Econ., Ph.D., , ,

Exploit Health-Focused Development Strategy for Making the Most Efficient and the Most Equitable Use of Limited Resources to Improve Health within a Broad Sociopolitical Strategy for the Benefit of the Entire Society

. . . . ... . , ...

(security) (insurance) .. "" () , () () . "" () , () () . () .

. . . ( .. , ) (- = - = + = ) . .. (.) , (.) (passive) (active) . .. , .. .. .

, () , () () (equity) (equality)* :-

*

Equity (1) the quality of being impartial or reasonable; fairness. (2) an impartial or fair act, decision, etc. (3) (Law) a system of jurisprudence

founded on principles of natural justice and fair conduct. It supplements the common law and mitigates its inflexibility, as by providing a remedy where none exists at law. (4) (Law) an equitable right or claim equity of redemption.

. : . . : (), , , , , . . : . . : . . . : . . . . . : . Equality (1) the state of being equal. (2) (Mathematics) a statement, usually an equation, indicating that quantities or expressions on either side of an equal sign are equal in value.

. . . . : . ( , , , ) . . : . . . : . ( ). . . . : . .

.. /, . ( ) . .. .. (.. ) . .. () - - - . . . .. . () ()

() / ( , , ) () (safety), () (efficacy), () (effectiveness), () / (benefit of entire society / potential population benefit) () (efficiency) :. (safety) , , , (safety monitoring program: SMP) . . (efficacy) / . . (effectiveness) ( / / ) . / ) , ) , ) ) . . / (benefit of entire society / potential population benefit) / .

. (efficiency) . (health-focused development strategy) , , , :. (equity) () () (financial), (asset) , ( health care personnel) (knowledge) (fact) (information) (data) . . , , , :.. (population health focus service) (disease focus) (individual care focus) . .. ( ,) //. .. . .. . .. () . .. (health care practice guidelines: HCPG)

(specify and quantify benefit, harm, and cost) (user friendly) ( ) :o o o / (, , ) () . . (multi-sectoral approach) .. , , , , . .. (health & safety focus management) . .. , , , (5E: Engineering, Enactment, Enforcement, Education, Economic) . . (community involvement) :.. (potential for achieving results at lower cost) , , . .. (relevance of the empowerment of communities) (). . .. (long-term social development) () .

. / .. .. (more than medical service) (non-medical intervention) / (disease management) / () /, () , () . ( .) (security/continuum care model)

(care delivery model)

(insurance model)

/ () / . / . / . / . (Population-Based Health Management): . (health problem/disease management) (continuum care model) (sustainable health security) (case/patient management) (insurance model) -

( . .). . () (). (health care), (health insurance), (health security), (health benefits) (reforming the health care system) . . (Care Management Model) . (insurance model) - (utilization review ) (Quality assurance function) - (compliance and assess orientation) - (no integration) . (care delivery model) - , (care map) - (linear integration) . (security model) (continuum care model) - (community health care) (optimum care site) - (continuous quality improvement) - (promote wellness and community health status) - (multidimensional integration) (medical/clinical service system) (disease) (dis-ease) (health system) . . . ()

. . (health care) (medical care) . (Aesculapius) (Panacea) (the goddess of cure) (Hygeia) (the goddess of health and well-being) . (barbers and surgeon) (fragmented medical service system) . . . ()

. (ambulatory setting) .

(disease management) . ( ), . (wellness management). (), , , , , , ( . .). , , , , , , . , (), , , , . / / .

. . : (.), . .. . : , . .. . : , .

. . : , . . -.NHS in England. NHS Core Principles. http://www.nhs.uk/England/AboutTheNhs/CorePrinciples.cmsx

.Peterson KW, Kane DP. Beyond disease management: Population-based health management. In: Disease Management: a systems approach

to improving patient outcomes. Todd WE, Nash D, editors. San Francisco: Jossey-Bass, 1996 pp. 305 346.

, ,

. . . () () . . (peril) ( ) (hazard peril) :. (physical hazard) . (moral hazard) - . (morale hazard) . . . (pure risk) (speculative risk). (gain) (profit) . . .

. (financial risk) (non-financial risk). ( ). . () .. . () .. . . (general risk) (particular risk). ( ). ( ). . . . (insurable risk) (uninsurable risk) . . . () . .

(actuarial science). (law of large numbers) (homogeneous exposure unit) . (critical mass). :. . . . . . . () . . ( ). ( ). . . . . .

. . . . . . () (third party) . () . () . . () . (adverse selection) . . . . .

. . . . . (cream skimming) ( ) . . , . .. , . , . , () , . .. . . (risk rating). . . (equity) ., . . .

. . . . . - . - ( ) . . . . (information asymmetry) . . . . . .

. . . . . .. 60,000 50,000

40,000 30,000 20,000 10,000 0

:

(fee-for-service). . (supplier-induced demand). . . ( .) . - .

. . . : . (copayment), (deductible), (coinsurance) (insurance ceiling). () . . () . , , . () . . () . . . .

. : (capitation) . . . . . . () , () () . - . . (health insurance market failure) . .

. .

. . . / . - - - . - - ( - ) - - . . - - - - - - - -

. () , () () . (national health insurance) ( ) .

. (Beveridge style model) . . . . . (vertical equity) . . (billing and administration costs) . (gross domestic product: GDP) (GDP ) . () () () () . . ( ) . (individual mandated & managed competition) () () .

(Bismarck style model) ( ) (sickness funds) . ( ). ( ) ( ). . : . . . . . . () () . () . () .

. . () () . . . . . (medical saving account) . . . . .

: Medicare Australia . () , () () . () () .

.

Getzen T. Health Economics: Fundamentals and Flows of Fund. 2 nd edition, Hamilton Printing, U.S.A. 2004 Henderson JW. Health Economics and Policy, Fourth edition, South-Western, U.S.A. 2009, , , , . , . . (): -

Folland S, Goodman A, Stano M. The Economics of Health and Health Care, Prentice-Hall, Inc, New Jersey, U.S.A. 2001. Smith C, Witter S. Risk Pooling in Health Care Financing: The implications for Health System Performance, World Bank, Washington, DC., U.S.A. 2004, Newhouse J. Free For All? Lessons from the RAND Health Insurance Experiment, Harvard University Press, U.S.A. 1996 Sriratanaban J. Health Insurance System in Thailand. NHSO, Nonthaburi, Thailand. 2001 Roemer MI, Hopkins CE, et al. Copayments for ambulatory care: penny-wise and pound-foolish. Medical Care 1975, Vol. 22(3), pp.457-466. Mooney G. Economics, Medicine and Health Care. Pearson Education Limited, U.K. 2003 Carrin R, James C. Reaching universal coverage via social health insurance: key design features in the transition period. WHO, Geneva 2004 Rice T. The Economics of Health Reconsidered, 2 nd edition, Health Administration Press, Chicago, U.S.A. 2003 Santerre RE, Neun SP. Health Economics: Theories, Insights, and Industry Studies. The Dryden Press, U.S.A. 2000 Rice T. The Economics of Health Reconsidered, 2 nd edition. Health Administration Press, Chicago, U.S.A. 2003 Kronick R, Goodman DC, Wennberg J, Wagner E. The marketplace in health care reform: The demographic limitations of managed competition. The New England journal of medicine 1993;328(2):148-52. World Health Organization. Medical Savings Accounts: Lessons Learned from Limited International Experience, Discussion Paper, Issue 3. Geneva 2002.

, . . () . . .. .

.. ( . ). . (.) . .. (means test) . .. ( ) . .. . . ..

. .. - 100% 15.3% 80% 1.5% 12.7% 66.5% 10.2% 5.6% 15.3% 12.6% 31.5% 54.5% 40% 29.0% 20% 8.5% 7.2% 20.8%

.

8.9% 9.4%

9.8% 8.9% 9.0%

7.6% 11.7% 73.5%

9.6% 10.7% 11.0% 11.4% 12.1% 74.7% 73.4% 72.2% 74.3% 73.6%

60%

0%

5.1% 5.7%

4.9% 4.0% 3.7%

2.6%

2534

2539

2544

2546 2547 2548 2549 2550

2552

.* .. (.) ( ) .. . . .. . .. (). . . .

*

.. .. ..

.. (expected utility theory) , (financial risk). (access motive). . . .. . . ( ) . . . (.. ) . ( .). ( ) .. , ., . . . .. .. . . (.. ).

. .. Health facility trends -Thailand Hospitals Hospital beds 1,400 1,300 1,200 1,100 1,000 900 800 700 600 500 400 300 200 100 0 1965 1970 1975 1980 1985 1990 1995 2000 2005 Private . 140,000 130,000 120,000 110,000 100,000 90,000 800 80,000 750 700 70,000 650 600 60,000 550 500 50,000 450 400 40,000 350 300 30,000 250 200 20,000 150 100 10,000 50 0 0 1965 1970 All beds 1975 1980 District 1985 1990 1995 2000 2005 Private

80,000 75,000 70,000 65,000 60,000 55,000 50,000 45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0

All hospitals

District ..

.public Other

..

. Other public

.

Population perhealth facility ..180,000 170,000 160,000 150,000 140,000 130,000 120,000 110,000 100,000 90,000 80,000 70,000 60,000 50,00030,000 25,000 20,000 15,000 10,000 5,000

Population per bed 1,400 1,300 1,200 1,100 1,000 900 800 700 600 500 400 1965 1970 1975 1980 1985 1990 1995 2000 2005

5,000 1965 1970 1975 1980 1985 1990 1995 2000 2005

Hospital

Health center

. .. . .. . . ( .). ( ) .. . . () .

. .. Health workforce trends -ThailandDoctors and nurses120,000 110,000 100,000 90,000 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0 1965 1970 1975 1980 1985 1990 1995 2000 200520,000 15,000 10,000 5,000 0

Nurses and midwives100,000 90,000 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0 1965 1970 1975 1980 TNs 1985 1990 1995 PNs 2000 200530,000 25,000 20,000 15,000 10,000 5,000 0

Doctors (MDs)

Nurses (RNs/TNs)

RNs

Midwives

per doctor and nurse Population 10,000 9,000 8,000 7,000 6,000 5,000 4,000 3,0005,000 4,500 4,000 3,500 3,000 2,500 2,000 1,500 1,000 500

Health centers and personnel 30,000 25,000 20,000 15,000 10,000 5,000 0 1965 1970 1975 1980 1985 1990 1995 2000 200510,000 9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0

500 1965 1970 1975 1980 1985 1990 1995 2000 2005

Doctor (MD)

Nurse (RN/TN)

HC personnel

centers Health

( ) ( .). . .. . . . . , (

. .. Health resource disparity -Thailand per doctor per nurse Population Population 11,000 10,000 9,000 8,000 7,000 5,000 4,000 3,000 2,000 1,000 6,000 1,300 1,200 1,100 1,000 900 800 700 600 500 400 300 200 100 0

International Health Policy Program -Thailand International Health Policy Program

0

-Thailand2540

1995

2000

2545

2005

2550

1995

2540

Bangkok

North-East

2545 Bangkok2000

2005 North-East

2550

bed Population per22 20 18 16 14 12 10 8 6 4 2 0

Bangkok-NorthEast ratio

900 800 700 600 500 400 300 200 100 0

1995

2540

2000

2545

2005

2550

1980

2525

1985

2530

1990

2535

1995

2540

2000

2545

2005

2550

Bangkok

North-East

Doctors-Pop.

Nurses-Pop.

28 Beds-Pop.

) . * . ( .). (.. ) . ( . ).

(Institute for Health Metrics and Evaluation (IHME) ( .) .. (infant mortality rate, IMR) (under-five mortality rate, U5MR) . . . (.. ) (maternal mortality ratio, MMR) . .

*

. , ./ .. -50% -./ - / -

40%

30%

11.5% 14.4% 18.9%-./

20%

18.6%

18.0%

-

18.1% 9.4% 1.9% 1.5% 1.5%-

10%

-./

0% 2539

2544

2546

2547

2548

. (IMR) (U5MR) (MMR) .. -120 100 80 60 40 20 025 15 25 20 25 25 25 30 25 35 25 40 25 45 25 50IMR U5MR MMR -IHME MMR -RAMOS MMR -TDRI

Institute of Health Metrics and Evaluation (2010) Chandoevwit, et.al. (2007)

( . .. . .. ). . RAMOS .

. .. 80 75 70 65 60 55 2518 2528 2538 2543 2548

.. , , ..

. .. 100% 19% 75% 50% 25% 29% 0% 26% 52% 67% 35% 49%

8% 25%

13%

40%

38%

Male

Female

Male

Female

DALYs Infections, maternal, perinatal, nutritional cond

YLLsNCD Injuries

(life expectancy, L) .. (L0) ( .). . (burden of disease): .. (years of life loss, YLLs) ( .) . ( ) ( ).

( ). . * . . . . . . . . . . . .. . . . .

*

. (decile) .. ( )8.17

8 7 6 5 4 3 2 1 02.23 1.89 1.78 1.77 5.46 4.58 4.58 3.67 3.32 3.29 1.75 1.48 3.16 2.78 1.62 1.54 4.82 3.74 3.65 2.87 2.93 2.38 1.39 1.4 2.57 2.52 2.22 1.57 1.37 2.45 2.36 2.06 1.41 1.32 1.99 1.97 1.68 1.48 1.35

2535 2537 2539 2541 2543 2545 1.64 1.57 1.55 1.45 1.15 1.27 1.43 1.27 1.07 1.1 2547 2549 2552

1

2

3

4

5

6

7

8

9

:

() ..

.

. ( .) .. (1st decile) . (10th decile) . . .. . . .. . . . .. . .. ( ) . . .

1

0

. ..

0.0 0.5 0.6 1.0 1.1 2.0 2.1 3.0 > 3.0

: ()

.. ( .. ) ( . ) (catastrophic expenditure).,, . .. . . ( .) ( .) ( . ). ( . ). . . .

. .. 5%34 41 54 27 85 94 76 66 60 65 91 43 56 18 90 93 32 55 22 58 84 49 48 44 62 61 37 31 35 46 67 30 33 45 36 47 39 64 42

4%

3%

2%

23 14 50 13 52 19 7475 96 12 20 83 73

72 21 51 16 24 92 26 95 63 77 15 53 40 71 86 70 17 80 57

1%11

10

25 81

0% 10% -1% 20% 30% 40% 50% 60% 70% 80%

: ()

* . . . . . . . , . . . *

. .

McIntyre D, Thiede M, Dahlgren G, Whitehead M. What are the economic consequences for households of illness and of paying for health care in low- and middle-income country contexts? Social Science and Medicine 2006;62:858-65.

Nyman JA. The value of health insurance: the access motive. Journal of Health Economics 1999;18:141-52. Von Neumann J, Morgenstern O. Theory of games and economic behavior, Princeton, Princeton University Press 1944. Friedman M, Savage LJ. The utility analysis of choices involving risk, Journal of Political Economy 1948;56:279-304. Chandoevwit W, Kasitipradith N, Soranastaporn S, Vacharanukulkieti K, Wibulpolprasert S. Using multiple data for calculating the maternal Pradhan M, Prescott N. Social risk management options for medical care in Indonesia. Health Economics 2002;11:431-46. Ranson MK. Reduction of catastrophic health care expenditures by a community-based health insurance scheme in Guja-rat, India: Current

mortality ratio in Thailand, TDRI Quarterly Review 2007;22:13-19.

experiences and challenges, Bulletin of the World Health Organization 2002;80:613-21. Wagstaff A, van Doorslaer E. Catastrophe and impoverishment in paying for health care: with applications to Vietnam

- , Health

Economics 2003;12:921-34.

, , . : . : : - .Van Doorslaer E, ODonnell O, Rannan-Eliya RP, Somanathan A, Adhikari SR, Garg CC, Harbianto D, Herrin AN, Huq MN, Ibragimova S, Karan countries in Asia: an analysis of household survey data, Lancet 2006;368:1357-64. A, Ng CW, Pande BR, Racelis R, Toa S, Tin K, Tisayaticom K, Trisnantoro L, Vasavid C, Zhao Y. Effect of payments for health care on poverty estimates in Limwattananon S, Tangcharoensathien V, Prakongsai P. Catastrophic and poverty impacts of health payments results from the national household surveys in Thailand, Bulletin of the World Health Organization 2007;85:600-6.

() (public formal sector) ( ) , () (private formal sector) , () (informal sector) . .

( .. ) :() (.. ) . () (.. ) ( ). . () .. .. (.. ) (.) . .

. .. - - - - . - ( ) () . () - ( ) () - () ( ) () - ( ) () - . () - () ( ) - - () - () - . () - - - .. ( ) () () - SIP () - () - SIP () - - () ( ) - - - - () , , - - ( ) - - (.. ) - (Hospital Accreditation) (..)

, .

( ) . . .. . ( ) . . .. . .. ( . ). , . . (informal sector) . : .. . .

. .. , , , , , . (.) . .. .. . ( ) . . . .. (public subsidized voluntary health insurance scheme) ( , .. ) ., (.. ) (.. ) .. .. . ..... .

. .. Health Financing in Thailand Health Care Reform: At the Frontier of Research And Policy Decisions Thailand at the Crossroad: Challenges for Healthcare Reform .. ... . (.. ) (-) the Institute ofTropical Medicine (Entwerp), the London School of Hygiene and Tropical Medicine, and Edinburgh University Achieving Universal Coverage of Healthcare: Experiences from the Middle and Upper Income Countries

(. . )

. (.), (.) . . . . .

.

2540

2544

2536, 2539, 2540

2535

UC2543 2541-2543 SIP (WB) 2542-2544

. . . . () , () () . .. .. . .. . .

. () , () , () , () . . . . . .

( ) . .. .. . (.) . .. . ( ) . .

. .. 100 90 80 70 60 50 40 30 20 10 0 2534 2539 2544 2546 2548 2550

.

: .. , , , ,

. . (new public management) , (supply side financing) (demand side financing), , . :() .. (public-private mixed) . () (.) . : . .

( ). . :. .. . . .. . , , (reinsurance) . () (.) . . ( ) . . .. . . .. . . . . . . ( ).

( ) . (.) (social investment project; SIP) . . . ( . . ) . . .. . .. . . ( ), . .. , , . .. . . ,

. .. . (disease management) . ( , , , ).

() () () . ( ) .. ( , , ) . . . ( ) ., ( HbA1C, , )., . ( ) .

. (fringe benefit) (%) (social security) (entitlement) (.) . (.%) (%) . , (public contracted) (public service unit registration & contracted) , , . . , / , / / / . ;

..

(public reimbursement) ,. (~, /)

/ . , ( )

:

,

,

. Coxibs50 45 40 35 30 25 20 15 10 5 0Oct Oct Oct Oct Oct Jul Jul Jul Jul Jul Jan Jan Jan Jan Jan Apr Apr Apr Apr Apr

Single source statins and new antihyperlipidemiaCS 50 45 40 35 30 25 20 15 10 5 0Oct Oct Oct Oct Jan Jan Jan Jan Apr Apr Apr Apr Jan Apr Oct Jul Jul Jul Jul Jul

CS

SS

SS

UC

UC

2003

2004

2005

2006

2007

2003

2004

2005

2006

2007

Cesarean section60% 50% 40%47% 45% 48% 50% 52% 50% 51 % 53% 54% 55% 56% 54% 56% 58% 59%

Laparoscopic cholecystectomy60%55% 51% 49% 48% 52% 47% 47% 50% 51% 53% 55% 55% 56% 54% 51%

CS50% 40%

CS

SS30% 20% 10% 0% Qtr Qtr Qtr Qtr Qtr Qtr Qtr Qtr Qtr Qtr Qtr Qtr Qtr Qtr Qtr 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 2004 2005 2006 20071 7% 1 7% 1 6% 1 7% 1 8% 20% 20% 22% 21 % 20% 1 9% 20% 20% 21 % 21 %

SS30% 24% 22% 23% 23% 25% 24% 26% 22% 18% 28% 24% 26% 27% 29% 28% 28% 24% 24% 28% 26% 27% 27% 26%

30%

UC

UC

20% 10% 0%

1 6%

1 6%

1 7%

1 7%

1 8%

1 8%

1 9%

20%

20%

20%

20%

20%

23%

21%

22%

24% 20%

22%

Qtr 1

Qtr Qtr Qtr 2 3 4 2004

Qtr Qtr 1 2

Qtr Qtr Qtr 3 4 1

Qtr Qtr 2 3 2006


Qtr 3

2005

Source: Limwattananon, J., S. Limwattanon, et al. (2009).

. . . . . .

. . . . . . ., . , . . . . .

. . . ( .). . 12,000 10,000 8,000

6,000 4,000 2,000 0 (2,000) 2540 2541 2542 2543 2544 2545 2546 2547 2548 2549

:

( .). . .. .. .. (.. ) . . , .

.. , , .. .. . .. (.. ) . . ()70,000 60,000 50,000 40,000 30,000 20,000 10,000 0

:

.. .. . .

.

. . . .. ... .. , , . . . :. . . . . , , , . . . .

. . . . .() . . . . . ( ) . .

. () . (local commissioning) (central purchasing) . . ( ) . (strategic partnership) . () . . . . (risk adjusted capitation) .

. . (drug utilization evaluation) , , , (reference price), . (risk adjusted capitation), . . . ( ) . . . :() . ()

. , , . . . . . (Gross Domestic Product, GDP) . . . .. , . . . .. . . -

. ( )350,000 300,000 3.52% 3.53% 250,000

3.84%

4.00% 3.74% 3.50% 3.40% 3.32% 3.68% 3.55% 3.47% 3.49% 3.70% 3.70%

4.5% 4.20% 4.0% 3.5% 3.0% 2.5% 2.0% 1.5% 1.0%%GDP

200,000 150,000 100,000 50,000 0 2537 2538 2539 2540 2541 2542 2543 2544 2545 2546 2547 2548 2549 2550 2551 %GDP

0.5% 0.0%

: ..

. 25%

20%

15%%

10%

GDP

5%

0%GGE as % GDP GGHE as % GDP GGHE as % GGE

GDP2537 9.8% 1.5% 15.0% 2538 9.9% 1.5% 15.6% 2539 10.2% 1.7% 16.5% 2540 10.1% 2.0% 20.0% 2541 11.1% 1.9% 16.8% 2542 11.5% 1.7% 15.2% 2543 11.3% 1.7% 15.2% 2544 11.3% 1.6% 14.5% 2545 11.1% 2.1% 19.3% 2546 10.7% 2.1% 19.1% 2547 11.1% 2.0% 18.4% 2548 11.9% 2.0% 16.8% 2549 11.8% 2.2% 18.9% 2550 12.2% 2.4% 20.0% 2551 12.4% 2.7% 22.0%

Source: IHPP (2010), NESDB (2010): Analysis of NHA and NI various years

.. . .. * * ( .).

*

.

.. .. .. . .. . .

. (.). ; (): -. Srithamrongsawat S. The Health Card Scheme: A Public Subsidized Voluntary Health Insurance Scheme. In: Pramualratana P, Wibulpolprasert S, editors. Health Insurance System in Thailand. Nonthaburi: Health System Research Insitute; 2002. Pannarunothai S, Srithamrongsawat S, Kongpan M, Thumvanna P. Financing reforms for the Thai health card scheme. Health Policy and Planning 2000;15(3):303-311. Pitayarangsarit S, Jongudoumsuk P, Sakulpanich T, Singhapan S, Homhual P. Policy Formulation Process. In: Tangcharoensathien V, Jongudoumsuk P, editors. From Policy to Implementation: Historical Events during 2001-2004 of Universal Coverage in Thailand. Nonthaburi: National Health Security Office; 2004. . . ; ():-. Limwattananon S, Limwattananon C, Pannarunothai S. Cost and Utilization of Drugs Prescribed for HospitalVisited Patients: Impacts of Universal Health Care Coverage Policy. Nonthaburi: Health System Research Institute; 2004. Limwattananon C, Limwattananon S, Pannarunothai S, Tangcharoensathien V. Analysis of practice variation due to payment methods across health insurance schemes. Nonthaburi: International Health Policy Program, Ministry of Public Health; 2009.

*

(), .

Thammatach-aree J. Variations in the performance of three public health insurance schemes in Thailand. PhD thesis, London: University of London; 2009. Martin P. The Contribution of Migrant Workers to Thailand: Towards Policy Development. Bangkok, Thailand: International Lobour Organization (ILO); 2009. Phophirul P, Rukumnuaykit P. Economic Contribution of Migrant Workers to Thailand. In: Health Related Issues among the Thailand Myanmar Border: A Synthesis of Body of Knowledge; 2007. , , , , . . : ; . , , , , , , . (Intermediate Care) . : ; . Kutzin J. Towards Universal Health Care Coverage: A Goal-oriented Framework for Policy Analysis. Washington DC: Health, Nutrition and Population (HNP) Discussion Paper, World Bank; 2000. Vasavid C, Hempisut P, Greetong T, Hongnuson N, Phetchanoon N, Trameekhun P, et al. Thai National Health Accounts: sustainable updates of 2006 - 2008 and diversification. Nonthaburi: International Health Policy Program, Ministry of Public Health; 2009.

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Medisave .. . Medisave . . () . --------------------------------------------------

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() , () , () , () , () , () , () () . - . () - () - . . . ( ) . . . . (employment injury benefit) - . (workmens compensation) . (employment injuries) .

. - . . . . . . . -. - . . .

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(Workmen Compensation Fund : WCF) . - . . . .. () - *, () - , () , () , () - , () , () , () . . . . - , , . . .. () () . () () () - . . *

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. . - . . . . .. , . . . , :() , () () , - .. .. .. () () () () , .. .. .. () () - , . () , () , () () .

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() () () . - - . . . . (capitation payment) - .. . . (fee for services) (capitation) .. / /. // . // .. . , , . . . . .. . // // . // //

// ( // x //) + ( . // x //). // //. :() () - () () . . - .. . - . .. . - .

. . - . . . . .. . .. - , . DRGs (case base payment) DRGs , - (global budget) , :() . .. // , , /, , , , . (.. ) // (chronic renal failure), (Parkinson disease), (myasthenia gravis), (diabetes incipidus) (multiple sclerosis), (dyslipidemia), (rheumatoid arthritis), (glaucoma), (nephritic syndrome), (systemic lupus erythematosus),

(aplastic anemia), (thallasemia), - (hemophilia), (psoriasis), (chronic vesiculobullous disease), (idiopathic thrombocytopenic purpura) (thyrotoxicosis) . DRGs . () . - . DRGs , , , , , , , , , Amplatzertm Septal Occluder. () (hospital accredit: HA) HA . , HA . () erythropoietin , () , () , () () . . .

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*

http://www.sso.go.th/sites/default/files/userfiles/file/download/EvaluateForm.zip

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(financial resources and allocation to purchasers) . ( ) , () , () , () (), () , () , () () . () .. . . ( ) ..

. . () (, ) (): Kutzin 1998

. (Capitation rate) .. , ,, , . . (.. ) .. . . . , , ( . ) . .

. . ()Items Outpatient service (OP) Inpatient service (IP) OP/IP for special area Prevention&Promotion Influenza vaccine High cost & disease management Capital replacement Emergency Medical Service Rehabilitation service No fault liability (Act41) Rural area hospital Compensation for health care personnel's work related injury Pay for quality performance Compensation for abolish 30Baht copayment Thai traditional medicine Promote primary care Support special tertiary care ARV drug Renal replacement therapy Total (Baht/Capita) US dollar (34 Baht/dollar) % growth 2546 574.00 303.00 175.00 57.00 83.40 10.00 2547 488.20 418.30 206.00 86.00 85.00 6.00 4.00 5.00 10.00 2548 533.01 435.01 210.00 124.21 76.80 6.00 4.00 0.20 7.07 2549 582.80 460.35 224.89 244.38 129.25 6.00 4.00 0.53 7.00 2550 645.52 513.96 248.04 260.58 142.55 10.00 4.00 0.53 30.00 0.40 20.00 24.11 2551 645.52 845.08 253.01 145.26 143.73 12.00 4.00 30.00 0.40 20.00 1.00 2552 666.96 837.11 72.25 262.06 7.60 179.47 148.69 5.00 1.00 0.85 20.00 1.00 2553 754.63 894.28 72.25 271.79 11.36 186.00 148.69 8.08 0.78 40.00

-

1,202.40 35.36

2.00 10.63 0.84 58.56 83.70 94.29 63.45 32.54 1,308.50 1,396.30 1,659.20 1,958.25 2,183.70 2,296.29 2,497.32 38.49 41.07 48.80 57.60 64.23 67.54 73.45 8.8% 6.7% 18.8% 18.0% 11.5% 5.2% 8.8%

:

. . . (allocating institution) .. (.) (.) . , , , :( ) () () ()

() () () () . . . .. . ( .) , , , , ; ; . . (Terms of Reference: TOR) . . (provider payment) (cost containment) (prospective payment) . (fee schedule) , (pay for performance) ( .).

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. Capitation with age adjustment OP general service Point system with global budget OP accident/emergency Out patient service Price list ceiling with global gudget OP high cost OP first service, non registration OP high cost investigation and heart procedure OP medical instrument OP disease management Point system with global budget Point list ceiling with global gudget Point system with price list Ceiling with global budget

IP medical instrument Inpatient service capitation Patient cases IP disease management IP service Quality indicator Price list with global budget Price list with global budget Disability health service Primary care Capital investment plan Capital replacment Performance indicator On top PCU Secondary& tertiary care Case base with global budget

Quality performance Thai traditional medicine

Fee schedule Renal replacement therapy ARV drug DM&HT management Fee schedule Fee schedule

No fault liability for health personnel Prevention & promotion Act41 (No fault liability)

Specific criteria

Capitation with activity price list Specific criteria

Popualation Patient

:

( ) (entitlement to benefit), () (service in the benefit package) () (payment by patients). . . , . (comprehensive package) ( ) , () , () , () , ()

. .. 60% 50%

40%OP 30% 20% IP PP

others

10%0% 2546 2547 2548 2549 2550 2551 2552 2553

:

() , () () , () , () ( ) . .

(achieving universal coverage) (health system performance achievement) ( .). . . .

. Public health insurance performance

Achieving universal coverage

Health system performance achievement

Revenue collection

Pooling risk

Purchasing mechanism

Cost containment

Health outcome

Efficiency

Quality

Equity

Accessibility

Adapted from: Figueras, et al. 2005; Carrin and James 2005.

. 120 100

80

percent

6040 20 0

2544 71.01

2545 92.47

2546 93.01

2547 95.47

2548 96.25

2549 97.82

2550 98.75

2551 99.16

2552 99.47

(achieving universal coverage) . ( .). . .. . .

. () (/) () (/) . . . . na . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

:

) .. - ) ..

. 70,000,000 60,000,000 50,000,000 40,000,000

30,000,000 20,000,000 10,000,000 2549 2550 2551 2552

:

. , ( . .. , .. ) . ( .). ( .). ( .).

. 3,000,000 2,500,000

2,000,0001,500,000 1,000,000 500,000 -

2549

2550

2551

2552

:

. 1.20IP utilization rate - UCS49-52, est.53-54

1.00

T49 T51 est.T53

T50 T52 est.T54

0.80

0.60

0.40

0.20

-

0

10

20

30

40

50

60

70

80

90

100

: Health Care Reform Project 2008

. 100.0 80.0 60.0 40.0 20.0 2539 2541

3 3 2545 2549 3 3 2543 3 3

: ,

. 3.00 2.50

2.001.50 1.00

0.502546 2547 2548 2549 2550 2551 2552

:

. 600,000 500,000 400,000

300,000 200,000100,000 -

2549525,932

2550484,824

2551453,387

2552486,043

68,613 24,747

75,199 49,732

66,172 32,117

58,012 65,243

:

. ( ) ( .). ( . ). ( . ). (compliance) .. .. ( . ). .. .

. 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2549 2550 2552

2549 2550

40% 57% 64%

58% 58% 78%

72% 68% 84%

60% 57% 80%

67% 60% 78%

66% 62% 80%

2552

: Health and Welfare Survey

. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

2549 2550 2552

2549 2550 2552

44% 61%

79% 85%

88% 94%

82% 85%

89% 91%

84% 90%

76%

91%

92%

91%

92%

91%

: Health and Welfare Survey

.. . .. ( . ). . ( . ). .

.

: Prakonsai, et al. (2009)

. . . ( ) .. . . . (hospital accreditation: HA). ( .). . . . statin .

. /..

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

: : HA

. 100 90

8070 60 50 40

30 2010 0

2546 83.01 45.66

2547 83.42 39.34

2548 82.35 47.72

2549 84.00 50.99

2550 83.16 56.57

2551 88.37 60.75

2552 89.32 60.3

:

. . . . . , ( . ).

. . .. . . :. . . . . . . . . . . () () . . ( ) (), () () () . () :-

. . . . . .

. , , . . . . . ( , ) . . . . . .

. . : ; . Nitayarumpong S. Universal Coverage of Health Care: Challenges for the Developing Countries. In: Nitayarumpong S, Mill A, editors. Achieving Universal Coverage of Health Care. Nonthaburi: Office of Health Care Reform; 1998. p. 238. Kutzin J. Enhancing the insurance function of health systems : A proposed conceptual framework. In: Nitayarumpong S, Mills A, editors. Achieving Universal Coverage of Health Care. Nonthaburi: Office of Health Care Reform; 1998. p. 238. Carrin G, James C. Key performance indicators for the implementation of social health insurance. Appl Health Econ Health Policy 2005;4(1):15-22.

, . : , , . : , , , . , . Carrin G, James C. Key performance indicators for the implementation of social health insurance. Appl Health Econ Health Policy. Figueras J, Robinson R, Jakubowski E. Purchasing to improve health systems performance:drawing the lessons. In: Figueras J, Robinson R,

. ; (): -. . ; ( ): -. . ; ():- 2005;4(1):15-22. Jakubowski E, editors. Purchasing to improve health systems performance. Berkshire: Open University Press; 2005. p. 44-82.

Limwattananon J, Limwattanon S, Pannarunothai S, Tangchareonsathien V. Analysis of practice variation due to payment methods across

health insurance schemes (Published process report). Nonthaburi 2009. Thammatacharee J. Variations in the performance of three public insurance schemes in Thailand [PhD Thesis]: LSHTM (University of London); 2009.

Chariyalerdsak S, Laohasiriwong W, Supakankanti S. A study of monitoring and evaluation of universal health coverage (UC) program phase

I. Nonthaburi: Health System Research Institute 2004.

. . (healthcare purchasing). . : . . . (purchaser) . ( .).

. - (market model) - (private indemnity mod el) - - (managed care model) - / (public - assistance model) (public - reimbursement model) - - (public contracting mod- - el) (national health insurance model) - - - - - + / + (UM) - () - - - - - () - - (UM) - -

Employer-based insurance

(national health service model)

-

() . (strategic purchasing) . ,

. : ( )

(healthcare purchasing) (third party) . .* (contracting) . ( .) , , , , . . . . () , ( ) ( ) .

*

Healthcare purchasing is the process by which pooled funds are paid to providers in order to deliver a specified or unspecified set of health

interventions.

. - - Medicare Medicaid - (general taxation) - - Centers for Medicare and Medicaid Services - National Health Service, Department of Health Strategic Health Authorities (SHA) - (sickness funds)

- - - - - - - - - ( )

: . (access) . . (quality) . . (equity) . . (technical efficiency) (allocative efficiency). . (good governance) .

(market mechanism) (price) (demand) (supply). :- , () (market power) . . ( , , ) (oligopoly market). ( ) (externalities) . . . ( ) . ( ) (public goods) (merit goods) . (free rider) . ( ) (imperfect information). . . (uncertainty of illness) .

. :() (coordination) (motivation). . . ( ) (transaction) (contract). . ( ) (bounded rationality). . ( ) (principal-agent framework). (principal) (agent) (imbalance of information) (opportunistic behavior) . () (governance structure). . (ownership), (reimbursement incentive), (regulation), (social environment), (markets), (hierarchies) (Network). :. (hierarchical) . . (network) .

. (market) . :() (moral hazard).

(moral hazard). (information asymmetry) . . (copayment) , (coinsurance) , (deductible). ( ) (adverse selection). . (community rating). ( ).

. . ( ) . . . (open-ended payment) (close-ended payment) . ( ) . (DRG-based payment) . (unbundling). .

() , ( ) , ( ) , ( ) () . , . (need assessments) . :. . . .

. . . . ( ) ( ). (comparative data) ( ) . () , ( ) , ( ) , ( ) , () ( ) . () , ( ) , ( ) , ( ) ( ) . . (determination of purchasing strategy) . () , ( ) , ( ) ( ) . () . ( ),

( ), ( ). . . ( ) :. (purchasing by item) . . (purchasing by episode of illness or use) () . . (purchasing by package or set of care) , . . (comprehensive or program-based purchasing) (disease management). . . . ( ) . :.

. . . . (. = , . = , .=) . FSc . FSc . FSc . DRG . PbP . Cap . - Cap FSc = PbP = DRG = Cap =

( ) . (quality audit), (utilization review). (managed care). , , , . () . , . :. (open-ended payment) .

(catastrophic illness) . . .. .. . . (close-ended payment) . . (capitation) . . . (service specification) , , . , , . () ( ) :() . (evidence-based clinical practice guideline)

. , , , . . (fee for service) (case-based (Capitation) (fee schedule) payment) : - + ( + ) +

( ) . . . ( ), ( ), ( ), . (contracting for services) , .

() , ( ) , ( ) , ( ) , () ( ) . () . (partnership) (purchaser-provider split) (contracting) (purchasing) (managed care) , (National Health Service) . ( ) . () . . . , , . . . , . () . . ( ).

( ). . () . . ( , , , , ); ( ); ; ( ); ( ). () . . . :. (data element) . . (real time) (batch work) . . ( ) .

. . () . . . . . - - - - - - - - - - - - - - - - - -

- - - - - - - - - - -

. . ..

, , .

. (quality based selective contracting) . . (quality-based purchasing) (value) . :. () . () , ( ) , ( ) , ( ) () . . . , , (.).

, . . (pay for performance, P4P) . ( ) ( ) (payment differentials based on quality) . :. ( ) . . (bonus) . . . . . ( ) .

. (Public domain information on comparative provider performance) ( ). . . () , ( ) (rating), ( ) (ranking) (provider report cards). (accreditation) Centers for Medicare and Medicaid Services (CMS) ; ( HEDIS Health care plan National Committee for Quality Assurance (NCQA) , HealthGrades.com -. , , , , , .

. . . .

. . .. ... : . Chassin MR, Kosecoff J, Park RE, Winslow CM, Kahn KL, Merrick NJ, Keesey J, Fink A, Solomon DH, Brook RH. Does inappropriate use explain geographic variations in the use of health care services? A study of three procedures. JAMA 1987;258:2533-7. Hofmarcher MM, Oxley H, Rusticelli E. Improved Health System Performance through better Care Coordination. OECD Health Working Papers, No. 30: OECD Publishing 2007. . . : . . Taylor RJ. Contracting for health services. In: Harding A, Preker AS, eds. Private participation in health services. The International Bank for Reconstruction and Development and The World Bank 2003, p 157 - 218. . . - . : . Sorkin AL. Health Economics: An introduction. 3rd ed. , New York: Lexington Books, An Imprint of Macmillan, Inc. 1992. Forder J, Robinson R, Hardy B. Theories of Purchasing. In: Figueras J, Robinson R, Jakubowski E. (eds). Purchasing to improve health system performance. Maidenhead: Open University Press. 2005. Folland S, Goodman AC, Stano M. The Economics of Health and Health Care. 2nd ed. Upper Saddle River, NJ: Prentice Hall. 1997. . . : . , . . : . Clark D, Neale B, Heather P. Contracting for palliative care. Soc Sci Med 1995;40:1193-202. vretveit J. The quality of health purchasing. Int J Health Care Qual Assur Inc Leadersh Health Serv. 2003;16:11627. . : . ; : . . (.). (.) . McNamara P. Purchaser strategies to influence quality of care: from rhetoric to global applications. Quality and Safety in Health Care. 2006;15. p.171-3. Waters HR, Morlock LL, Hatt L. Quality-based purchasing in health care. Int J Health Plann Manage. 2004;19:36581. CMS. Centers for Medicare and Medicaid Services. http://www.medicare.gov. Accessed: 31 October 2010. NCQA. National Committee for Quality Assurance. http://www.ncqa.org. Accessed: 31 October 2010. HealthGrades. http://www.healthgrades.com. Accessed: 31 October 2010. Leatherman S, McCarthy D. Public disclosure of health care performance reports: experience, evidence and issues for policy. Int J Qual Health Care 1999;11:93-8.

(Fee-for-Services) (retrospective) . , . , ( , , , ). . (open-ended fees), (negotiated fee schedule) (regulated fee schedule) . . . (utilization review) . (prior authorization) . , ( ), , , , . :/ = (1 x 1) + (2 x 2) + (3 x 3) + (n x n)

. .

(performance based payment) ( ) . ( , , ) , , . (fee-for-services), (per episode), (per disease), (Capitation). :() . ( ) . () .

. . () . . , () . . () . . . (supply induce demand).,, . . : . (claim processing) . . . (claim audit) . (utilization review)

. (prior authorization) . . (fee schedule). . (coinsurance) . . . .

(reducing the level or rate of increase in health care costs) , , , , . . (real terms cost). . ( ) . .

. (productivity) ( ). (volume of services) (intensity of services). () () . E = Q.P.V.I (Expenditure) = (Quantity of inputs per unit of service) X (Price of inputs) X (Volume of services) X (Intensity of services) , . . () , () , () () ( /) . . . () ( ) () . . . (measures operating on demand) (cost-sharing) (

). . ( ). () . . . (gate keeping) () . . (measures operating on supply) :() (production efficiency) . () ( ), , , () . () ( , , ) (quota), (prescription patterns), (budget ceiling) (doctor profiles) . (direct control) (certificate-of-need). (Roemer's Law) (supply of health facilities) . ( ) . , , .

. . . . (sophisticate care) . (pharmaceutical cost control). . . :() (price control) , , , , . () (limiting number of products on the market). () (promoting the use of generic or to allow generic substitution). () (positive and negative drug lists). . (GP fund-holder) (HMO). . (utilization management). . . . . , ., , .

(indirect control) (retrospective fee-for-service payment) ( ) . (prospective payment schemes) () ( ) . ( , , ) (GDP) . (DRGs) ., , (readmission) (diagnostic creep). (budget holding) (managed care) , .,,

. , ( ). ( ) . . . .

. . ()

70,000 60,000 50,000 40,000 30,000 20,000 10,000 0

DF

47 49 50 DRG

2544-47

33

34

35

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

51 25

25

25

25

25

25

25

25

25

25

25

25

25

25

25

25

25

25

25

..

..

:

( .) . . . . . . . . . -

25

52

. . . 90%13 8 14 114 9 2

80%

114 8 4 5 2 5 22 10 7 4 5 10 7 13 114 87 7 8 6 6 6 13 1 10 13 10 6 7 9 7 7 8 1 114 8 217 3 14 10 6 7 10 6 6 8 10 6 7 6 114 7 2

115 3 5

70%13 7 7 7

10 6 7 2 10 6 710 7 15 8 13 7 5 6 10 6 6 1 10 6 7 1 13 7 7 9

114 9 6 10 6 6 9 13 7 5 8

10 6 7 0

60%

50%

80%40%10 6 8 0

114 9 2 115 3 5

75%30% 10%

114 8 4 10 7 4 560% 70% 80%

20%

30%

40%

50%

70%

10 6 7 9 10 6 7 7

10 7 13 13 7 7 8 114 7 2 10 6 6 8 114 8 1

22525 10 6 6 6 14 17 3

) ( )

.

10 6 7 6

65%

10 6 7 2

114 9 6 10 6 7 0

114 8 2 13 7 8 1

10 6 7 8

10 7 15

10 6 6 9 13 7 5 6 13 7 5 8

60%13 7 7 7 10 6 6 1 10 6 7 1

55%13 7 7 9

50% 10%

20%

30%

40%

50%

60%

( ) )

(.) ( ). ( / ) ( , ). (.) .. () (original brand) (generic equivalent/ bioequivalent) () (therapeutic equivalent).

. Coxibs50 45 40 35 30 25 20 15 10 5 0Oct Oct Oct Oct Oct Jul Jul Jul Jul Jul Jan Jan Jan Jan Jan Apr Apr Apr Apr Apr

Single source statins and new antihyperlipidemiaCS 50 45 40 35 30 25 20 15 10 5 0Oct Oct Oct Oct Jan Jan Jan Jan Apr Apr Apr Apr Jan Apr Oct Jul Jul Jul Jul Jul

CS

SS

SS

UC

UC

2003

2004

2005

2006

2007

2003

2004

2005

2006

2007

Cesarean section60% 50% 40%47% 45% 48% 50% 52% 50% 51 % 53% 54% 55% 56% 54% 56% 58% 59%

Laparoscopic cholecystectomy60%55% 51 % 49% 48% 52% 47% 47% 50% 51 % 53% 55% 55% 56% 54% 51 %

CS50% 40%

CS

SS30% 20% 10% 0% Qtr Qtr Qtr Qtr Qtr 1 2 3 4 1 2004 Qtr Qtr Qtr Qtr Qtr 2 3 4 1 2 2005 Qtr Qtr Qtr Qtr Qtr 3 4 1 2 3 20071 7% 1 7% 1 6% 1 7% 1 8% 20% 20% 22% 21 % 20% 1 9% 20% 20% 21 % 21 %

SS30% 24% 22% 23% 23% 25% 24% 26% 22% 1 8% 28% 24% 26% 27% 29% 28% 28% 24% 24% 28% 26% 27% 27% 26%

30%

UC

UC

20% 10% 0%

1 6%

1 6%

1 7%

1 7%

1 8%

1 8%

1 9%

20%

20%

20%

20%

20%

23%

21 %

22%

24% 20%

22%

Qtr 1


Qtr Qtr 1 2

Qtr Qtr Qtr 3 4 1

Qtr Qtr 2 3 2006


Qtr 3

2006

2005

Source: Limwattananon, J., S. Limwattanon, et al. (2009).

., . cox-2 inhibitor (Coxibs) , (cesarean section) (laparoscopic cholecystectomy) . . . . . .

. :() (item of drug), (dosage form), (), . . () (positive and negative list) () (utilization review and management) ( ) (prior authorization) (utilization review) . () (fee schedule) (drug reference price) . () . () . () . (prospective payment) (close-end budget) . .

Ron A, Abel-smith B, Tamburi G. Health Insurance in Developing Countries: The Social Security Approach. Geneva: International Labor Office; 1990. Robinson JC. Theory and practice in the design of physician payment incentives. Milbank Quarterly 2001;79:14977. Hillman BJ, Joseph CA, Mabry MR, Sunshine JH, Kennedy SD, Noether M. Frequency and costs of diagnostic imaging in office practice--a comparison of self-referring and radiologist-referring physicians. N Engl J Med 1990;323:1604-8. Langenbrunner JC, Liu X. How to pay? Understanding and using incentives. Washington, DC: World Bank 2004. Hellinger FJ. The impact of financial incentives on physician behavior in managed care plans: a review of the evidence. Med Care Res Rev 1996;53:294-314. Jencks SF, Schieber GJ. Containing U.S. health care costs: what bullet to bite? Health Care Financ Rev Annu Suppl 1991:1-12. Garrison LP Jr. Assessment of the effectiveness of supply-side cost-containment measures. Health Care Financ Rev Annu Suppl. 1991:13-20. Abel-Smith B. Cost containment and new priorities in the European community. Milbank Q 1992;70:393-416. Joskow PL. Alternative Regulatory Mechanisms for Controlling Hospital Costs. American Enterprise Institute 1981. JICWELS. Textbook for the 8th study Programme for the Asian Social Insurance Administrators, 27 September - 8 October 1999. Tokyo: Japan International Corporation and Welfare Services; 1999. Kutzin J, Barnum H. Institutional features of health insurance programs and their effects on developing country health systems. Int J Health Plann Manage 1992;7:51-72. Mrquez P. Containing health costs in the Americas. Health Policy Plan 1990;5:299-315. Roemer MI. Bed supply and hospital utilization: a natural experiment. Hospitals 1961;35:36-42. Gosden T, Torgerson DJ. The effect of fundholding on prescribing and referral costs: a review of the evidence. Health Policy 1997;40:103-14. Hillman AL, Pauly MV, Escarce JJ, Ripley K, Gaynor M, Clouse J, Ross R. Financial incentives and drug spending in managed care. Health Aff (Millwood) 1999;18:189-200. Committee on Utilization Management by Third Parties, Division of Health Care Services, Institute Of Medicine. Gray BH, Field MJ, editors. Controlling Costs and Changing Patient Care? The Role of Utilization Management. Washington DC: National Academy Press; 1989. Bailit HL, Sennett C. Utilization management as a cost-containment strategy. Health Care Financ Rev Annu Suppl 1991:87-93. Wickizer TM. The effects of utilization review on hospital use and expenditures: a covariance analysis. Health Serv Res 1992;27:103-21. Wickizer TM, Feldstein PJ, Wheeler JR, McDonald MC. Reducing hospital use and expenditures through utilization review. Findings from an outcome evaluation. Qual Assur Util Rev 1990;5:80-5. Carrin G, Hanvoravongchai P. Provider payments and patient charges as policy tools for cost-containment: How successful are they in high-income countries? Hum Resour Health 2003;1:6. Altman SH, Cohen AB. The need for a national global budget. Health Aff (Millwood) 1993;12 Suppl:194-203.

Gay EG, Kronenfeld JJ. Regulation, retrenchment--the DRG experience: problems from changing reimbursement practice. Soc Sci Med 1990;31:1103-18. Leibson CL, Naessens JM, Campion ME, Krishan I, Ballard DJ. Trends in elderly hospitalization and readmission rates for a geographically defined population: pre- and post-prospective payment. J Am Geriatr Soc 1991;39:895-904. Gross R, Nirel N. Does budget-holding have a long-term effect on expenditure, staff and patients? Health Policy 1997;40:43-67. Gross R, Nirel N, Boussidan S, Zmora I, Elhayany A, Regev S. The influence of budget-holding on cost containment and work procedures in primary care clinics. Soc Sci Med 1996l;43:173-86. Chaix-Couturier C, Durand-Zaleski I, Jolly D, Durieux P. Effects of financial incentives on medical practice: results from a systematic review of the literature and methodological issues. Int J Qual Health Care 2000;12:13342. Limwattananon S, Limwattananon C, Pannarunothai S. Cost and Utilization of Drugs Prescribed for HospitalVisited Patients: Impacts of Universal Health Care Coverage Policy. Nonthaburi: Health System Research Institute; 2004. Limwattananon C, Limwattananon S, Pannarunothai S, Tangcharoensathien V. Analysis of practice variation due to payment methods across health insurance schemes. Nonthaburi: International Health Policy Program, Ministry of Public Health; 2009.

()

. (Diagnosis Related Group: DRG) (casemix system) .

(risk pooling). . . (payment method) (provider) (insurer) (system objective). (capitation) ( //) . . (case based payment method) (short episode), (low annual probability) (high variation in cost). (pay for performance) . (casemix system) (production function) (direct labor costs,

. Diagnosis related group () Thai Mental health casemix classification (TMHCC) Sub-acute and non-acute patient (SNAP) Adjusted clinical group (ACG) Healthcare resource group (HRG) ()

) (direct material costs, ) (overhead costs, ). . (capitation) . . . (mental health casemix classification, MHCC), (sub-acute and non-acute patient, SNAP) . ..

. (total cost) (length of stay, LOS) .

(relative weight, RW) . (principal diagnosis) (co-morbidity) (complication) (). . . (Thai Mental health casemix classification:TMHCC)

. . . (Sub-acute and non-acute patient: SNAP) . . . (Adjusted clinical group: ACG) ( ) . (health risk) . . . (HRG) (National Health Service, NHS) (-

) .

(Medicare) . . . (global budget) . . (intensity of service) . . (up-coding) . (sequencing) (addition or deletion) .

. (standard dataset) .

. . . , (health economist) . ( , , , , , ) . (medical coder) . - . . (medical information technologist) . . . . .

. .

.. (reinsurance) . .. .. . . - . .. .. (Medicare DRG) . . .. . .. (DRG grouper) . ICD-10 ICD-9cm (principal diagnosis) (co-morbidity) (complication) . () . . . ( . .). .. .

(DRG 490 ungroupable) . .

. (Australian Refined DRG) . (major diagnostic category, MDC) ; (surgical DRG) (medical DRG) ; = , = , = , = , = . . , . (bilaterality, ) (multiplicity, ). (ICD-9cm with extension code) , ( ). (casemix)

. . . Medicare . Medicare . Australian Refined . . . ICD-10 / ICD-9cm () (RW) . .

ICD-10

ICD-9cm

. .

ICD-10

ICD-9cm

,

. .

ICD-10, ICD-10TM ICD-10

ICD-9cm 2005 with extension code ICD-9cm 2010 Ext, HoNOS, modified Barthel index

,

. .

DRG ,, TMHCC , SNAP

. . . . . .

: - ICD-10 International Classification of Disease version 10, ICD-10TM International Classification of Disease version 10 Thai Modification, ICD-9cm International Classification of Disease version 9 Clinical Modification, HoNOS Health of the Nation Outcome Scale, RW relative weight

: () (), ()

(Health of the Nation Outcome Scale: HoNOS) (modified Barthel index) . (MDC) , (MDC 28) , , .

.. .

(Reclassification) (flow chart) (MDC) (tracheostomy) , (disease cluster, DC) (laparoscopic) . . (Recalibration) . . (billing) . ( ) . . .

. . ( ) ( outlier trim point OT) . (Rebasing) (base rate) . . (global budget) . . () () . . . . ( ) ( ) , ,

(DRG creep) . . . () . . . . . . . . . . . . . . * . . . . . . . (/) . . . . . . . (/) , , , , , , * - . . - () ( x ) = /(x)

// // . , / , /. . . , , .

, ( .). .

. . . . (global budget) . .

. . , . .

. () , () () (unbundle) . (economies of scale). . . . (Indirect medical education), . . . . . . , .

, , , . ( , , , ) .

. . . . .. . (Expanded DRG EDRG) (comorbidity) (complication) . . . . .

Fetter RB, Shin Y, Freeman JL, Averill RF, Thompson JD. Case mix definition by diagnosis-related groups. Med Care 1980;18(2 Suppl):iii, 1-53.

, , , . . : .

, , , , . . : . Starfield B, Weiner J, Mumford L, Steinwachs D. Ambulatory care groups: a categorization of diagnoses for research and management. Health Sutch S. Casemix in the United Kingdom: From development to plans. In Kimberly J, Pouvourville G, DAunno T (eds). The Globalization of Serv Res 1991;26:53-74. Managerial Innovation in Health Care. Cambridge: Cambridge University Press 2008.

Chilingerian J. Origins of DRGs in the United States: A technical political and cultural story. In Kimberly J, Pouvourville G, DAunno T (eds). The Globalization of Managerial Innovation in Health Care. Cambridge: Cambridge University Press 2008.

Kimberly J, Pouvourville G, DAunno T. The Globalization of Managerial Innovation in Health Care. Cambridge: CamLuft HS. Total Cure The Antidote to the Health Care Crisis. Cambridge: Harvard University Press 2008.

bridge University Press 2008.

, , , , , , (capitation) .. . .. (diagnosis related group) . (fee for services) . .

(prospective payment) . . (risk adjusted capitation) ( ) (flat rate capitation) . , . (Health Maintenance Organization, HMO) . . (cost containment) .

. (Line item budget)

(Provider behaviour) +/ ++ +++ +/ +/ ++ +++ +/ +/ ++ ++ +++ +++ +++ +++ ++

(Global budget)

(Capitation)

(Diagnostic related payment)

(fee for service)

:

+++ ; ++ ; +/ ; ;

() (bonus) (pay for performance) ( ), () (consumer choices of contractor) , () / .

(capitation) . . .. . .. -

(fee for service reimbursement) . .. . ., .. .. . .. .. . (technical feasibility), . (financial sustainability) (cost containment system) , (close-end) (performance related payment). (policy design). (fee for service reimbursement model) (opened end) (supply induced demand) .. . (pilot project) . . .

.

56% 44% ( 269)**

94% 6% ( 976)*

* .. http://report.nhso.go.th/hmain/counthtype.jsp ** .. ..

(Capitation Payment) . . :. .

. . . . () , () . . . . () , () , () , () , () . () , () , () () .

() ; () () , , , , ; () () . . . . . () , () , () , () , () () . . .. (ICD-10)

. .. . .. (basic capitation) (risk adjusted capitation) . .. (vendor managed inventory: VMI) CD-4, viral load drug resistance testing. .. (hospital accreditation: HA) (). . . :. ( .) .

. .. .. .. .. () ( ) % () .. () () .. () () .. () . . () . . (differential capitation by age structure) - . . .

. . .. .. () (project based) . (vertical programs) () (facility based) () (community based) .. () . () () () .. () . () (express demand) () () / (area based) .. () . (central procurement) () () () / .. () . (central procurement) () (fee for service) () / .

. . . ( .). . .

:() (additional payment) ( ), ( ) . () . () ( ) . () (hospital accreditation-HA) . .

. ( ) .

.. .. . . (out of pocket payment at point of service) ( , ). , . . ( .). ( , ). , - , , , . . (official payment) (unofficial payment). .

. (informal payment) ( , . .. * () , , , , () , , , , . . . . (): * National Health Account : * ,

, ) . . . :. ( ) ( ) (financial pressures) . . . . . ( ) ( ).

. . . . . , . . , (generic products) (good manufacturing product, GMP) (bioequivalent) (brand product) . . . (hospital accreditation) (clinical practice guideline) . . . (fee for ser vice) (capitation) (fee schedule) . . . :. . . . . (universal anti-retro viral therapy, ART) .

. . , . / . . . . .

World Health Organization, World Health Report 2000: health systems, improving performance, Geneva, WHO 2000. Department of Health Systems Financing WHO, Technical Brief for Policy-Makers number 2: Provider Payment and Cost Containment Tangcharoensathien V, Walee-Ittikul S. Social Security, who gains, who loses? The Thai Medical Council Bulletin 1991;20(3): 215-235.

Lessons from OECD Countries. Geneva, World Health Organization, 2007.

: . . : . ;:-. , , , , . : ;:-.Evans D and Etinne C. Health system financing and the path to universal coverage. Bulletin of World Health Organization 2010; 88: 402-3.

, . .. . . . . .

() , () (Equity, Quality, Efficiency, Social Accountability: EQESA). . () (access), () (cost) () (quality) . :- . (integrated health system) (hospital care) . . . . (competition) . ( ) ( ) . (command) (control) (contractual relationship)

(purchaser) . (performance indicators) (payment mechanism) . . . . . . (decentralization) ( ). . . (decentralization) . ( ). . .

(national standard) . . (cost effectiveness) . . . .,,, :. . . . . . . (healthy public policy). .

:. , , , . ( ) . .

. . . . ( / ) . .: 2543

Excellent center3rd LINE HEALTH REFERRED CASE 2nd LINE HEALTH REFERRED CASE 1st Line Health

2

. ( ) . , / , ( .) . .

. . , , , , , , -

, -

: -

. . . .

..

. (contractual relationship). :. () () . . . . . . . : ( ) . . . . .

. . . . .. . ( ) . ( ) . . ( ) . : . , , . . . . .

. , . . (inpatient care) (major surgery) (ambulatory care) . ( ) . :. . . . . . ( ) . . .

. :. , , , . . . , , , . . . . . . . .

. . . . ( ) .

(first line health services) , , , , . . . : (extended OPD)

. ( ) ( ) . :. . . . . . . . . . . (population-based) (service-based) . . (service-based)

. (.) .. , . .. :. . (community medical unit), ., . . . . , ., . . . . . , , . . . . . . . . , , . .. , , , . (first responder) (basic life support)

(advance life support) . .. ( - /). ( .. .. ). .. .. . (stroke fast track) (ST elevated acute myocardial infarction: STEMI) ST elevated . (continuous ambulatory peritoneal dialysis; CAPD) .

. (supply budgeting) (demand budgeting) . . .

( ) . . . . . . .. - -

;

. .

.. ( . .) . (, ). . . . .. /.. / . [.] . [.] . [.] . [.] ( / []) . . . [.] [.] [.] . . . [.] [.] [.] . . . [.] [.] [.] . . . [.] [.] [.] .. . [.] . [.] . [.] . [.]

. , , , , ,

, . . . . . . . . . . ( . .). . .. ( , ) . -

.. . . . . .

. .. .. . . . . . . . . . . . (n=) (n=) (n=) . . . . . . . . . . . . (n=) (n=) (n=) . . . . . . . . . . . (n=) (n=) (n=): ..

. .. .. . . . . . . . . . . . . : ..

. . . . . . .

, . . . (integrated health system) . . . . () () .. . (. ) . ( .. / , .. ). . . -

.: ()120 100 15.2 80 62.7 60 59.6 40 20 0 33.6 22.4 5.7 . . 5.2 . . 42.7 19.4 52.1 73.5

7.1

, , ,

, , ,

:

. . ( .)

. .. () . . . . . . * . . . . . . () . . . . . . * . . . . . . na . . . . .* : - -

. -t0.60 t0.50 t0.40 t0.30 t0.20 t0.10 t0.00 / // . ./. . : t0.50 t0.31 t0.53 t0.28 t0.53 t0.30 t0.50 t0.30 t0.54 t0.25

t0.09t0.10

t0.10t0.10

t0.10t0.07

t0.11t0.10

t0.10t0.11

. . .. . .

. . .. (Cardiovascular diseases) . ( ) . ( ) . () . ( ) . ( ) (Acute and Emergency Cares) . ( ) : ,

. . .

. . .

. .

. .

. .

. .

.

.

.

: . . .. . .. .

. . () . . , , , ( ), , , . . . ( . ) .. . ( ). . (

) . ( ) (7-Eleven) . .. () ,

: ..

.. . . . . () () . . () ( ) .

.. , .

. () . . . N1 . . S1 . . N2 . . S2 . . N3 . . S3* . . N4 . . S4 . . . = : (..-.. ) * S ..

. . . , ,

. ( .). . . . .. . N1 , , , , , , N2 , , , , , , N3 , , , , , , N4 , , , , , , S1 , , , , , , S2 , , , , , , S3 , , , , , , S4 , , , , , ,:

. () N1 N2 N3 S2 S3 S4 . ( N ) , , . . . . . . URI, tonsillitis, pharyngitis . . . . . . HT, DM, DM&HT . . . . . . Vaccination . . . . . . PU . . . . . . Acute Diarrhea . . . . . . Wound_ . . . . . . ANC . . . . . . Pneumonia . . . . . . . =

, . . . . . . . . .

. . . .

. . ( ) ( . . / . . : .. .

.) . . . . . . . ..

. . , , , ., , , , , . ..

. () () . - / .. / . . . . . . . . . . . . . . . . . . . . .

: -

. .. -

: -

() . .. .. .

. . . - . . . . - . . . . . / . . . . . / (/) ,. ,. ,. ,. ,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,. . . . .

. . . . (hospital accreditation) . -

. .

. . . .

. . . . ( .. ) .. . ..

. (ASEAN medical hub) . .

. . . . . .

. . . . . . . . . . .

. . . . . . .

World Health Organization, Health Systems: improving Performance , The world Health Report 2000 Alliance for Health Policy and System Research, Strengthening health systems: the role and promise of policy and system research, chapter 1, 2004. http://www.who.int/healthsystems/topics/delivery/en/index.html (cited on 27 August 2010)

Sultz HA, Young KM. Health Care USA understanding its Organization and Delivery, 4th editon. Bosston Mass: Jone & Bartlett publishing. 2003. . : .. . .. , . .. . .. .

. . . . . . Walter A. Shewhart (.. ) (process quality control chart) (control limit) , Motorolla (.. ) (sigma) . (six sigma: 6) . . (continuous quality improvement: CQI). W. Edwards Deming .

. . (ISO) (International Organization for Standardization) .. . ISO 9000 , ISO 14000 ISO 18000 . ( ) : .. (Malcolm Baldrige National Quality Award: MBNQA) .. .. . MBNQA (Thailand Quality Award: TQA) .. . .. ( .) (MBNQA , TQA ) , , , , , . :. . . (objectivity) ,

(key performance indicator: KPI). (benchmark) . . .. (MBNQA) (TQA) , , . , (), . balanced scorecard , , /. . (re-engineering) (breakthrough improvement and innovation). MBNQA (effectiveness) (lean) (efficiency) ( ) . (waste) (value) , . (value stream map - VSM) (spaghetti diagram).

. . (composite indicators) . . / / (seamless total integrated processes).

( ) , , , . . . .. Florence Nightingale . . . Earnest A. Codman (end result system of hospital standardization) (American College of Surgeons) .. .. .

(hospital standardization program) .. . .. , .. (American College of Physicians), (American Hospital Association), (American Medical Association) (Canadian Medical Association) (Joint Commission on Accreditation of Hospitals) (standardization) (accreditation). .. (Social Security Amendments of 1965) (Medicare) . . (Joint Commission on Accreditation of Healthcare Organization: JCAHO) .. Joint Commission .. . . , . :. . . . . . . :

. . . . . (threshold) . . (quality assurance). . . . . . (CQI) , . . ( ) . .

(criteria for performance excellence) (general criteria), (education criteria) (health care criteria) . (lean management) ( ) . . . . (customer-focused) (people-centered and humanized health care). (adverse event) . U.S. National Academy of Sciences Institute of Medicine (IOM) To Err is Human : Building a Safer Health System (2000), Crossing the Quality Chasm: A New Health System for the 21st Century (2001); U.K. Chief Medical Officer An Organization with a Memory (2000) Building a Safer NHS for Patients (2001). . . :. . . .

. ( ) (safety margin) . . . (efficacy) (effectiveness) . . . . . (Swiss cheese model of accident causation) .. . , . . . :. ( ) trigger tool . . . . .

.

. ( ) . . (failure mode & effect analysis) . ., . . .

. .. . .. . . .

( ) :- .. . - .. , , ; ; ; . - ( .. ) (license) . . () . ( ). ( CQI, TQM, benchmarking, Lean) . (Hospital Accreditation: HA) (.) .. () . . (Hospital Accreditation: HA) . (accredited). . :-

.. / .. () (hospital accreditation) .. (.) (comprehensive health service) . .. (.) (TQM)/ (CQI) . .. . . .. . (.) .. . .. . .. . (.) . .. . .. . HA . . .

. .. . (HPH Accreditation) . .. . (TQA). .. . () .. :. (learning) (auditing) . . / (people-centered health care) (humanized health care) . (move the whole organization). . (optimal results). . continuous quality improvement: CQI (Plan Do Study Act). . , (3P: Purpose, Process, and Performance). . . (chapter) .. . .

.

. () () () , .. . . . :. . . (International Society for Quality in Health Care: ISQua) . ISQua . ISQua .. . . . ( )

. . (Joint Commission International: JCI) (Joint Commission: JCI) .. . JCI HA . JCI (third edition) .. (chapter) (sections) (Chapter International Patient Safety Goals) () , () , () , () , , () () . : () , () , () , () , () , () () . : () , () , () , , () , () () . JCI (medical hub) JCI .

.

( Medicare Medicare Joint Commission) . . . (pay for performance: P4P) . P4P () , () P4P , () P4P, () . P4P :- (reduce payment for bad performance or bad efficiency) - (market-based control for patient safety) . . (length of stay: LOS) (total additional LOS from adverse events) .

P4P . . ( ) ( ) . ( ) .. :. . . . . . . (stroke) . ST elevated (STEMI) (hospital accreditation: HA) .

, . CQI, TQM, Lean .

() . ( ) . . () . . (pay for performance) . .

. . Patient Safety : Concept and Practice. :

; .. .

. .. (). HA . .

.. . ..

. .. . .. .

; .. . /

(Quality Performance Payment Guideline). .. .

. ; ; .. . TQM/CQI . : ; .

. . HA Update . ; . . . Lean & Seamless Healthcare. ; . . . HA Update . ; . . Agency for Healthcare Research and Quality. AHRQ Resources on Pay for Performance (P4P). [online]

[cited 2010 March 30] available from: URL: http://www.ahrq.gov/qual/pay4per.htm. Baldrige National Quality Program. Criteria for Performance Excellence. [online] [cited 2010 March 24]

available from: URL: http://www.baldrige.nist.gov/Criteria.htm. Graban M. Lean Hospitals: improving quality, patient safety, and employee satisfaction. New York: Prod-

uctivity Press; 2009.. Hjort B. The HIM Role in Patient Safety and Quality of Care (AHIMA Practice Brief) Journal Of AHMIA 76,

no.1 (January 2005): 56A-G.. Joint Commission. A Journey Through the History of The Joint Commission. [online] [cited 2010 March

24] available from: URL: http://www.jointcommission.org/AboutUs/ joint_commission_history.htm. Joint Commission International. About Joint Commission International. [online] [cited 2009 December 20]

available from: URL: http://www.jointcommissioninternational.org/about-jci/. Joint Commission on Accreditation of Healthcare Organizations. Advanced Performance Improvement for

Hospitals. 2000.. Thai Industrial Standards Institute. ISO 9000 : 2000. [online] [cited 2010

March 23] available from: URL: http://app.tisi.go.th/9ky2k/9000.html. World Health Organization (Western Pacific Region). People-Centred Health Care: A Policy Framework.

2007.

(disease management) (Boston Consulting Group) .. . (population-based care), (disease state management), (continuous health care improvement); () (disease state) (acute episode) . . . :- (tertiary prevention) . . . . . .

. . .

. .

.

. (Health Evi

dence Network: HEN) (WHO Euro) :. (comprehensive care) . , (integrated care, care continuum, coordination of the different components) . (population orientation) . (active client-patient management tools) . , (evidence-based guidelines, protocols, care pathways) . (information technology, system solutions) . (continuous quality improvement). (Disease Management Association of America: DMAA) :. . . . . , . . . . . . . : (patient population) (recipient) (intervention content) (delivery personnel) . (method of communication) . (intensity and complexity) .

.

. (environment) . . (outcome measures) , .

( ) () () () () () . . . ( ) , () () . ( ) . . . ( ) (high prevalence of chronic disease state), () , () , () () . , , , , , . ( , ); ( , , ); ( ); ( ); (ambulatory infec

tious diseases) ( , ); ( ); ; ( , , , , ). . . ( ) (self-management support), () (delivery system design), () (decision support and clinical information systems). (American Healthways) ( ) (program organization), () (pro

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