1. International Health Policy Program -Thailand Determinants of clinical practice variations and influence of provider payment methods: A case study from Thailand Viroj Tangcharoensathien, MD PhD Phusit Prakongsai, MD Supon Limwattananon, PhD Chulaporn Limwattananon, PhD Walaiporn Patcharanarumol, MPH International Health Policy Program (IHPP) Ministry of Public Health, Thailand Presentation to the 6 th IHEA World Congress 10 July 2007, Copenhagen

2. International Health Policy Program -Thailand 2 Outline of presentation Background information and objectives of the study Three tracers for exploring clinical practice variations: – Cesarean section procedure; – Treatments for acute non-lymphoid leukemia (ANLL); – Controller medication for chronic asthmatic patients. Discussions Conclusions and policy recommendations

3. Health care finance and service provisions of the Thai health care system after implementation of the universal coverage policy General tax General tax Standard Benefit package Tripartite contributions Payroll taxes Risk related contributions Capitation Capitation & global Co-payment budget with DRG for IP Services Fee for services Fee for services - OP Population Patients Ministry of Finance - CSMBS (6 million beneficiaries) National Health Insurance Office The UC scheme (48 millions of pop.) Social Security Office - SSS (7 millions of formal employees) Voluntary private insurance Public & Private Contractor networks

4. International Health Policy Program -Thailand 4 Objectives To describe variations in clinical practices, costs of medical interventions, and clinical outcomes among three different health insurance schemes having different provider payment methods. Health intervention tracers  Caesarian section procedure  Treatments for acute non-lymphoid leukemia (ANLL)  Controller medication for chronic asthmatic patients Multivariate analysis (controlled for case-mix difference)  Probit and logistic regressions for likelihood of receiving the interventions  Weibull regression for patient survival rate

5. International Health Policy Program -Thailand 5 200420052006 Number of admissions in total 3,829,5334,507,7244,895,136 Number of deliveries in total 361,426429,548441,407 Deliveries as % of total admissions 9.4%9.5%9.0% Caesarean sections as % of total deliveries 16.3%18.3%20.1% Hospital Admissions and Deliveries

6. International Health Policy Program -Thailand 6 Resource Use for Delivery Length of hospital stay (mean + SD) 200420052006 UC 2.9 + 4.4 days2.9 + 3.1 days2.9 + 2.2 days SSS 2.9 + 4.8 days2.9 + 6.5 days2.9 + 6.3 days CSMBS 3.6 + 3.8 days3.8 + 2.7 days4.0 + 2.8 days ROP 2.7 + 1.2 days2.9 + 1.7 days3.0 + 2.1 days

7. International Health Policy Program -Thailand 7 Resource Use for Delivery DRG-based relative weights (mean + SD) 200420052006 UC 0.45 + 0.220.47 + 0.220.48 + 0.22 SSS 0.45 + 0.200.49 + 0.200.48 + 0.21 CSMBS 0.51 + 0.240.56 + 0.260.59 + 0.25 ROP 0.41 + 0.170.45 + 0.190.46 + 0.22

8. International Health Policy Program -Thailand 8 Percentage of caesarian section to total deliveries by health insurance schemes Source: Electronic claim database of inpatients from National Health Security Office, 2004-2006 (N=13,232,393 hospital admissions)

9. International Health Policy Program -Thailand 9 Likelihood of having caesarian section Probit estimation (N=1,229,458 deliveries) dF/dXP-value95% LL95% UL SSS vs. UC0.007<0.0010.0050.009 CSMBS vs. UC0.158<0.0010.1430.173 ROP vs. UC0.0070.340-0.0080.023 Age 20-35 vs. <20 yr0.075<0.0010.0730.077 Age >35 vs. <20 yr0.168<0.0010.1650.171 District vs. Other hosp.-0.175<0.001-0.179-0.170 Provincial vs. Other hosp.0.071<0.0010.0670.075 Central vs. Bangkok0.008<0.0010.0060.009 North-East vs. Bangkok-0.006<0.001-0.008-0.004 South vs. Bangkok-0.009<0.001-0.011-0.006 Years 2005 vs. 20040.014<0.0010.0120.016 Years 2006 vs. 20040.029<0.0010.0280.031

10. International Health Policy Program -Thailand 10 Likelihood of having caesarian section Logit estimation (N=1,229,458 deliveries) Odds ratioP-value95% LL95% UL SSS vs. UC1.04<0.0011.021.06 CSMBS vs. UC2.44<0.0012.282.62 ROP vs. UC1.060.3340.941.19 Age 20-35 vs. <20 yr1.87<0.0011.841.89 Age >35 vs. <20 yr2.86<0.0012.812.91 District vs. Other hosp.0.26<0.0010.250.27 Provincial vs. Other hosp.1.62<0.0011.581.67 Central vs. Bangkok1.07<0.0011.051.08 North-East vs. Bangkok0.95<0.0010.940.97 South vs. Bangkok0. 93<0.0010.920.95 Years 2005 vs. 20041.12<0.0011.101.13 Years 2006 vs. 20041.25<0.0011.231.27

11. ANLL induction treatment from Adult Hematological Malignancy Registry, Thailand Number of patients N 581 Palliative care/ no chemo RX Chemotherapy ADR+Ara a IDR+Ara b OtherM3 Rx c UC33636.9%22.0%20.2%8.3%12.5% SSS667.6%21.2%47.0%4.6%19.7% CSMBS11929.4%17.7%30.3%16.8%5.9% ROP6031.7%13.3%30.0%11.7%13.3% a ADR+Ara: Adriamycin 3 days + Cytarabine 7 days b IDR+Ara: Idarubicin 3 days + Cytarabine 7 days c M3 (acute promyelocytic leukemia) Rx: All-trans retinoic acid or AsO 3 (+ADR or IDR)

12. Direct costs of medical treatment for ANLL induction treatment* and palliative care Costs of induction treatmentCosts of palliative care Median (USD) Quartile 1 (USD) Quartile 3 (USD) Median (USD) Quartile 1 (USD) Quartile 3 (USD) UC3,1949777,7201,0263073,053 SSS8,4384,83316,8181,9883873,815 CSMBS4,9371,58011,7972,0076293,690 Rest of pop. 3,5936139,4091,1626562,994 * Excluded cost of bone marrow transplant USD 1 = 35.50 Thai Baht

13. International Health Policy Program -Thailand 13 Survivals of ANLL Patients (N=509 cases) Number of patients N 509 Median survival* (months) Survival rate* 6-month12-month24-month UC2983.4540.3%23.6%4.5% SSS599.2162.3%38.6%20.5% CSMBS1088.3358.7%35.7%13.9% Rest of pop.4410.3460.7%45.5%42.1% * Adjusted for age 50 yr

14. International Health Policy Program -Thailand 14 Relative risk of dying –ANLL patients (N=565) Relative risk*P-value 95% LL95% UL SSS vs. UC0.610.0040.430.85 CSMBS vs. UC0.650.0010.500.83 ROP vs. UC0.640.0190.440.93 Age (1-yr increase)1.010.0171.001.01 Male vs. Female0.960.6710.791.16 ADR+Ara vs. No chemo Rx0.45<0.0010.340.61 IDR+Ara vs. No chemo Rx0.45<0.0010.340.59 Other chemo vs. No chemo Rx 0.680.0220.490.94 M3 Rx vs. No chemo Rx0.31<0.0010.210.46 * Time-to-event analysis based on Weibull regression

15. International Health Policy Program -Thailand 15 Percentage of patients receiving inhaled cortico-steroids Chronic asthma adults (N=6,176) from 18 provincial hospitals UC-E* (N = 2,553) UC-P** (N = 866) SSS (N = 624) CSMBS (N = 1,668) ROP (N = 465) Year 2001 25.3%47.7%39.4%40.5%34.4% Year 200225.0%50.0%39.3%41.2%27.1% * UC-E: UC members exempted from copay per visit ** UC-P: UC members required copay per visit

16. International Health Policy Program -Thailand 16 Odds of receiving inhaled cortico-steriods Odds ratio*P-value 95% LL95% UL UC-E vs. SSS0.840.0260.720.98 UC-P vs. SSS1.47< 0.0011.241.73 CSMBS vs. SSS1.51< 0.0011.291.77 ROP vs. SSS0.930.4920.761.14 Age 36-49 vs. 18-35 yr1.010.9150.881.15 Age > 50 vs. 18-35 yr0.44< 0.0010.390.5 Male vs. Female0.890.0090.820.97 Prior admission due to asthma vs. No admission 3.00< 0.0012.573.5 Prior rescue medication vs. No rescue medication 1.68< 0.0011.521.86 Years 2002 vs. 20010.780.0930.581.04 * Based on logistic regression, adjusted for indicators of 18 study hospitals

17. 20012002 Likelihood of receiving inhaled cortico-steroids Chronic Asthma Adults (N=6,176) Patients with history of admission due to asthma (N=489) Patients who ever used rescue medication (N=1,512) CSMBS UC-P SSS ROP UC-E Year Patients with no asthma admission nor prior rescue medication (N=4,175)

18. International Health Policy Program -Thailand 18 Effects on Annual Medication Costs per Patient Beta-coefficient*P-value % difference** (95% CI) UC-E vs. SSS-0.0680.006 -6.5% (-11.0 – -1.9%) UC-P vs. SSS-0.0940.001 -9.0% (-13.9 – -3.7%) CSMBS vs. SSS0.0400.121 4.1% (-1.1 – 9.6%) ROP vs. SSS-0.305< 0.001 -26.3% (-31.0 – -21.3%) Age 36-49 vs. 18-35 yr0.155< 0.001 16.7% (11.5 – 22.1%) Age > 50 vs. 18-35 yr0.264< 0.001 30.3% (24.7 – 36.1%) Male vs. Female0.295< 0.001 34.3% (30.7 – 38.0%) Inhaled steroids vs. No inhaled steroids 1.074< 0.001 192.6% (183.5 – 202.0%) Years 2001 vs. 20000.202< 0.001 22.4% (18.5 – 26.5%) Years 2002 vs. 20000.064< 0.001 6.6% (3.2 – 10.2%) * Based on generalized linear model, adjusted for indicators of 18 study hospitals ** Relative difference in cost per patient, compared with the reference category

19. International Health Policy Program -Thailand 19 Discussions 1 – Determinants of clinical practice variations Very complex relationship, whereas provider payment is one of the determinants Multiple determinants – Structural District hospitals have less Ob-Gyn specialists and facilities [blood, anaesthesia] for caesarean section than others No haematologist in provincial hospitals to initiate chemotherapy for ANLL District staff mostly new graduate MD, whereas internal medicine specialists in provincial hospital – competency in application of inhaled cortico-steroid – Demand side characteristics Prior exposure to rescue drugs, admission of asthma and use of inhaled medicines Older age pregnancy and higher chance for caesarean section Patient preference and self demand for caesarean section

20. International Health Policy Program -Thailand 20 Discussions 2 – Insurance status and provider payment methods Hospital policy Variations in drug list – low cost generic versions for capitation model of SHI and UC, Original versions and non-ED for fee for services CSMBS and out-of-pocket payment patients Clinician prescribing preference Non-ED and brand drugs for CSMBS Being a “Private patients” in public hospitals Ob-gyn specialists in Thailand are bound to conduct delivery, time management usually results in medically non-indicated caesarean section [Tangcharoensathien et al 2002] Special payment for high cost care such as chemotherapy SHI - fee schedule with ceiling at ~870 USD per year CSMBS - fee for services UC – central fund using DRG with global budget payment, and disease management

21. International Health Policy Program -Thailand 21 Conclusions – Practice variations: Determinants are complex and multiple, provider payment is one of the determinants resulting in cost and outcome variations Further detail investigations required for each specific tracer. – Caesarean Highest rate among CSMBS, plus confounder of “being a private patient” of OBGYN. – ANLL Lower access to chemotherapy, poorer survival outcome among UC patients and in favour of SHI patients Provider payment, availability of haematologist and clinical experiences in induction treatment are complex determinants. – Use of inhaling cortico-steroid in asthma Severity of disease is important (using admission and use of rescue drugs as a proxy indicator) In favour of CSMBS and self pay before UC and UC-P after UC scheme launched Not that expensive and not unaffordable, but perhaps clinician’s awareness of the use of inhaling cortico-steroid

22. International Health Policy Program -Thailand 22 Policy Recommendations – Minimize practice variations Further expansion the coverage of clinical practice guidelines, and advocate their use, e.g. the use of inhaled cortico-steroid, Single-out some key interventions from capitation payment with special additional payment e.g. fee schedule with close monitoring e.g. Chemotherapy or additional payments for high cost care Adequate payment for high cost and effective intervention, e.g. some curable cancers. Monitor and routine report among peers on practice variations, e.g. Caesarean, self control of unnecessary non-clinically indicated Caesarean.

23. International Health Policy Program -Thailand 23 Acknowledgements National Statistical Office of Thailand Ministry of Public Health (MOPH) Thailand Research Fund (TRF) and Health Systems Research Institute (HSRI) for institutional grants Centre for Health Informatics for the dataset of hospital admissions Thai Society of Haematology for Leukaemia registry 18 regional and provincial hospitals of MOPH