Impact of Elective Surgery in Private Hospitals under the Civil Servant Medical

Benefit Scheme (CSMBS) to Health System

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ส ำนักงำนวจัิยเพื่อกำรพัฒนำหลักประกันสุขภำพไทย

Phatthanawilai Inmai

Samrit Srithamrongsawat

Naresuan University Health Insurance System Research Office (HISRO)

outline

1. Introduction

2. Objective

3. Methodology

4. Results

5. Conclusion and recommendation

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Introduction

• Since May 2011, CSMBS patients have been

allowed to get 77 items of elective surgeries in private hospitals.

• This policy aims to reduce access and waiting time for surgery appointments in private hospitals.

• 80 hospitals applied. Only 32 hospitals were approved by CGD, but only 26 could send completed and accurate reimburse document.

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Introduction

• Private hospitals use prospective payment system.

• The scheme pays private hospitals by Diagnosis Related Group (DRG) and the hospitals can charge extra for bed, board and doctor fee etc.

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Objectives

• To assess utilization trend for cataract surgery,

childbirth and knee replacement in public and private hospitals before and after policy implementation.

• To study the burden of expenditure on patients and the health insurance scheme (CSMBS).

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Methodology • This study used three databases:

1. Claim administrative databases of the CSMBS in private hospitals. Data was collected on May 1St, 2011 to April 30th, 2012.

2. In-patient database (IPD) of the CSMBS in public and private hospitals.

3. In-patient database (IPD) of the universal coverage scheme (UCS) in public and private hospitals.

Population : patient services (CSMBS) of elective surgery in private hospital which participated. It is 4,706 admissions. Including, the CSMBS patients in IPD about six thousand hundred baht and the UC patients around 5 million admissions.

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Selected ICD-code

• Intra Ocular Lens Replacement for cataract;

ICD10: H25 – H28 and ICD9CM: 13.11 – 13.69

• Childbirth; ICD10: O80 – O84

• Knee replacement; ICD9CM: 81.54 – 81.55

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RESULTS

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Table 1 descriptive analysis

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descriptive percent sex male 39% female 61% average age (year) 71±13

Intra Ocular Lens Replacement for cataract

73±9

Childbirth 33±6 Knee replacement 72±12 others 49±68 kind of beneficiary official 78%+1.5% government pension. 20.5%

relationship between beneficiary with patients oneself 22.8% parent 69.2% child 0.3% spouse 7.7%

utilization trend: before and after policy implementation of CSMBS in public hospitals

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32,579

20,767

4,107

31,482

20,438

4,056

-

5,000

10,000

15,000

20,000

25,000

30,000

35,000

cataract childbirth kneereplacement

after and before policy for public hospitals

before after

(3.37)

(1.58)

(1.24)

(4.00)

(3.50)

(3.00)

(2.50)

(2.00)

(1.50)

(1.00)

(0.50)

-

IOL forcataract

child birth kneereplacement

% growth rate

Source: Claim administrative databases of the CSMBS in private hospitals and IPD database of the CSMBS in public hospital

Utilization in private hospitals

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cataract, 80

childbirth, 5

knee replacement,

2 others, 13

Utilization of elective surgery in UCS H

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Source: Claim administrative databases of the UCS in private hospitals and IPD database of the UCS in public hospital

33,475

179,680

2,069

37,924

186,684

2,713 -

50,000

100,000

150,000

200,000

cataract childbirth knee replacement

public hospitals before

after

13,558

6,122

323

20,165

6,354

272 -

10,000

20,000

30,000

cataract childbirth knee replacement

private hospitals before

after

13.29% 3.90%

31.13%

48.73%

3.79%

-15.79% -20%

0%

20%

40%

60%

IOL for cataract child birth knee replacement

%growth rate public

private

burden of expenditure on patients

• Almost all medical expenses

paid by CGD (95.9%) such as

– Medicines in National List of

Essential Medicines

– Artificial organ and instrument

lists

– Doctor free

– Bed and board

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CGD, 95.9

pateints, 4.1

Median of expenditure for CSMBS per month

• Reimburse to private hospitals for elective surgery in 1 year was 155.5 million baht

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22

30

0

5

10

15

20

25

30

35

before after

mill

ion

bah

t

Reimburse for private hospital by procedures

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0

2

4

6

8

10

12

14

16

18

May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12

mill

ion

bah

t

cataract childbirth knee replacement others

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• burden of expenditure for IOL for cataract surgery

0

5,00

010

,000

15,0

0020

,000

25,0

0030

,000

cata

ract

Hos 1

Hos 2

Hos 3

Hos 4

Hos 5 Hos 6

Hos 7

Hos 8

Hos 9

Hos 10

Hos 11

Hos 12

Hos 13 Hos 14

Hos 15

Hos 16

Hos 17

Hos 18

Hos 19

Hos 20

burden of expenditure

Almost all medical expenses paid by CGD, Ministry of Commerce is 95.9%

1,985

burden of expenditure for childbirth

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0

5,0

00

10

,000

15

,000

20

,000

25

,000

30

,000

child

bir

th

hos1

hos2

hos3

hos4

hos5

hos6

hos7

hos8

hos9

hos10

hos11

hos12 hos13

hos14 hos15

hos16

hos17 hos18

hos19

2,155

burden of expenditure for knee replacement

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0

50

,000

10

00

00

15

00

00

kne

eR

ep

lacem

ent

Hos1

Hos2

Hos3

Hos4

20,155

conclusion

• This policy increased accessibility of IOL replacement for cataract patients due to increased of reimbursement.

• This policy had positive impact on cataract UC patients to access to public hospitals.

• The copayment of knee replacement was burden of expenditures for patients

• Expenditures in CSMBS was clearly increased after policy implementation but it still less compared to Thailand health expenditures (0.6%).

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recommendation

• More private hospitals should be encouraged to participate with CSMBS surgery plan.

• More procedures should be considered to provided more choice for patients.

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reference

• กรมบญัชกีลาง. การเบกิจา่ยตรงประเภทผูป้ว่ยในสถานพยาบาลของเอกชนตามเกณฑก์ลุม่วนิิจฉยัโรครว่ม (DRGs). กระทรวงการคลงั; ๒๕๕๔.

• กรมบญัชกีลาง. การเบกิจา่ยเงนิคา่รกัษาพยาบาลประเภทผูป้ว่ยในตามเกณฑก์ลุม่วนิิจฉยัโรครว่ม (DRGs) กระทรวงการคลงั; ๒๕๕๔.

• สมัฤทธิ ์ศรธี ารงสวสัดิ,์ นพคุณ ธรรมธชัอาร,ี พชันี ธรรมวนันา, และ สุธรีดา ฉิมน้อย. ศกัยภาพระบบสวสัดกิารรกัษาพยาบาลขา้ราชการในการก ากบัโรงพยาบาลเอกชนคูส่ญัญา. นนทบุร:ี ส านกังานวจิยัเพือ่การพฒันาหลกัประกนัสุขภาพไทย; ๒๕๕๕.

• Rayburn JM, Rayburn L.G., Punam RL. Study indicates mixed cost containment-efficiency results from PPS implementation. Journal of Health and Social Policy (๔); ๑๙๙๒. p. ๑๙-๓๐.

• Rosko MD. Impact of HMO penetration and other environmental factors on hospital X-efficiency. Medical Care Research Review; ๒๐๐๑. ๕๘: ๔๓๐-๔๕๔.

• Lin, HC, Xirasagar, S., and Tang, CH. Costs per discharge and hospital ownership under prospective payment and cost-based reimbursement systems in Taiwan. Health Policy Plan; ๒๐๐๔. ๑๙(๓): ๑๖๖ -๑๗๖.

• สุธรีดา ฉิมน้อย, พฒันาวไิล อนิใหม, สรินิาฏ นิภาพร. และสมัฤทธิ ์ศรธี ารงสวสัดิ.์ ประสบการณ์ผูป้ว่ยสทิธสิวสัดกิารรกัษาพยาบาลขา้ราชการในการรบับรกิารผา่ตดัแบบนดัหมายลว่งหน้าในโรงพยาบาลเอกชน. นนทบุร:ี ส านกังานวจิยัเพือ่การพฒันาหลกัประกนัสุขภาพไทย; ๒๕๕๕. (อยูร่ะหวา่งรอตพีมิพ)์

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THANK YOU

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