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Decomposing health expenditure : The case of CSMBS outpatients in Saraburi hospital

จิระวัฒน์ ปั้นเปี่ยมรัษฎ์; นฎา วะสี; วรรณวิภางค์ มานะโชติพงษ์; Jirawat Panpiemras; Nada Wasi; Wanwiphang Manachotphong;
Date: 2556-06-01
Abstract
One of the major public health policy debates in the recent years is the rising costs of Civil Servants Medical Benefit Scheme (CSMBS), especially for outpatient care. Nationally, the CSMBS outpatient costs had steadily increased since the 1990s but started skyrocketing in 2004. Several government agencies and scholars have tended to blame this rapid rise on the new reimbursement policy (the Direct Payment (DP) program), which took place in the same year. Before the DP program was introduced, CSMBS beneficiaries had to cover the full cost of their outpatient services first, and process the reimbursement afterward. The DP program replaced this old payment system by having the government pay to the hospitals directly. Although the DP program seems to be the most probable source of the rising CSMBS costs, there is no careful analysis to support the argument. Comparing aggregate costs beforeand- after the policy change would overstate the DP effect due to other factors (e.g., a steady increase in the number of aging population and a self-selection problem). Our study aims to carefully examine the impact of the DP on utilization and cost per patient. We employ patientlevel data from Saraburi Hospital, a large regional hospital, which CSMBS costs closely mimics the nation’s trend. Its CSMBS outpatient costs rose approximately 10% per year prior to 2004and soared to 31-37% per year between 2004 and 2009. Our analysis focuses on two issues. First, we examine the key determinants of the change in outpatient costs during 2004-2009, by breaking down the total change in outpatient costs into the change in the number of patients being treated and the change in cost per treated patient. Second, we study the impact at the initial stage of the DP program where eligibility was restricted to beneficiaries with four specific chronic diseases. Our results indicate that during the first two years where only chronic disease patients were eligible, the increase in the costs was driven by the higher cost per patient rather than the larger number of patients being treated. This suggests that some enrolling patients might over utilize healthcare services or ask for unnecessary prescriptions. In contrast, when the program was fully expanded to cover all CSMBS beneficiaries, the number of new patients turned to be the major factor accounting for the increase in the costs. This is not surprising given that patients with chronic diseases were more likely to incur higher costs, and most of the patients with chronic diseases had enrolled earlier. The effect of the initial stage of the DP program on visits and cost per patient were assessed by the difference-in-difference approach. We find that, on average, patients enrolled in the DP program increased their number of visits by 18.3%. In addition, the average outpatient cost per participant increased by 35.4% comparing to their cost before enrollment. Finally, we show that the estimates from simply comparing visits or costs before-andafter policy change largely overstated the effect of the DP program. For visits, the estimate from the simple comparison is +24.5%, while our estimate from the differences-in-differences approach is +18.3%. The simple comparison also suggests a considerably larger effect of the DP program on the outpatient costs (+108.8% vs. +35.4%). These results underscore the need for careful evaluation of policy changes. Our study only takes a modest step toward such direction. An important area for future research is to identify sources of treatment intensity associated with certain prescriptions or diagnostics. We are not able to trace such details since the outpatient financing records from Saraburi Hospital do not contain charges by item. A clearer understanding of the factors accounting for the recent rise in the healthcare costs will prove critical for crafting cost containment strategies.
Copyright ผลงานวิชาการเหล่านี้เป็นลิขสิทธิ์ของสถาบันวิจัยระบบสาธารณสุข หากมีการนำไปใช้อ้างอิง โปรดอ้างถึงสถาบันวิจัยระบบสาธารณสุข ในฐานะเจ้าของลิขสิทธิ์ตามพระราชบัญญัติสงวนลิขสิทธิ์สำหรับการนำงานวิจัยไปใช้ประโยชน์ในเชิงพาณิชย์
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