Abstract
This study aimed to examine principles and ways to arrange a centralized mechanism
of health insurance programs in Thaialnd and other countries in managing care for high-cost
the chronically ills, and develop guidelines for the three Thai national health security schemes,
including commonalities and differences in cancers, chronic care for end-stage kidney diseases,
and HIV/AIDS. In addition, it explored how Thai secondary- and tertiary-care hospitals provided
care for these three groups of patients under conditions set by the three health security
schemes, and identified any impacts on treatment and continuity of care for high-cost chronic
diseases, particularly when patients switched schemes. Finally, the study purposes included
development of policy proposals for reorganizing management systems for high-cost chronic
care of the health secuirity schemes. Three major methologies were applied, including
literature review on Thai and international experiences, key stakeholder interviews and case
studies in six selected public hospitals.
The study found that management systems of the three health security schemes of
Thailand for high-cost chronic diseases varied in terms of conceptual thoughts, policies,
implementation, as well as performance monitoring. The variations were identified both among
programs within the schemes, and between the schemes. There was no central information
system and management mechanism that was designed with patient-centered intention, or with
particular aims that differed from acute care, namely focusing on continuity of care. Thus, the
systems did not support coordination and monitoring beneficiaries’ data to allow tracking
scheme changing, health service utilization and health outcomes in order to review health
benefits, service operation, as well as predict and manage health expenses in caring for the
diseases and their complications.
Assessed from governing bodies of the scheme and current operations, The Civil
Servant Medical Benefit Scheme (CSMBS) had the most limited capability to issue proactive
policies in managing high-cost chronic diseases. The Universal Coverage Scheme (UC) and
the Social Security Scheme (SSS) seemed to have quite similar directions in defining benefit
packages, despite differences in designing approaches. Each scheme had its own processes
and patient access channels, which resulted in patient re-registration and in coverage gap of
15-45 days when patients need to change schemes.More differences could be found in payment mechanisms for different services and
payment methods. In addition, they differed in quality management, requirements and
standards, some of which affected patient access to care, service arranagement in hospitals or
other service providers. Hospitals did not separate clinics or service units for chronic patients
from different schemes, except in some hospitals for chronic hemo-dialysis.
Policy recommendations for management of high-cost chronic diseases may include
integrated policies for managing the diseases among the three national health schemes, aiming
for coverage, access, quality, efficiency and equity, having an integrated governing body at a
policy level to determine criteria for selecting and designing health benefits for eligible high-cost
chronic diseases, especially benefits for particular disease groups such that they would be
flexible, up-to-date, appropriate and cost-effective. Moreover, clinical practice guidelines and
recommendations applicable for all schemes should be reviewed and developed. They should
take into account capabilities and limitations of the health services system of the country,
suggesting areas for development and not aggravating unrealistic expectations among patients.
Besides, critical points or areas of the services should be determined and subsequently used to
monitor quality of care and access.
In addition, a common system for registering chronic patients should be set up, or
linked among different relevant databases to enable patients to receive continuous care and
ensure portability of benefit coverage in order to avoid coverage gap. Quality assurance
activities for the providers should also be standardized. Care should become multidisciplinary
and makes best use of existing database. Key performance measures should be set up and
used to provide feedback for providers with recommendations for improvement. They could
also be applied during site visits and contract reviews, as well as feed back to primary service
providers of targeted population.
