Sustainability and effectiveness Sustainability and effectiveness

of of

health care delivery :health care delivery :

National experience of Thailand National experience of Thailand

Piya Netrawichien,MDChantana Boon-Arj

2

1)   Health care coverage in 1)   Health care coverage in ThailandThailand

Structure of the Structure of the presentationpresentation

2)   Health care delivery under the 2)   Health care delivery under the Social Security Scheme (SSS)Social Security Scheme (SSS)

3) Health care delivery under the 3) Health care delivery under the Universal Health Care Scheme Universal Health Care Scheme (UC) (UC)

3

   1) Fringe benefit schemes1) Fringe benefit schemes -  Civil Servant Medical Benefit Scheme -  State Enterprise Medical Benefit Scheme 2) Health Insurance under 2) Health Insurance under the Social Security Schemethe Social Security Scheme

   3) Universal Health Care 3) Universal Health Care SchemeScheme

Health care coverage in Health care coverage in

ThailandThailand

4

1) Financing of the Scheme 1) Financing of the Scheme

    - Contribution and compulsory - Contribution and compulsory systemsystem

- Sickness include medical care and - Sickness include medical care and cash benefitcash benefit

Health care delivery under the Social Security Scheme

(SSS)

5

Some illnesses/treatments are not covered Some illnesses/treatments are not covered for example : Drug addiction, cosmetic surgery, for example : Drug addiction, cosmetic surgery, researching treatment, infertility condition, etc. researching treatment, infertility condition, etc.

- Ambulance and transportation services; - Ambulance and transportation services; andand

- Ancillary services- Ancillary services

- Medication and pharmaceutical - Medication and pharmaceutical productsproducts

- General practitioner and specialist - General practitioner and specialist care; care;

2) The Medical Benefit Package2) The Medical Benefit Package

- Outpatient and inpatient care;- Outpatient and inpatient care;

6

3) Health care provider3) Health care provider

Requirement on hospital Requirement on hospital standards,standards,

- a minimum of 100 beds- a minimum of 100 beds

- 11 standards- 11 standards

- referral system- referral system

7

4)  Payment mechanism4)  Payment mechanism

Capitation PaymentCapitation Payment

- based on the number of registered - based on the number of registered insured persons insured persons

- 1,250 bahts per person per year- 1,250 bahts per person per year

- Monthly payment- Monthly payment

- - At the beginning of the month – 75%At the beginning of the month – 75%

- - At the end of the month – 25%At the end of the month – 25%

8

Additional payment for special high Additional payment for special high cost servicescost services

- reimbursement with fixed fee schedules - reimbursement with fixed fee schedules

such as open heart surgery, coronary bypass, such as open heart surgery, coronary bypass,

brain surgery etc.brain surgery etc.

Additional payment for utilization Additional payment for utilization incentivesincentives - extra capitation payments to hospitals - extra capitation payments to hospitals

whose caseloads are within the specific whose caseloads are within the specific

percentile rankpercentile rank

9

Additional payment for risk Additional payment for risk adjusted capitationadjusted capitation

- payment for risk adjusted capitation - payment for risk adjusted capitation

due to the 25 chronic diseases that occurred to due to the 25 chronic diseases that occurred to

the insured persons (out patient)the insured persons (out patient)

Payment for care arising from Payment for care arising from emergencies and accidentsemergencies and accidents

10

5)5) Quality Assurance SystemQuality Assurance System

Hospital quality assurance projectHospital quality assurance project

11

6)6) Sustainability of Social Security Sustainability of Social Security FundFund ILO preliminary actuarial review of the ILO preliminary actuarial review of the

reserve fund for short-term reserve fund for short-term benefits including sickness benefit is benefits including sickness benefit is expected to exceed 10 times benefits expected to exceed 10 times benefits expenditure in 2015.expenditure in 2015.

Therefore, the Social Security fund is still Therefore, the Social Security fund is still sustainable in long run.sustainable in long run.

12

Health care delivery under the Health care delivery under the Universal Health Care Scheme Universal Health Care Scheme

(UC)(UC)

13

Interest on assets Interest on assets Other cash income earned Other cash income earned Contributions by Contributions by beneficiaries beneficiaries

Donations Donations

Fines from violation of the act Fines from violation of the act

1) Financing of the scheme 1) Financing of the scheme UC is financed by general tax revenue with UC is financed by general tax revenue with

other 7 sources of income other 7 sources of income

Contributions from local governments Contributions from local governments

Co-payments by patients Co-payments by patients

14

2) Benefit Package include:2) Benefit Package include:

Benefit package do not cover:Benefit package do not cover:

Curative and rehabilitation care Curative and rehabilitation care

Health promotion and disease preventionHealth promotion and disease prevention

Groups of medical services beyond Groups of medical services beyond the basic needs the basic needs

Groups of medical service for which Groups of medical service for which specific budgets have been allocated specific budgets have been allocated

15

3) Health care provider 3) Health care provider

Service Units under UCService Units under UC

Category 1 : Contracted units of Category 1 : Contracted units of primary care (CUP) primary care (CUP)

Category 2 : Subcontractors of a Category 2 : Subcontractors of a CUP CUP Category 3 : Contracted units of Category 3 : Contracted units of

secondary care (CUS) or secondary care (CUS) or contracted units of tertiary contracted units of tertiary care (CUT) care (CUT)

Category 4 : Units of super tertiary Category 4 : Units of super tertiary care care

16

Process of registration (for private Process of registration (for private health care provider) health care provider)

branch offices negotiate with local health branch offices negotiate with local health facilities who wish to participate facilities who wish to participate

certification of the qualification and certification of the qualification and registration of health facilities will be registration of health facilities will be announced to the publicannounced to the public

health facilities and NHSO signed the health facilities and NHSO signed the contractcontract

Management of Services SystemManagement of Services System

17

Management of capitation budgetManagement of capitation budget

4) Payment Mechanism 4) Payment Mechanism

Per capita budget Baht 1,659 (2006) Per capita budget Baht 1,659 (2006)

Age dAge differential capitation for curative ifferential capitation for curative carecare Flat rate capitation for prevention and Flat rate capitation for prevention and

promotion servicespromotion services

18

Management of accident, Management of accident, emergency and high cost care fund emergency and high cost care fund

Reimbursement of outpatient and Reimbursement of outpatient and inpatients inpatients Reimbursement of high cost care Reimbursement of high cost care

Reimbursement of medical prostheses Reimbursement of medical prostheses and instrumentsand instruments

19

Management of capital replacement Management of capital replacement fund fund

Capital replacement plan Capital replacement plan

20

Management of no fault liability Management of no fault liability fund fund

Financial assistance to UC beneficiaries Financial assistance to UC beneficiaries

21

5)5) Quality Assurance SystemQuality Assurance System

Upgrading health centres to meet Upgrading health centres to meet

standards standards of PCU of PCU

Promoting hospital accreditationPromoting hospital accreditation

Promoting quality and standard of Promoting quality and standard of

excellent excellent centres centres

22

6)6) Sustainability of the Scheme Sustainability of the Scheme

Feasibility studies on alternative Feasibility studies on alternative

sources of fundingsources of funding, e.g., sin , e.g., sin

tax, value added tax, in addition to tax, value added tax, in addition to

improving efficiency of the current improving efficiency of the current

insurance schemes, are being insurance schemes, are being

undertaken in order to improve undertaken in order to improve

financial sustainability of the UC financial sustainability of the UC

Scheme and controlling health care Scheme and controlling health care

costscosts

23

SAWASDEE