1. DOES YOUR HEALTHCARE DEPEND ON HOW YOUR INSURER PAYS PROVIDER? VARIATION IN UTILIZATION AND OUTCOEMS IN THAILAND Sanita Hirunrassamee, Ph.D. 1 and Sauwakon Ratanawijitrasin, Ph.D. 2 1 Pharmacy Division,Phramongkutklao Hospital, Thailand. 2 Associate Professor, Faculty of Social Sciences and Humanities, Mahidol University, Thailand.

2. Group of Payment methods Close –endedOpen-ended Schemes UCSSSCSMBS Type of diseases GeneralHigh-costGeneralHigh-costGeneralHigh-cost Point of services OPIPOPIPOPIPOPIPOPIPOPIP Payment methods Capi- tation DRG With Global budget Per item per year with ceilin g (03) / Per item per visit with ceilin g (04-05) DRG With Global budget Capitation plus an add-on payment relying on UR Per item per year with ceiling Fee-for-service Tracer Outcome: Efficiency & Access to… AUGIB Drug & procedure Drug & procedure Drug & procedure Epilepsy New drug Lung cancer New drug & procedure New drug & procedure New drug & procedure

3. Hospitals face different incentives & pressures from financial mechanisms in a multiple health insurance environment.

4. Objective: To examine resource utilization patterns and health outcomes under the multiple payment methods, focusing on assessing Access to Medicines Access to Medical technologies Treatment outcomes (compared to CPGs) Efficiency in resource use among beneficiaries of the 3 government health insurance schemes in Thailand What happen to access and efficiency in this environment?

5. Data Source u 3 government hospitals v 1 tertiary care facility v 2 secondary care facilities u FY 2003-2005 data e-database –Patient demographic data –Health insurance benefits –Items and costs of prescribed drugs and treatment procedures …for assessment of access to care … Paper med. record –Clinical outcome …for assessment of efficiency of health care services…

6. AUGIB v evaluated at end of treatment Epilepsy v evaluated at end of year Analysis Health insurance payment Access to care Efficiency :Cost-effectiveness technique Costs = hospital costs Treatment Outcomes Lung cancer v evaluated at end of year

7. Health insurance payment methods p value UCSSS CSMBS AUGIB DRGCAP FFS Required drugs % of patient with PPIs100.00% 99.69%0.912 H-COST & H-TECH EQUIP. % of patient with Gastroscope 53.56%55.56%68.55%0.110 Epilepsy CAP+ DRG CAPFFS New drugs % of patient with New AEDs 12.93%19.12%30.73%0.000* Lung cancer Per item w ceiling FFS New drugs% of patient with New antineoplastic drugs 19.05%9.68%66.92%0.000* H-COST & H-TECH EQUIP. CT scan or MRI59.52%35.48%74.62%0.000*

8. Subgroup analysis p= 0.00 UC

9. Efficiency Health insurance payment methods p value UCSSSCSMBS AUGIB DRGCAPFFS Average drug cost (baht) per patient 1,742 1,591 4,8490.026* Number of cured patient97%100%96% 1.000 Drug cost (baht) per cured patient 1,805 1,591* 5,037 Epilepsy CAP+ DRGCAPFFS Average drug cost (baht) per patient5,7569,301 5,957 0.05* No. patient with SF79%64%90% 0.000* Drug cost (baht) per patient with SF 7,31814,417 6,624* Lung cancer Per item w ceiling FFS Average drug cost (baht) per case 44,268 54,647 156,2830.000* No. success case40%23%61%0.015* Drug cost (baht) per success case 110,672* 236,803 255,462

10. Price as major condition: limit access to care

11. Access todiffCost /DDDComparatorType Comparator New AEDsSig 49-2511-31 Phenobarbital - valpoic acid Con. AEDs New New antineoplastic drug Sig 8767 /1 gm (Gemtarabine) 1048/50 mg (doxorubicin) Con. antineoplastic New PPIsNS3-3001- 37 (cimetidine, ranitidine) H2 anatagionistRequired Inj. PPIsSig 170-3003-54Oral PPIs Required Original PPIsSig 54-3003-5Local -made Required diffCharge GastroscopeNS1500-3000 CT scansig5000-8000 MRIsig8000-15000