Abstract
Background:
Hip fracture among older adults is a growing public health challenge in Thailand, associated
with high mortality, loss of functional independence, and substantial health system burden.
Despite national efforts to promote early surgery and multidisciplinary care, gaps remain in access,
continuity of care, and alignment of provider payment with health outcomes. This study aimed
to generate policy recommendations for value-based hip fracture care and appropriate provider
payment mechanisms.
Methods:
A mixed-methods study was conducted. The qualitative component included focus group
discussions and in-depth interviews with healthcare providers (n=34) and patients, caregivers, or
relatives (n=31) from hospitals across four regions, selected using purposive and snowball
sampling. Additional focus groups were conducted with providers experienced in financial
incentive schemes in Health Region 1. The quantitative component comprised (1) a structured
survey of hospitals assessing comprehensive care capacity, and (2) analysis of national
administrative data on hip fracture service utilization from 12 health regions between 2020 and
2024.
Results:
The national hip fracture surgery rate remained suboptimal (approximately 70%). Patients
undergoing surgery had a 3.7-fold lower 3-month mortality compared with those not receiving
surgery. Key barriers included unclear national policy direction, inconsistent communication and
monitoring, patient and family concerns regarding surgical risks and long-term care burden,
inefficient referral systems, and limited access to post-acute and continuous care. Current
payment structures were misaligned with actual costs, constraining hospitals' capacity for surgical
and multidisciplinary services. Financial incentives at the hospital level were associated with
reduced short-term mortality but showed limited impact on longer-term outcomes, such as
readmissions or recurrent fractures. The absence of integrated performance indicators, linked data
systems, and outcome-based payment mechanisms hindered the transition toward value-based
care.
Conclusions:
Strengthening hip fracture care in Thailand requires clearer national policy signals, improved
referral and integrated care pathways, and enhanced patient engagement. A value-based payment
model linked to outcomes across the continuum of care, spanning primary prevention, acute
care, and rehabilitation, is essential to improve both short- and long-term outcomes.
Complementary system reforms, including standardized clinical pathways, data integration, and
community-based support, are critical to ensure sustainable and equitable service delivery.
