ความสามารถในการจ่ายค่ารักษาพยาบาล และสภาวะเจ็บป่วยจนล้มละลายของผู้ป่วยในที่จ่ายค่ารักษาพยาบาลเอง ในจังหวัดสงขลา

Abstract

Study On Family’s Ability To Pay And Financially Catastrophic Illness (FCI) Among Out-of-Pocket In-Patients: Songkhla Province This current research aims to develop basic knowledge about family’s ability to pay and financially catastrophic illness (FCI). The objectives of the study are: 1) to describe family’s ability to pay for hospital charges, 2) to find out the relationship between family’s ability to pay and socio-demographic determinants, 3) to analyse financial coping strategies for the costs of illness, 4) to study disease profiles, hospital charges, length of stay, affordable out-of-pocket expenses, and clinical outcome in the current admission and, to estimate the incidence of financially catastrophic illness among out-of-pocket in-patients in Songkhla Province. Methodology includes both quantitative and qualitative methods. This research is divided into two studies: FCI-1 Study and FCI-2 study. FCI-1 Study (sample are out-of-pocket Songkhla in-patients) comprises of a hospital-based survey and a time-series study, while FCI-2 Study (sample are out-of-pocket Songkhla in-patients asking for fee exemption) comprises of a hospital-based survey and a qualitative in-depth interview. FCI-1 Study , hospital-based study results: A total of 1731 inpatients was recruited from November 1998 to April 1999 in 6 types of hospitals. There was no inability-to-pay problem among those who sought care at private hospital while those who sought care at government hospitals such problem varied from 23.8-36.8 percent. Ability to pay was highly associated with education level, occupation, and family income. Approximately 15 percent of total subjects had their family income less than 2800 Baht / month. Life-table method revealed that half of the sample (50%) could afford hospital charges at expense of 14700 Baht. 89 percent used cash or mobilized savings for paying the first bill while 8 percent had to borrowed cash. About 21 percent of total used borrowing as one of finance sources in the current admission. Our findings show that family income, patient’s education and occupation in unable-to-pay cases were lower than those in able-to-pay. Charge as percent of income in unable-to-pay was 3 times higher than able-to-pay group. Case-mix index, length of hospital stay and charges were statistically different between able vs. unable-to-pay group. Orthopaedics, paediatrics and surgical cases stayed longer than others with a tendency to be unable-to-pay cases. On average, affordable out-of-pocket expenses paid for one episode of admission were about 6 percent of gross annual income. The hospitals, on average, subsidized 58 percent of total charges to unable-to-pay cases. The incidence of FCI was 7.5 percent of total out-of-pocket admissions if defined FCI as out-of-pocket greater than 15% of income. The incidence of FCI events was 3.6 per 1000 out-of-pocket admissions and 48.5 per 1000 out-of-pocket admissions if considered school leaving of the children and indebtedness as criterion of financial catastrophe respectively. Time-series study results: A sample of 144 cases was sub-selected from FCI-1 hospital-based study. Sixty-one percent used intra-household resources to pay for all hospital bills. Ten percent paid by intra-household resources first and then asked for discount at the discharged day. Nearly 5 percent postponed the bill and then used intra-household resources to pay all. Five percent used intra-household resources to pay some parts and asked for fee exemption for the remaining. FCI-2, hospital-based study results: 300 inpatients who asked for exemption in Hat-Yai and PSU Hospital between May and June 1999 were studied. Index patients had rather low family income, low education, and poor employment status. They tended to be old male, and resided in rural area. Approximately 22 percent of total subjects had their family income less than 2800 Baht / month. 36 percent borrowed cash to pay the first bill. 62% of total used borrowing as one of finance sources in current admission. Orthopedics and surgical case were more costly while paediatric cases had longer hospital stay as compared to others. OBGYN and pediatric cases had a good clinical outcome while surgical cases had rather poor outcome. On average, affordable out-of-pocket expenses paid for one episode of admission among study cases were about 11 percent of gross annual income. The hospitals, on average, subsidized 63 percent of total charges to unable-to-pay cases. FCI qualitative findings: 38 in-patients who were Songkhla residents, whose admission incurred medical expenses above 40000 Baht, and declared not being able to pay the bills were in-depth interviewed between April and June 1999. Several patterns of resource mobilization to pay for the bills were captured. Cash / savings was the most common resource use. Usually, more than one strategies were used to cope with the costs of illness. Family networks played an important role if cash / savings was not available. Additional resources from assets sale, loans, and community support were also sought. Taking a loan was limited because economic crisis led to difficulty to earn money or lose confidence of capacity to pay back. The patient / family who got community support should be guaranteed as a good socialized person. If any resources were exhaustive, asking support from the hospitals were the last option. However, exemption policies were not well known by general population. A large number of families did not know whether the fee exemptions existed until they were notified by medical social workers. Not only the financial implication, but also some social impacts hit to the families. Current illness led to loss of income earning capacity in the families, in particular, financial consequences were more severe if principal income earner was a case. In conclusion, out-of-pocket patients are mixtures of upper, middle, and lower socioeconomic status. Family’s ability to pay depends not only on SES but also on coping strategies adopted to deal with the costs of illness. Higher SES and strong kinship and social networks are better ability to pay for the bills. The incidence of FCI varied depending on the definitions. Financial requirements for protection against FCI among out-of-pocket admissions in Songkhla were computed. Current hospital subsidization for those who were unable to pay was about 3.45 million Baht per year. If the expenses were considered that the patients should not pay more than15 percent of gross annual income for a single admission, the government or the hospitals had to subsidise 6.56 million Baht per year.To raise 7 million to protect FCI, every currently uninsured should contribute about 20 Baht for yearly premium and pay user charges of not more than 15 percent of annual family income as deductible amount for each admission.