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ระบบประกันสุขภาพ. ทพ.ดร. วิรัตน์ เอื้องพูลสวัสดิ์ สำนักงานหลักประกันสุขภาพแห่งชาติ เขต 12 (สงขลา). ระบบสุขภาพ (Health System) หมายถึง ระบบความสัมพันธ์ทั้งมวลที่เกี่ยวข้องกับสุขภาพ มีจุดมุ่งหมายหลัก เพื่อทำให้เกิดการปรับปรุง พัฒนาสุขภาพของประชาชนเป็นสำคัญ.

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ระบบประกันสุขภาพ

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..

12 ()


(Health System)

2

1.

2.


2000

.

.

.




DarkSide

Bright Side

  • /

  • /

  • /


.


.

.


  • World Health Report 2008


.

.

,

././..

(.,)

,,,,


(Health Insurance System)



?

(Health Insurance)

(pooling risk ) (sharing risk)


Key functions of health insurance

  • Access to care

  • Financial protections of family incomes


(Uncertainty)

  • (contacting diseases)

  • (severity of illness)

  • (medical expenditure)

=

=


  • (Inequity)

    • (financial contribution)

    • (access & utilization)

    • (expenditure)


(pooling and sharing risk)

()

Pool risk

()


(

)

(

)

(Inter-personal income subsidy)


  • demand supply

    supply demand

  • Supply


  • supply ()

  • supply

Provider

Purchaser

Cost containment


B

A

/

/

C

DIRECT PAYMENTS

HEALTH SERVICES

CLAIMS

REGULATION

INSURANCE

COVERAGE

MONEY

(TAXES OR

PREMIUMS)

MONEY

PAYMENT

(FEES, GLOBAL

BUDGET)

D

REGULATION


  • (Revenue collection)

  • (Co-payment or Cost-sharing)

  • (Payment to providers)


(Revenue collection)

  • (Taxation)

  • (Premiums)

    • Premium

      (individual risk rating)

    • Premium

      (community risk rating)

    • Premium

      (income-related premium)


(Co-payment or cost sharing)

  • (nominal fee)

  • (deductible)

  • % (coinsurance)

  • %

  • (benefit maximum)


(Payment to provider)

  • (Retrospective reimbursement)

  • (Prospective payment)

  • (Mixed payment)


Line Item Budget

Global Budget

Capitation

Case-based i.e. Diagnostic Related Payment

Fee-for-service

Per diem


Provider payment mechanisms and provider behaviour

Key: +++ very positiveeffect; ++ somepositiveeffect; +/- little or no variable effect; - - some negative effect; - - - very negative effect


()

(tax-based health insurance) Beveridge model

(compulsory social insurance) Bismarck model

(voluntary health insurance)

(medical saving account)


  • (Adverse selection) voluntary insurance

  • (User moral hazard)

  • risk selection voluntary insurance

  • (Provider moral hazard)

    • (Over-service)

    • (Under-service)


  • Adverse selection

    • (risk adjusted premium)

  • User Moral Hazard

    • (co-payment)


  • Risk selection

    • (community rating premium)


  • Provider Moral Hazard

      • (fund holder)

      • (rule for payment)

      • (prospective)

      • (global budget, capitation)

    • (competition)

    • (utilization and management review)


Thailand: historical development

Establishment of prepayment schemes

User fees

Informal exemption

1945

Expansion of prepayment schemes

1970

1975

LIC

1980

CSMBS

1-3rd NHP

1962-76

Provincial

hospitals

1983

CHF

1990

SSS

1980

SSS

CSMBS

LIC MWS

Universal Coverage

4th -5th NHP

(1977-86)

District hospitals

Health centers

1990

1994

PVHI

SSS

2000

2001

Universal Coverage

CSMBS

Health Infrastructure

2001

Samrit Srithamrongsawat


The challenge of health insurance systems in Thailand

  • one single system

  • one standard for all

  • the system for all (no matter rich or poor)

  • efficient and effective system (cost-effectiveness)

  • cost containment



  • +


2543

%


CurrenthealthinsurancesystemsinThailand

  • Universal Health Care Scheme

  • Fringe Benefit SchemeCivil Servant Medical Benefit Scheme (CSMBS) State Enterprises Medical Benefit Scheme (SEMBS)

  • Social Security Scheme (SSS)


Civil Servant Medical Benefit Scheme (CSMBS)


Social Security Scheme (SSS)


Universal Health Care Scheme


Benefit Coverage

Benefit coverage comparison for 3 Main Health Schemes in Thailand


: .


.

2545=224%

100%

79%

60%

: .



80%

20%

20%

80%




2554-5


2555

51


UC 2555 5

52


2554

53


Situation analysis

Feasibility study

Policy formulation

Strategic planning

Communication

Implementation

Monitoring and evaluation


100%

80.64

3-15

24.43

89.57

35-44

38.29

96.15

60-74

32.28

20

40

60

80

55

(: 2550)


56

: .. 2551


2554

  • .

  • ..

  • .1 (Comprehensive care)

  • .

57



2554

3.

( 2.25 ./. UC )

.


1.

2.

3.

4.


.

6.1 /

6.2 //

6.3

6.4 / (.)

6.5

6.6


UC . ..

2552 2545 32%

: 0110 .5


UC . ..

2552 2545 23%

: . .


?

I II III IV V VI VII VIII IX X


2

. (3)

. (3)

. (2)

1

8

3

. (2)

(2)

7

(2)

. (3)

5

10

. (3)

. (3)

9

4

6

. (3)

. (3)

13

. (1), . (1),

. (2), .(2),

(2), . (2), . (2),

. (2), (2)

. (3)

11

23

1

. (2)

. (3)

12

2

3

05/10/57

2546 - 2548


. (3)

. (3)

. (4)

. (4)

. (4)

. (4)

2

. (2)

. (4)

. (4)

. (4), . (4)

. (4)

1

. (4)

. (4)

. (4)

8

3

. (2)

(2)

. (4)

. (4)

. (4)

. (4)

. (4)

7

. (3)

. (4)

. (4)

(2)

. (3)

(4)

. (4)

5

10

. (3)

. (4)

. (4)

.(4)

9

4

. (3)

. (4)

. (4)

. (4)

. (4)

. (4)

6

. (3)

. (3)

. (4)

. (4)

13

. (1), . (1),

. (2), .(2),

(2), . (2), . (2),

. (2), (2)

. ()

. (3)

. (4)

. (4)

. (4)

11

62

1 = 2

. (2)

. (3)

. (4)

. (4)

. (4)

12

2 = 12

3 = 11

2551-2552

4 = 37

05/10/57

66


10

.

: .


UC

    • 95 UC 75

:


Total health expenditure 1994-2005

Achieving UC

36

36

37

37

46

53

45

45

44

44

53

55

64

64

63

63

47

54

56

47

55

55

56

45

Total health expenditure during 2003-2005 ranged from 3.49 to 3.55% of GDP, THE per capita approx 100 USD

: IHPP


Financial Equity

Household health expenditure as % of income by per-income deciles, prior to UC (1992-2000) and after UC 2002

percentage

9

8.17

8

76

4.82

5

3.74

3.65

4

2.87

2.57

3

2.45

1.99

2.77

1.64

1.27

2.59

2

2.2

2.14

1.98

1.74

1.9

1.92

1.83

1

1.71

0

1

2

3

4

5

6

7

8

9

10

Decile

1992

1994

1996

1998

2000

2002

Source: Data in 1992-2000 from Thailand Health Profile 1999-2000. Data in 2002 from analysis of Socio-Economic Survey 2002 conducted by NSO. Remark: Health expenditure of household was percentage out of income.


UC


UC

    • sub-acute



    • (Free tradearea) (Medical hub of Asia)


. 55-59



()



55-59


MERCI BEAUCOUP


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