Health insurance schemes and patterns of drug use and care in Diabetic Outpatients

Abstract

The objectives of this study were to describe response of hospitals and physicians to different payment incentives of health insurance schemes and to compare patterns of drug use and care process among diabetic outpatients covered by health insurance schemes with different payment incentives including dynamics of change in patterns of drug use over time, before and after the implementation of the 30-Baht Policy for every Disease. The effects of different payment incentives of three major health insurance schemes in health care systems of Thailand were studied including universal health care coverage or the 30-Baht Scheme with capitation payment, Civil Servant Medical Benefit Scheme and patients paying for drugs on an out-of-pocket basis, and Social Security Scheme with capitation payment. In addition, dynamic impacts of the 30-Baht Policy implementation on patterns of drug use were also determined. Four public hospitals with availability and accessibility of electronic dispensing database and medical record were recruited. This study consists of three approaches: 1) health care professional interviews and document reviews for response of hospitals and physicians to different payment incentives of health insurance schemes, 2) electronic dispensing database analyses for patterns of drug use, and 3) medical record reviews for patterns of care processes in diabetic outpatients ranging in age from 41 to 60. As for patterns of drug use, a longitudinal study design of quasi-experimental with an interrupted time series was carried out using segmented regression analysis. It was found that three hospitals had a policy of equity care for all patients regardless of health insurance schemes, while one hospital had a policy to restrict use of expensive drugs, especially not in the National Essential Lists of Drug (NELD), for capitation patients contrasted sharply with fee-for- service patients. Prescribers in every hospital had concern to prescribe more inexpensive drugs in the NELD for capitation patients whereas they had concern to expand opportunity for fee-for-service patients to intensify access to new drugs with high costs. Conforming to the physicians’ concerns, the average charge of drugs prescribed per visit, the proportion of charge of drugs not in the NELD per visit, and the proportion of visits with original high cost drugs prescribed for fee-for-service patients tended to be higher than for capitation patients. After the 30-Baht Policy implementation, these effects were more intense, and a potential cost-shifting from the 30-Baht patients to fee-for-service patients was also detected. Payment incentives of the schemes and impacts of the 30- Baht Policy implementation seemed not to have an effect on physicians’ orders for required laboratory tests and physical examinations. However, most of the procedures were under-provided to patients. These results suggest that payment incentives of health insurance schemes have an effect on patterns of drug use in diabetic outpatients. Therefore, mechanisms to monitor a risk of under treatment in capitation patients and of over treatment in fee-for- service patients should be established in order to guarantee quality of care.