Medical Benefit Scheme Research Articles

Access to precision medicine in Thailand: a comparative study

PurposeThis study explored health insurance coverage of genetic testing and potential factors associated with precision medicine (PM) reimbursement in Thailand.Design/methodology/approachThe study employed a targeted review method. Thirteen PMs were selected to represent four PM categories: targeted cancer therapy candidate, prediction of adverse drug reactions (ADRs), dose adjustment and cancer risk prediction. Content analysis was performed to compare access to PMs among three health insurance schemes in Thailand. The primary outcome of the study was evaluating PM test reimbursement status. Secondary outcomes included clinical practice guidelines, PMs statement in FDA-approved leaflet and economic evaluation.FindingsCivil Servant Medical Benefits Scheme (CSMBS) provided more generous access to PM than Universal Coverage Scheme (UCS) and Social Security Scheme (SSS). Evidence of economic evaluations likely impacted the reimbursement decisions of SSS and UCS, while the information provided in FDA-approved leaflets seemed to impact the reimbursement decisions of CSMBS. Three health insurance schemes provided adequate access to PM tests for some cancer-targeted therapies, while gaps existed for access to PM tests for serious ADRs prevention, dose adjustment and cancer risk prediction.Originality/valueThis was the first study to explore the situation of access to PMs in Thailand. The evidence alerts public health insurance schemes to reconsider access to PMs. Development of health technology assessment guidelines for PM test reimbursement decisions should be prioritized.

Participatory and responsive governance in universal health coverage: an analysis of legislative provisions in Thailand

Participatory and responsive governance in universal health coverage (UHC) systems synergistically ensure the needs of citizens are protected and met. In Thailand, UHC constitutes of three public insurance schemes: Civil...

Health Technology Assessment in Australia: The Pharmaceutical Benefits Advisory Committee and Medical Services Advisory Committee

Health technology assessment (HTA) was introduced in Australia for the reimbursement of pharmaceuticals in 1992 and in the following years for procedures, diagnostic tests, and devices. The Australian health system is largely funded by the government. The Pharmaceutical Benefits Scheme is a national list of prescription pharmaceuticals for which the patient pays a small copayment. HTA submissions to the Pharmaceutical Benefits Scheme are assessed by the Pharmaceutical Benefits Advisory Committee. The Medical Benefits Scheme provides ambulatory medical services and HTA submissions are assessed by the Medical Services Advisory Committee. This article describes the processes of reimbursement in Australia as well as the special case of codependent technologies (eg, diagnostic test and a therapeutic drug) where a combined Medical Services Advisory Committee and Pharmaceutical Benefits Advisory Committee application is required. There are many future challenges for HTA in Australia, with growing pressure to provide early access to promising treatments and high cost personalized medicines looming on the horizon. However, Australia is well placed to deal with these issues as the early adoption of HTA and coexistence between industry, academia and the payer has proven to be a fertile environment for developing capacity to undertake and evaluate HTA.

Rates, costs and determinants of lumbar spine imaging in population-based women born in 1973-1978: Data from the Australian Longitudinal Study on Women's Health.

ObjectiveThere are concerns that lumbar spine imaging represents low value care. Our aim was to examine the use of lumbar spine imaging [radiography, computed tomography (CT), magnetic resonance imaging (MRI)] over 20 years, and costs and person-level characteristics of imaging in a large cohort of Australian women.MethodsThe Australian Longitudinal Study on Women’s Health (ALSWH) is a longitudinal population-based survey of women randomly selected from national health insurance scheme (Medicare) database. This study examined 13458 women born in 1973–1978 who consented to link their ALSWH and Medical Benefits Scheme records. Self-reported data on demographics, body mass index, depression, physical and mental health, and back pain were collected in each survey performed in 1996, 2000, 2003, 2006, 2009, 2012, and 2015. Data on lumbar spine imaging from 1996 to 2015 were obtained from the Medical Benefits Scheme database.Results38.9% of women underwent some form of lumbar spine imaging over 20 years. While radiography increased from 1996 to 2011 and decreased thereafter, CT and MRI continued to increase from 1996 to 2015. In women with self-reported back pain, depression and poorer physical health were associated with imaging, with no significant differences in types of imaging. Based on imaging rates in ALSWH, the estimated costs for Australian women aged 30–39 years were AU$51,735,649 over 2011–2015.ConclusionsLumbar spine imaging was common in population-based Australian women, with rates increasing over 20 years. Depression and poor physical health were associated with lumbar spine imaging. Raising awareness of this in clinicians is likely to result in significant cost savings if clinical guidelines are followed, with the potential of freeing resources for high value care and health outcomes.

The Impact of a Billing System on Healthcare Utilization: Evidence from the Thai Civil Servant Medical Benefit Scheme

AbstractThis study examines how a new billing process of the Thai Civil Servant Medical Benefit Scheme affects outpatient care utilization. Unlike policy changes considered in most existing studies, there is no change in cost‐sharing for the scheme considered here. Previously, the beneficiaries had to pay out of pocket and receive their reimbursement later. The new billing system allows hospitals to charge the government directly. Using patient‐level data from a large hospital, we find that the change affects outpatient utilization through both visiting rates and treatment intensity. These positive impacts are moderate, but persistent. The estimates are not sensitive to our choice of a time window, but their magnitudes can be sensitive to model specifications. Our analysis also suggests that patients with lower utilization rates (conditional on illnesses) prior to the change in the billing process increase their healthcare utilization more proportionally.

Effect of Insurance Type on Stage at Presentation, Surgical Approach, Tumor Recurrence and Cancer-Specific Survival in Resectable Non-Small Lung Cancer Patients.

PurposeThe aim of this study was to identify the association between Thailand’s insurance types and stage at presentation, surgical approach, tumor recurrence and cancer-specific survival in resectable non-small cell lung cancer (NSCLC) patients in northern Thailand.Patients and MethodsMedical records of patients with NSCLC who underwent pulmonary resection at Chiang Mai University Hospital from January 2007 through December 2015 were retrospectively reviewed. Patients were divided into two groups: patients with the Universal Coverage Scheme (UCS) or Social Security Scheme (SSS) and patients with the Civil Servant Medical Benefit Scheme (CSMBS) or private insurance (PI). Patient characteristics were assessed. The primary outcome was cancer-specific survival while the secondary outcome was tumor recurrence. Cox’s regression and matching propensity score analysis was used to analyze data.ResultsThis study included 583 patients: 344 with UCS or SSS and 239 with CSMBS or PI. Patients with UCS or SSS were more likely to be active smokers, have a lower percent predicted FEV1, present with higher-stage tumors and worse differentiated tumors, present with tumor necrosis, and undergo an open surgical approach than those with CSMBS or PI. At multivariable analysis of all patients cohort, there were no significant differences in terms of early stage at presentation (adjusted odds ratio (ORadj) = 0.94, 95% confidence interval (CI) = 0.65–1.37), undergoing lobectomy (ORadj = 0.59, 95% CI = 0.24–1.46), and recurrent-free survival (adjusted hazard ratio (HRadj) =1.20, 95% CI = 0.88–1.65) between groups (UCS/SSS versus CSMBS/PI). However, patients with UCS or SSS had shorter cancer-specific survival (HRadj = 1.61, 95% CI = 1.22–2.15). The results from the propensity score matched patient cohort were not different from those analyses on the full patient cohort.ConclusionThai insurance types have an effect on cancer-specific survival. The Thai government should recognize the importance of these differences, and further multi-center studies with a larger sample size are warranted to confirm this result.

Rates, costs and determinants of lumbar spine imaging in population-based women born in 1973-1978: a prospective cohort study

Purpose: Lumbar spine imaging for non-specific low back pain is designated as low value care. Of concern is the overuse of lumbar spine imaging, including radiography, computed tomography (CT) and magnetic resonance imaging (MRI), which is discordant with the clinical guidelines. The aim of this study was to examine the use of lumbar spine imaging over 20 years, and costs and person-level characteristics associated with lumbar spine imaging in a large cohort of Australian women. Methods: The Australian Longitudinal Study on Women’s Health (ALSWH) is a longitudinal population-based survey of women randomly selected from national health insurance scheme (Medicare) database. This study examined 13458 women born in 1973-1978 who consented to link their ALSWH and Medical Benefits Scheme records. Self-reported data on demographics, body mass index, depression, physical and mental health, and back pain were collected in each survey performed in 1996, 2000, 2003, 2006, 2009, 2012, and 2015. Data on lumbar spine imaging from 1996 to 2015 were obtained from the Medical Benefits Scheme database. Results: 38.9% of women underwent some form of lumbar spine imaging over 20 years. While radiography increased from 1996 to 2011 and decreased thereafter, CT and MRI continued to increase from 1996 to 2015. The increased imaging rates were not simply due to ageing, but also time period related factors. In women with self-reported back pain, depression and poorer physical and mental health were associated with imaging, with no significant differences in types of imaging. Based on imaging rates in ALSWH, the estimated costs for Australian women aged 30-39 years were $51,735,649 over 2011-2015, with a potential cost saving of >$36 million in this population alone if clinical guidelines were followed. Conclusions: Lumbar spine imaging was common in population-based Australian women, with rates increasing from 1996 to 2015 which were explained by effect of ageing and time period. This study highlights the potential for substantial cost savings if imaging was performed as recommended by clinical guidelines. Depression, physical and mental health were associated with lumbar spine imaging. Targeting women with these conditions and raising awareness of this in primary care providers are likely to result in significant cost savings if clinical guidelines are followed, with the potential of freeing resources for high value care and health outcomes.

Changes in Prescribed Treatments Following Parathyroidectomy for Primary Hyperparathyroidism in Older Adults

© The Author(s). Aim and objective: Primary hyperparathyroidism (PHPT) is associated with multiple comorbidities and diverse symptomology that often require management with prescribed medications. Parathyroidectomy is an established treatment for PHPT but may also reduce the need for medications required to treat the associated conditions. We examined the changes in dispensed drugs given to a cohort of older adults with PHPT before and following parathyroidectomy. Materials and methods: A publicly available administrative Pharmaceutical and Medical Benefits Scheme database was used for this study. Participants aged >45 years undergoing parathyroidectomy for PHPT were identified by procedure codes for the period 2008 to 2014. Anatomic Therapeutic Chemical codes (ATC) assigned to drugs prescribed to individual participants, pre-and postoperatively, were used to define therapeutic groups and calculate cohort prevalences. Changes in dispensed medications following parathyroidectomy were assessed by the modulation of ATC class prevalence estimates of drugs prescribed using the Autoregressive Integrated Moving Averages (ARIMA) time-series methodology. Results: Six hundred and ten persons aged >45 years (M 72.1, SD 7.0) undergoing parathyroidectomy for PHPT were recruited. Preoperative dispensed treatment prevalences were highest for agents acting on the renin–angiotensin system (48%), dyslipidemia (45%), acid disorders (37%), antibiotics (31%), and analgesics (20%). Treatment prevalences for all ATC defined medications remained either unchanged or increased 3 years postoperatively. Polypharmacy following surgery also increased from an average 5.9 (SD = 4.0, range 0–23) prescribed medications for chronic conditions preoperatively to 7.0 (SD = 4.0) at 2 years (p < 0.001). Conclusion: The prevalence of ATC classified drugs prescribed and dispensed for chronic conditions in older adults with PHPT changed minimally following parathyroidectomy and polypharmacy of dispensed medications increased. Clinical significance: Parathyroidectomy performed in older persons for PHPT has a limited impact on the prevalence of dispensed drugs used to treat many of the associated chronic conditions. Mesh: Big data; Chronic conditions; Drug utilization; Hyperparathyroidism; Polypharmacy; Primary; Surgery.

Insights into implementation of routine depression screening and psychosocial assessment in a private hospital setting: A qualitative study.

Studies continue to show that women who give birth in the private maternity sector are less likely to receive depression screening and psychosocial assessment as a routine component of maternity care. However, examples of successfully implemented routine psychosocial assessment programs are beginning to emerge, and there is great value in better understanding the factors that can contribute to the successful delivery of emotional health care in this context. The aim of this study was to identify factors that facilitated successful implementation of antenatal psychosocial assessment in a private hospital setting. This study employed a qualitative research design. Semi-structured interviews were used to explore the views and experiences of health professionals involved in implementation of the program at the participating site. Nine health professionals participated in the study (three midwives, three obstetricians, two managers and one mental health worker). Factors that facilitated successful implementation of the program were reflected in five key themes: (i) multidisciplinary support for the program; (ii) training and clinical supervision; (iii) allocation of sufficient resources; (iv) availability of local referral pathways; and (v) normalisation of the process. This study shows that barriers to implementation of perinatal depression screening and psychosocial assessment are surmountable and will provide confidence to other services, that routine 'mental health assessment' as required under updated Medical Benefits Scheme items for obstetric services, can be successfully implemented and sustained in private hospital settings.

Prevalence and healthcare usage of knee pain in South Australia: a population‐based study

It is known that South Australia (SA) has the highest rate of knee arthroscopy use of any state in Australia; however, Level 1 evidence demonstrates that knee arthroscopy in patients with uncomplicated knee osteoarthritis confers no benefit. In SA, which patients are presenting with knee pain and what treatments are they receiving? To determine the prevalence, persistence and treatment modalities of knee pain in SA. This study analysed data from the North-West Adelaide Health Study (1999-2015), a longitudinal, population-based cohort study of people aged 18 years and over (n = 4060), initially randomly selected from the north-west region of Adelaide, SA. It incorporated clinic assessments, self-completed questionnaires and telephone interviews to collect demographic, anthropometric and biochemical data over four main stages (1, 2, 3 and North-West 15 (NW15)). Data were linked to Medical Benefits Scheme data. In stages 3 and NW15 of the North-West Adelaide Health Study, 30-35% of participants reported knee pain (n = 803, 452). Demographic variables associated with knee pain included older age and lower educational level, while risk factors included obesity and high waist circumference. In the 12 months preceding NW15, 33% of participants with knee pain/stiffness consulted a general practitioner for their knee pain, 10.2% an orthopaedic surgeon, and 12.6% a physiotherapist. Between 2011 and 2015, 3.0% the cohort underwent a knee arthroscopy, and 3.1% underwent knee magnetic resonance imaging. Knee pain affects large proportions of the SA population. Knee pain was persistent with underuse of non-pharmacological treatments and high use of specialist referral. These data support the need for a national strategy to manage osteoarthritis effectively.

Health Insurance and Colorectal Cancer Survival in Khon Kaen, Thailand.

Background:Evidence from healthcare studies demonstrates that patients’ health insurance affects service accessibility and the outcome of treatment. However, assessment on how colorectal cancer survival relates to health insurance is limited. Objective:The study examined the association between health insurance and colorectal cancer survival in Khon Kaen, Thailand. Methods:The retrospective cohort study was conducted with 1,931 colorectal cancer patients from Khon Kaen cancer registry between January 1, 2003 and December 31, 2012, and was followed-up until December 31, 2015. Relative survival was used to estimate the survival rate. Cox proportional hazard regression was used to estimate the relationship between health insurance and colorectal cancer survival, represented with the hazard ratio. Result:Most of the participants were males, and the median age was 62 years. The median survival time was 2.25 years (95% CI: 2.00-2.51). The five-year observed survival rate and relative survival rate were 36.87 (95% CI: 34.66-39.08) and, 42.28 (95% CI: 39.75-44.81), respectively. The factors that showed significant associations with poorer survival after adjustment for gender and age were non-surgical treatments (HRadj=1.88;95%CI=1.45-2.45), advanced stage (III+IV) (HRadj=2.50; 95%CI=2.00-3.12), histological grading in poorly differentiated (HRadj=1.84; 95%CI=1.32-2.56), and Universal Coverage Scheme (HRadj=1.37;95%CI=1.09-1.72). Conclusion:The survival of colorectal cancer patients in the Universal Coverage Scheme was likely to be poorer than in the Civil Servant Medical Benefit Scheme. This indicates an urgent need for a national program for colorectal cancer screening in the general population and access to health insurance.

Cervical re-explorations and proxy survival following parathyroidectomy for primary hyperparathyroidism using Australian administrative data.

Administrative data may have utility in the impartial assessment of surgical outcomes and rare events. We have used a publicly available sample of the Australian pharmaceutical and health service provision (medical benefits scheme) databases to assess outcomes following parathyroidectomy for primary hyperparathyroidism (PHP). A cohort study using linked pharmaceutical and medical benefits schemes data was performed covering the period 1993-2014. Procedure codes identified participants undergoing parathyroidectomy for PHP and subsequent cervical re-exploration surgery (CRX), and the last service date used as a proxy for survival. Time to CRX and survival were modelled using Kaplan-Meier analysis. Demographic data and the era of parathyroid surgery were managed as covariates for Cox regression survival analyses. A total of 2165 persons undergoing parathyroidectomy for PHP were identified. Median follow-up was 5.3 years (range 0.2-22). The annual number of parathyroidectomies for PHP increased gradually; 72 individuals underwent CRX (3.3%). The median time to CRX was 152 days (confidence interval 0-396) in 2000-2004 reducing to 47 days (confidence interval 15-78) for the period 2010-2014 (log-rank P = 0.027). The proportion of persons requiring CRX reduced over time from 6.1% in 1997 to 2.1% in 2012 (r2 = 0.5817, P = 0.023). Overall median survival (24.6 years) was poorer when compared with age matched controls (log-rank P = 0.025) but was not associated with CRX or gender. Administrative data can be used for the assessment of surgical outcomes and may be useful for comparisons of surgical performance, and the appraisal of infrequent events. CRX rates following parathyroidectomy for PHP are improving in Australia.

Impact of treatment and insurance on socioeconomic disparities on the survival of renal cancer patients in Thailand.

576 Background: Access to care is an important aspect of high-quality cancer care. Patients' health insurance status is a factor influencing an individual's ability to access high-quality cancer care. The increased costs of cancer care are negatively impacting patients. 75% of Thai people use the Thailand’s Universal Coverage Scheme (UCS), about 15% use the Civil Servant Medical Benefit Scheme (CSMBS) or the Social Security Scheme (SSS). Only CSMBS can reimburse cost of the targeted therapy. Multiple new therapies have emerged for the treatment of metastatic renal cell carcinoma (mRCC) that showed OS increased in following introduction of targeted therapies and immunotherapy. However, many patients lack access to affordable, high-quality cancer care. Aim: To determine the relationship between treatment affordability, insurance status and RCC cancer survival. Methods: Retrospectively reviewed 281 medical records of RCC patients at the Ramathibodi hospital between January 2009 and December 2017. We searched the Surveillance, Epidemiology, and End Results dataset. Kaplan–Meier methods and multivariable Cox regression models were used to analyze survival outcomes and risk factors. Results: 281 RCC patients, and 127 metastasis were identified. Median age was 59.1 years, and 74.7% were male gender. There were clear cell carcinoma (77.9%), and non-clear cell was 17.1%. IMDC prognostic model categorized as favorable/intermediate/poor risk group as 14.2%/51.2%/29.1%. 41.7% has health insurance status as CSMBS, 7% in SSS and 50.9% in UCS. Only 50% of SSS and UCS paid out of their pocket of mRCC treatment. First line treatment for mRCC were targeted therapy with VEGFR TKI 73.9%, but 26.8% received only supportive care. Median OS was 24 months in the treatment group and only 4.1 months in the best supportive care group (p &lt;0.05). Health insurance status and medication affordability was confirmed as an independent prognostic factor for mRCC patients. Conclusions: Insurance status and medication affordability are important predictive factors for mRCC, and improving access to affordable targeted therapies is likely to improve outcomes in mRCC.

Moscow screening: breast cancer screening with mammography as a method of improving early stage cancer detection

A list of organizational, management, and clinical steps that are crucial for creating an effective breast cancer screening program as part of the state medical benefits scheme in Moscow is presented. We identified key performance indicators for each stage of the screening program. Performance of radiologists and radiology technicians was evaluated, including assessing the accuracy of both single and double reading of mammograms. We streamlined an efficient system for patient routing between the stages of the screening program and developed methodological materials for patients and medical specialists. A shortened structured protocol for mammography interpretation, including second reading, was created in compliance with terms of Moscow Compulsory Medical Insurance Fund. We conceived a framework of educational activities to assess and improve skills and knowledge of radiologists and other specialists participating in the screening.

Equity of a government subsidised exercise referral scheme: A population study

BackgroundHealth inequities could increase if utilisation of physical activity interventions is lower among socioeconomically disadvantaged groups. We examined associations between area level socioeconomic disadvantage and utilisation of Australian government-subsidised, general practitioner (GP)-referred, accredited exercise physiologist (AEPs) services. MethodsWe conducted a cross-sectional analysis of Australian Medical Benefits Scheme (MBS) data (N = 228,771 AEP services) for the 2015–2016 financial year and aggregated publicly available data from several sources. Spearman's correlations examined associations between utilisation of AEP services and area-level socioeconomic disadvantage, indicated by Index of Relative Socioeconomic Disadvantage (IRSD) decile scores. Lower IRSD scores indicate greater levels of socioeconomic disadvantage. ResultsSignificant correlations between IRSD score and study variables were as follows: Out-of-pocket expenses/service (rs = 0.52); number of patients/AEP provider (rs = −0.42); number of patients/1000 population (rs = −0.24); AEP services/1000 population (rs = −0.18); average services/patient (rs = 0.24); and AEP provider/1000 population (rs = 0.14). ConclusionPatients living in areas of greater disadvantage utilised government-subsidised, GP-referred AEP services at a higher rate and paid lower out-of-pocket fees than those living in more affluent areas. Thus, AEP services are equitably distributed, from a utilisation perspective, and acceptable to patients living in areas of disadvantage. However, the higher caseloads and lower fees that characterise AEP services in areas of greater disadvantage may result in shorter consultation times. Further research on exercise referral schemes is warranted, particularly whether socioeconomic disadvantage is associated with adherence to exercise sessions and health outcomes.

Patients\u2019 perspectives regarding hospital visits in the universal health coverage system of Thailand: a qualitative study

BackgroundA universal health coverage policy was implemented in Thailand in 2002 and led to an increase in accessibility to, and equity of, healthcare services. The Thai government and academics have focused on the large-scale aspects, including effectiveness and impacts, of universal health coverage over one decade. Here, we aimed to identify patients’ perspectives on hospital visits under universal health coverage.MethodsA qualitative study was carried out in four public hospitals in rural Thailand. We collected data through focus group discussions (FGDs) and in-depth interviews (IDIs). The semi-structured interview guide was designed to elicit perspectives on hospital visits among participants covered by the Universal Coverage Scheme, Social Security Scheme or Civil Servant Medical Benefit Scheme. Data were transcribed and analysed using a thematic approach.ResultsTwenty-nine participants (mean age, 56.76 ± 16.65 years) participated in five FGDs and one IDI. The emerging themes and sub-themes were identified. Factors influencing decisions to visit hospitals were free healthcare services, perception of serious illness, the need for special tests, and continuity of care. Long waiting times were barriers to hospital visits. Employees, who could not leave their work during office hours, could not access some services such as health check-ups. From the viewpoint of participants, public hospitals provided quality and equitable healthcare services. Nevertheless, shared decision making for treatment plans was not common.ConclusionsThe factors and barriers to utilisation of healthcare services provide exploratory data to understand the healthcare-seeking behaviours of patients. Perceptions towards free services under universal health coverage are positive, but participation in decision making is rare. Future studies should focus on finding ways to balance the needs and barriers to hospital visits and to introduce the concept of shared decision making to both doctors and patients.

PCV61 - Impacts Of ACC/AHA Cholesterol Management Guideline On Statin Consumptions: A Preliminary Study

To evaluate the effects of ACC/AHA cholesterol management guideline on cost of treatment in patients with statins Hospital electronic databases of a university hospital in Thailand were used to determine the impacts of ACC/AHA guideline on utilization of statins. Statin consumptions of outpatient during six-year period (2012-2017), before and after of ACC/AHA guideline implementation, were identified by using Interrupted time-series analysis. Average cost of statin consumptions per prescription in each payment mechanism of health insurance schemes were identified to measure the change of stain consumptions before and after the guidelines’ publication. Based on the estimation of interrupted time- series technique, the intervention was not statistically significant but the trends of statin consumptions were changed dramatically in patients with Universal Healthcare Coverage (UC) scheme and with Social Security (SS) Health insurance scheme. Cost of statin treatment in both schemes were increased after the implementation of ACC/AHA guideline. Controversy, the statin treatment cost per patient under the Civil Servant Medical Benefit Scheme (CSMBS) was declined during short term period after the guidelines’ publication. Policies related quality of care especially clinical practice guidelines might increase access to necessary high price medicines in the UC and SS patients. Moreover, the impacts of the policies could urged rational drug use in patients with all health insurance schemes.

HE3 - A Tale of Two Universal Health Insurance Schemes in One Country: Horizontal Inequality of Government Medical and Pharmaceutical Benefits for Australian Children

To assess the progressivity of government spending in the two universal health insurance schemes– Medical and Pharmaceutical benefits– for Australian children. The Medical benefit scheme is designed to be predominantly income-neutral for children and the Pharmaceutical benefit scheme favoring the poor, however the actual distributions of the spending are unknown. Using the birth cohort of the nationally representative Longitudinal Study of Australian Children conducted during 2003-2014 linked with the Medical and Pharmaceutical claims data, we assessed the distributions of out-of-hospital government Medical and Pharmaceutical spending by household income using concentration indices. The distributions of the spending for children over the whole period covering birth to 11 years of age were assessed. Survey population weights were applied in all analysis so that the results are population-representative. Children with no linked claim record or with household income missing were dropped from the analysis, leaving 4853 children (95.0% of the original sample) corresponding to a weight-adjusted population of 225608 children. The results show that despite the strong progressive design of Pharmaceutical benefits, Pharmaceutical spending over 0-11 years of age favored the poor only insignificantly (concentration index -0.067, 95% CI -0.155, 0.023). The Medical spending on the other hand favored the rich slightly (concentration index 0.043, 95% CI 0.028, 0.058), despite its design to be predominantly income-neutral. The total Medical and Pharmaceutical government spending– sum of the two schemes– was slightly pro-rich (concentration index 0.035, 95% CI 0.018, 0.052). The income-related distributions of the publicly funded, universal, Medical and Pharmaceutical benefits for children in Australia slightly deviated from their designs regarding income, which may reflect differences in parents’ healthcare-seeking preferences and access or barriers to health. Results will inform the design and reform of universal health insurance schemes especially for young children.

Survival Analysis and Associated Factors in THAI Patients on Peritoneal Dialysis under the PD-First Policy

The peritoneal dialysis First (PD-First) policy means that PD is the first modality of dialysis chosen for patients with end-stage renal disease (ESRD), as put forth by the Universal Health Coverage (UHC) scheme. It was initiated in Thailand in 2008. Our aim is to analyze patient survival, technique survival, and associated factors. Data of PD patients from January 2008 to November 2016 were studied. We calculated patient and technique survival rates (censored for death and kidney transplantation). Factors associated with survival were analyzed by the Cox proportional hazard model. Patient and technique survival rates between 2008 - 2012 and 2013 - 2016 were compared. Our study included 11,477 patients. The mean (standard deviation [SD]) age at initiation of PD was 54.0 (14.4) years. The level of education in 85.2% of cases was illiterate or primary school. A total of 60.9% of patients developed ESRD secondary to diabetes. The 1- to 5-year patient survival rates were 82.6, 71.8, 64.0, 58.5, and 54.0%, respectively. The first-year technique survival rate was 94.8%. The patient and technique survival rates during 2013 - 2016 were better than those seen during 2008 - 2012. Factors associated with lower patient survival rates were: female gender, increased age at start of PD, coverage with civil servant medical benefit scheme, low educational levels, and a history of diabetes. Most patients had diabetes and low educational levels as seen in the outcomes in the previous literature. These factors impacted the survival of patients under the PD-First policy.

Inpatient care expenditure of the elderly with chronic diseases who use public health insurance: Disparity in their last year of life

The Thai elderly are eligible for the Civil Servant Medical Benefit Scheme (CS) or Universal Coverage Scheme (UCS) depending on their pre-retirement or their children work status. This study aimed to investigate the disparity in inpatient care expenditures in the last year of life among Thai elderly individuals who used the two public health insurance schemes. Using death registration and inpatient administrative data from 2007 to 2011, our subpopulation group included the elderly with four chronic disease groups: diabetes mellitus, hypertension and cardiovascular disease, heart disease, and cancer. Among 1,242,150 elderly decedents, about 40% of them had at least one of the four chronic disease conditions and were hospitalized in their last year of life. The results showed that the means of inpatient care expenditures in the last year of life paid by CS and UCS per decedent were 99,672 Thai Baht and 52,472 Thai Baht, respectively. On average, UCS used higher healthcare resources by diagnosis-related group relative weight measure per decedent compared with CS. In all cases, the rates of payment for inpatient treatment per diagnosis-related group adjusted relative weight were higher for CS than UCS. This study found that the disparities in inpatient care expenditures in the last year of life stemmed mainly from the difference in payment rates. To mitigate this disparity, unified payment rates for various types of treatment that reflect costs of hospital care across insurance schemes were recommended.