A View on National Health Insurance and Related Pharmaceutical Issues in Thailand
The Kingdom of Thailand has approximately 64 million people and with a gross national income of approximately US$3979.53 per capita in 2009. On average, Thai citizens spent approximately 4% of their annual income on health care services. The country is one of the Asia-Pacific countries with a rapidly emerging national health insurance system. Recently, there have been a few changes which make a different facet of health care ser-vices in the country.
One major change in the structure of the national health insurance started in 2002, when a Univer-sal Coverage (UC) health insurance policy was launched. It was based on the country’s constitu-tional law, which was thought to enable the entire population with access health care services. Since then, the national health insurance system in Thailand has three major schemes, including the Civil Servant Medical Benefit Scheme (CSMBS), the Social Security Scheme (SSS), and the Uni-versal Coverage Scheme (UC). The UC covers about 75% of the country’s population, while the CSMBS and SSS together cover approximately 22%. The CSMBS was established to provide health care to government employees, their de-pendents, and government retirees. It basically provides coverage for inpatient and outpatient ser-vices, emergency services, and pharmaceuticals. The CSMBS uses prospective payment (following a diagnosis-related group (DRG) approach) for inpatient services, a fee-for-service type of pay-ment for outpatient services and is fully funded by a general tax. The SSS is a compulsory insurance scheme for employees in the private sector and it covers only the employees themselves. Its inpa-tient and outpatient services are provided through both private and public hospitals. The SSS pay-ment mechanism operates with a capitation basis and copayments are added for some necessary but expensive services. Its source of funds basi-cally comes from employees, employers, and the government. Lastly, the UC is more or less social welfare by nature for people who are not eligible for the CSMBS and SSS. Remuneration in the UC system applies DRGs for inpatient services while capitation is applied for outpatient services, while funding is being dependent on general taxes.
Basically, the beneficiaries of all three schemes are eligible for pharmaceuticals that are included in the National List of Essential Drugs (NLED). If importantly needed, the beneficiaries might also receive pharmaceuticals that are not included in the list, but technically, prior authorization from a physician is needed. However, these pharmaceu-ticals not surprisingly are usually relatively more expensive products. Due to the fee-for-service payment, beneficiaries of the more generous in-surance scheme, the CSMBS, tend to have more access the products outside of the NLED. It is likely that hospitals benefit more from an increase in pharmaceutical expenditures in this group. In-tuitively, most hospitals have better control over the pharmaceuticals obtained by the UC and SSS beneficiaries. It is disincentive for the hospitals to allow a higher utilization of expensive pharma-ceuticals for the UC and SSS beneficiaries, since their payment type is capitation. In other words, even if this might hint at cost shifting tendencies in this sector, up to now it has not been empirically substantiated. The CSMBS health expenditure per capita recently was around five-fold the health expenditure per capita under UC. The increase in pharmaceutical expenditure within the CSMBS has been outrageous after the CSMBS adopted the di-rect payment system a couple of years ago. Since then, spending and utilization of services under the CSMBS has moved in the government’s focus.
Needless to mention, that the CSMBS is perceived as a privileged health plan while the UC and SSS are sometimes viewed as standard schemes in the public. In general, equity across these schemes is questioned in discussions. The UC law stated clearly that all health insurance schemes should be unified after all of them are enacted and in place. However, when the Thai government tried to propose that the country should have a unique national health insurance scheme under the capi-tation type of payment or the UC scheme, many civil servants were very offended and opposed the potential changes. They claimed that the health insurance is part of their fringe benefits that the government has promised them since their first day of work. Therefore, the focus on the CSMBS was shifted towards expenditure issues, since the increase in the CSMBS expenditure is viewed by some policymakers or payers solely as overutiliza-tion. On the other hand, the issues of access and quality of care are major concerns for the UC and SSS beneficiaries. Following these discussions, the Thai government has explored, proposed, and implemented various efforts to solve these prob-lems. In the following some examples are given:
As mentioned above, the NLED has been one of the several strategies in the past to foster a more ap-propriate and efficient use of pharmaceuticals. The NLED is responsible for selecting pharmaceutical products to be listed. Many clinicians and pharma-cists from across the country are regularly invited to determine the list. Recently, economic evalua-tion has become an important piece of informa-tion that is used for informing these decisions. The pharmaceutical industry is asked to submit this in-formation (also requiring local data), even though some government experts have the concern that the provided information might not be fully valid and reliable. On the other hand, the industry has a concern that the transparency of the selection pro-cess (e.g. the importance of the economic data vs. the clinical evidence) is not fully given. In my view, the government has planned well for adopting the economic evaluation in the decision process. For instance, the Intervention and Technology Assess-ment (HITAP), an agency that is responsible for health technology assessment, was founded three years ago and its competence and capacity has developed very fast. It is recognized at both na-tional and international levels.
Evidently the NLED does not effectively work in terms of controlling costs for the CSMBS. Hence, additional methods for controlling the costs of drugs had to be implemented. For instance, pre-scriptions for some high cost pharmaceuticals, e.g. targeted anticancer agents, need to be reviewed by medical auditors. When it has been determined that a patient is eligible for one of these agents, his or her drug utilization data needs to be submitted for a review. Technically, this method encourages rationale drug use and has saved a large amount of money for the government. However, its efficiency has never been empirically evaluated. Also, many prescribers are sometimes uncomfortable with the review results, especially when they think their pa-tients should receive a specific product.
Since accessibility and quality of care are major concerns for the UC, various policies are launched to serve these purposes. Even though capitation is the primary payment type for the UC, more pay-ments are sometimes added. The UC has also continuously expanded its coverage to product groups like anti-retro viral drugs, renal dialysis, etc. However, the principle of additional payment and expansion of coverage needs to be further developed. Hospital accreditation is a quality assurance tool for overall services that are provided for the UC, SSS, and CSMBS. The effect of any policy that is spe-cifically directed at pharmaceutical spending has been assessed but still need more investigation. However, the UC has been aware and has tried to develop a database in order to monitor or evaluate the quality of drug use.
Among all three schemes, the SSS seems to have fewer problems on cost es-calation, especially with the utilization of pharmaceuticals. It is possible that the SSS beneficiaries are of working age and they rarely use health care services. Also, the SSS beneficiaries are not the large group of the population. In the early phase of the SSS, it experienced underutilization. Later, the SSS has expanded its coverage in order to increase accessibility for their beneficiaries. A major prob-lem of the SSS currently is that the capitation type of payment is not attracting to private hospitals or clinics. Similar to the CSMBS and UC, issues of accessibility or equity, quality, and efficiency should be examined.
While all three schemes cannot be combined anytime soon, there will be more policies forthcoming to ensure accessibility, equity, quality, and ef-ficiency. The Thai government heavily invests in research and development which are believed to bring better policies to the health care system. For instance, reference pricing has become a large area of research sparked by increased spending within the CSMBS for drugs. Other methods, such as cost sharing, pharmaceutical expenditure reviews, etc, have also been studied. Even though the national health insurance system may not be the best in the Asia-Pacific region yet, apparently Thai government puts a high priority on people’s health and has a very strong commitment to improve the people’s quality of life. It will be interesting to see, how the Thai national health insurance system will evolve in the next decade.
1 Gross national income 2009, Atlas method. http://siteresources.worldbank. org/DATASTATISTICS/Resources/GNI.pdf. [Accessed September 27, 2010].