Impact of universal coverage policy implementation on public hospitals, and their responses that affect medical services Jiruth Sriratanaban Universal Coverage Scheme Assessment of the first 10 years : Impact on health systems 1 UCS impacts on health system: Impact of universal coverage policy implementation on public hospitals, and their responses that affect medical services Jiruth Sriratanaban, M.D., Ph.D.* * Associate Professor, Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, THAILAND. Acknowledgement: This study is a part of the 10-year evaluation study of the Universal Coverage Scheme (UCS) in Thailand, TOR 5: Impacts of the Universal Coverage on the Thai Health Systems, funded by the Health Insurance Systems Research Office (HIRSO), Health Systems Research Institute (HSRI). Background and study rationale Thailand has established universal health coverage for all citizens since the end of 2001. From then, Thais are entitled to one of the three major public health security schemes. The first and the oldest one is the Civil Servants Medical Benefit Scheme (CSMBS) which provides health benefits for six million of government officers and their families, including parents. Likewise, around 10 million employees in the private sector receive health protection from the national Social Security Scheme (SSS). The rest of the population (47 millions) are covered by the National Health Security Scheme, commonly known as the UC scheme, enacted by law in 2002. Although the UC scheme has been successful in increasing access to care and enhancing equity for the Thai population by strategies, such as supports for primary care, health promotion, and disease prevention, the UC policy and its implementation have put enormous pressure on hospitals for changes in the ways they operated and provided medical services, particularly institutionalized and specialized health care. These policy interventions were said to include, for example, close-ended hospital payment mechanisms, applications of new rules and regulations, and some requirements on patient management, such as disease management programs. Whereas private hospitals can choose whether to serve UC patients, public hospitals are required by the government to participate in the scheme. Therefore, public hospitals have to comply to all interventions—more or less—and adapt themselves in order to secure their positioning and maintain their financial viability. While other aspects of improvements and system performance were documented in previous studies on the Thai UC system, impacts of the UC on medical care and the hospitals that have led to changes in their organizations have not been clearly understood. Such organizational 2 responses in how medical services are provided may have affected significantly on many performance improvements in the Thai health system, as well as undermined gap areas—such as quality of care, future progress, and sustainability of the system. Research objectives This study aimed to assess impact of UC implementation on public hospitals, including organization management and their other responses. The assessment also includes medical care provision by hospitals, arrangement of specialized medical services, patient referral system, and patient access to hospital and specialized medical care. Nevertheless, as a part of the larger series of the 10-year evaluation study of the UC scheme, key elements of the UC strategic purchasing were initially proposed before commencing the study by the steering team to form the conceptual framework of the study (Figure 1). Strategic purchasing was, thus, defined as health care purchasing approaches deployed by NHSO, which had specific intent to influence how health care is provided in one direction or another, such as containing cost or promoting access. Figure 1 Conceptual framework Changes in provision of medical services between pre-/ UC implementation: early UC period and 10 years Strategic purchasing later [Type, Quantity, Quality] Observed or - Payment mechanisms - Hospital care documented - Regulations and - Specialized medical care health system system re-design - Patient referral performance - Selective contracting - Access to hospital and specialized medical care Study methodology Qualitative methodologies were primary tools for data collection, including document and literature reviews, and in-depth interviews. Reviews of document and literature include related documents on the universal coverage programs, initiatives and system performance were gathered from the National Health Security Office (NHSO). These include annual reports, performance reports of projects, and minutes of the National Health Security Board and the executive boards. Nonetheless, the reviews are limited to those available from NHSO in a public domain, NHSO’s internal performance reports if they can be released, and published and non- published research reports on the establishment of UC and other related issues. 3 Furthermore, research literatures on UC in Thailand for the past 10 years (2002-2011) were searched from the PubMed database and the digital library of the Health Systems Research Institute in Thailand. Key words for the literature search included universal coverage, national health insurance, health security, universal health care, reimbursement, and Thailand. They were screened for findings on effects or impacts on medical care, patient referral, and hospitals, as well as how the hospitals responded or made changes to their structure, management, or service offerings. In addition, in-depth interviews were conducted. The interviewees included the NHSO’s present director and former director on policy and planning, and hospital executives, management teams and physicians of nine selected case-study hospitals. Based on the literature findings and suggestions of the NHSO director on policy and planning, the group of the case-study hospitals was selected to include all major groups of public hospitals in UC, including two regional medical centers, one general hospital and two community hospitals of the Ministry of Public Health, two university hospitals—one in Bangkok and one in the upcountry, one Bangkok Metropolitan hospital and one military hospital. Three of them were in Bangkok, three in the central region, two in the northeastern region and one in the northern region of the country. Among these nine hospitals, three of them were intentionally selected from one province to represent three levels of MOPH hospitals—regional medical centers, general hospitals and community hospitals. The hospitals in Bangkok have joined the scheme later in 2002. The rest of the case-study hospitals in the other provinces besides Bangkok have participated in the UC initiative since it was piloted in April 2002. Key questions for the interviews focused on institutional medical care and management of hospitals. They include information related to any changes in 1) organization policy and direction, 2) organization restructuring, 3) internal regulations, 4) internal financial incentive, 5) information systems, 6) hospital’s drug formularies and use of medicine and medical technology, 7) health care teams, 8) application of clinical practice guidelines, 9) settings of care and excellent centers, 10) public-private mix (Outsourcing), 11) patient referral and management of referral network, and 12) Patient access to hospital care and expensive or costly interventions. Details are described in the TABLE 1 on the following page. Reviewed data and data collected from the interviews and provider observations were analyzed by content analysis and data triangulation. The scope of the analyses were limited to hospitalized or institutionalized care that are provided on the inpatient care basis, patient referral (excluding patients’ self-referral) and specialized medical care that require medical specialists or specialized medical personnel, or need advanced technology not generally available in public hospitals, or can be provided only by a small number of tertiary care medical centers, or use expensive medicine or medical instruments. 4 Figure 2 Characteristics of the sample hospitals Hospital Ownership Missions and Unique situations or special comments and size location #1 University Teaching, - Largest university hospital BKK Tertiary care - Very few large public hospitals nearby 2200+ beds - A lot of referred cases from up-country #2 Bangkok Teaching, - Largest BMA hospital, located in the inner area BKK Metropo- Tertiary care of Bangkok litan 1000 beds - Nearby BMA health centers are under different Adminis- department (Department of Health) of BMA tration #3 Military Teaching, - Only one tertiary-care public hospital in north BKK Tertiary care of Bangkok 700 beds - Working on many pilot projects with NHSO #4 MOPH Tertiary-care, - Main referral center of the central region Rural, Teaching - Located relatively closely to tertiary-care and Central affiliation general hospitals in the same, as well as nearby 680 beds provinces #5 MOPH Community - Fast growing district next to the Muang Rural, 70 beds (Central) district of the province, with mixture Central of heavy and light industry, and agricultural sectors #6 University Teaching, - Main referral center of the region and the Rural, Tertiary care province North 1400 beds - No general hospital in the Muang (central) district of the province #7 MOPH General - Not located in the Muang district of the Rural, 200 beds province Central - Geographically central to