Variations in the performance of three public insurance schemes in Thailand

Abstract

International experience shows that achieving universal coverage has been an important way to ensure equity of access to health care and to protect people from bankruptcy due to severe illness. One common approach to universal coverage has been to expand public health insurance to cover all people in a country. In Thailand, universal coverage of health care in Thailand was achieved by expanding public insurance to the uninsured. Before universal coverage, there were two main public insurance schemes, the Civil Servant Medical Benefit Scheme (CSMBS) and the Social Security Scheme (SSS). Merging two other schemes targeted at lower income groups, (the low income card scheme and health card scheme), and adding the uninsured population, produced the Universal Coverage Scheme (UC), a third and much larger scheme. The three schemes differ in a number of ways including funding, payment of provider and benefit package. There has been considerable concern that these characteristics might affect the performance of the insurance schemes. The aim of this study was to evaluate the three public health insurance schemes in terms of their performance in selected areas. The first objective was to assess and explain variation in performance in terms of utilization, length of stay (LOS), and early readmission. The second was to identify the quality of care provided in each Insurance scheme using Diabetes Mellitus (OM) as a tracer of performance and examining LOS, early readmission, and various other indicators of quality of care. To answer the first objective, the Health and Welfare Survey 2005 was used to analyse uti lization by scheme and national claims data were used to analyse LOS and early readmission of OM patients. To assess quality of care in detail, primary quantitative and qualitative data were collected on OM patients and providers in Samutsakhon province. The study indicates that the type of insurance scheme influences performance. The utilization review found that SSS members had a higher probability of using ambulatory services but a lower probability of being hospitalized. CSMBS members had a higher probability of being hospitalized. Members of the VC scheme had shorter LOS than CSMBS members and a higher probability of readmission relative to both SSS and CSMBS members. The empirical study found that CSMBS members were more likely to receive care consistent with standard guidelines. However, intermediate outcomes such as fasting plasma glucose, and Haemoglobin Ale level, were not as good as might be expected possibly due to the effects of other factors such as body mass index and patient behaviour. The qualitative study found that different patient groups had different expectations and perceptions of quality of service and that the insurance scheme and hospital policy influenced provider behaviour. The study demonstrates that, despite universal coverage, patients covered by different insurance schemes experienced variation in quantity and quality of care. Countries moving toward universal coverage should pay particular attention to the features of the insurance scheme design, especially with respect to management, organization, provider payment and the benefit package, as these features influence the performance of the scheme and the ability to achieve health system goals.