Viroj Tangcharoensathien, MD PhD Phusit Prakongsai, MD Supon Limwattananon, PhD

1. Determinants of clinical practice variations and influence of provider payment methods: A case study from Thailand Viroj Tangcharoensathien, MD PhD Phusit Prakongsai, MD Supon Limwattananon, PhD Chulaporn Limwattananon, PhD Walaiporn Patcharanarumol, MPH International Health Policy Program (IHPP) Ministry of Public Health, Thailand Presentation to the 6th IHEA World Congress 10 July 2007, Copenhagen

2. Outline of presentation • Background information and objectives of the study • Three tracers for exploring clinical practice variations: • Cesarean section procedure; • Treatments for acute non-lymphoid leukemia (ANLL); • Controller medication for chronic asthmatic patients. • Discussions • Conclusions and policy recommendations

3. Health care finance and service provisions of the Thai health care system after implementation of the universal coverage policy General tax General tax Standard Benefit package Tripartite contributions Payroll taxes Risk related contributions Capitation Capitation & global Co-payment budget with DRG for IP Services Fee for services Fee for services - OP Ministry of Finance - CSMBS (6 million beneficiaries) National Health Insurance Office The UC scheme (48 millions of pop.) Social Security Office - SSS (7 millions of formal employees) Voluntary private insurance Public & Private Contractor networks Population Patients

4. Objectives • To describe variations in clinical practices, costs of medical interventions, and clinical outcomes among three different health insurance schemes having different provider payment methods. Health intervention tracers • Caesarian section procedure • Treatments for acute non-lymphoid leukemia (ANLL) • Controller medication for chronic asthmatic patients Multivariate analysis (controlled for case-mix difference) • Probit and logistic regressions for likelihood of receiving the interventions • Weibull regression for patient survival rate

5. Hospital Admissions and Deliveries

6. Percentage of caesarian section to total deliveriesby health insurance schemes Source: Electronic claim database of inpatients from National Health Security Office, 2004-2006 (N=13,232,393 hospital admissions)

7. Likelihood of having caesarian sectionLogit estimation (N=1,229,458 deliveries)

8. ANLL induction treatment from Adult Hematological Malignancy Registry, Thailand a ADR+Ara: Adriamycin 3 days + Cytarabine 7 days b IDR+Ara: Idarubicin 3 days + Cytarabine 7 days c M3 (acute promyelocytic leukemia) Rx: All-trans retinoic acid or AsO3 (+ADR or IDR)

9. Direct costs of medical treatment forANLL induction treatment* and palliative care * Excluded cost of bone marrow transplant USD 1 = 35.50 Thai Baht

10. Survivals of ANLL Patients (N=509 cases) * Adjusted for age 50 yr

11. Relative risk of dying –ANLL patients(N=565) * Time-to-event analysis based on Weibull regression

12. Percentage of patients receiving inhaled cortico-steroidsChronic asthma adults (N=6,176)from 18 provincial hospitals * UC-E: UC members exempted from copay per visit ** UC-P: UC members required copay per visit

13. Odds of receiving inhaled cortico-steriods * Based on logistic regression, adjusted for indicators of 18 study hospitals

14. Likelihood of receiving inhaled cortico-steroids Chronic Asthma Adults (N=6,176) CSMBS UC-P SSS ROP UC-E Patients with history of admission due to asthma (N=489) Patients who ever used rescue medication (N=1,512) Patients with no asthma admission nor prior rescue medication (N=4,175) CSMBS UC-P SSS ROP UC-E Year 2001 2002 2001 2002

15. Discussions 1 • Determinants of clinical practice variations • Very complex relationship, whereas provider payment is one of the determinants • Multiple determinants • Structural • District hospitals have less Ob-Gyn specialists and facilities [blood, anaesthesia] for caesarean section than others • No haematologist in provincial hospitals to initiate chemotherapy for ANLL • District staff mostly new graduate MD, whereas internal medicine specialists in provincial hospital – competency in application of inhaled cortico-steroid • Demand side characteristics • Prior exposure to rescue drugs, admission of asthma and use of inhaled medicines • Older age pregnancy and higher chance for caesarean section • Patient preference and self demand for caesarean section

16. Discussions 2 • Insurance status and provider payment methods • Hospital policy • Variations in drug list – low cost generic versions for capitation model of SHI and UC, • Original versions and non-ED for fee for services CSMBS and out-of-pocket payment patients • Clinician prescribing preference • Non-ED and brand drugs for CSMBS • Being a “Private patients” in public hospitals • Ob-gyn specialists in Thailand are bound to conduct delivery, time management usually results in medically non-indicated caesarean section [Tangcharoensathien et al 2002] • Special payment for high cost care such as chemotherapy • SHI - fee schedule with ceiling at ~870 USD per year • CSMBS - fee for services • UC – central fund using DRG with global budget payment, and disease management

17. Conclusions • Practice variations: • Determinants are complex and multiple, provider payment is one of the determinants resulting in cost and outcome variations • Further detail investigations required for each specific tracer. • Caesarean • Highest rate among CSMBS, plus confounder of “being a private patient” of OBGYN. • ANLL • Lower access to chemotherapy, poorer survival outcome among UC patients and in favour of SHI patients • Provider payment, availability of haematologist and clinical experiences in induction treatment are complex determinants. • Use of inhaling cortico-steroid in asthma • Severity of disease is important (using admission and use of rescue drugs as a proxy indicator) • In favour of CSMBS and self pay before UC and UC-P after UC scheme launched • Not that expensive and not unaffordable, but perhaps clinician’s awareness of the use of inhaling cortico-steroid

18. Policy Recommendations • Minimize practice variations • Further expansion the coverage of clinical practice guidelines, and advocate their use, e.g. the use of inhaled cortico-steroid, • Single-out some key interventions from capitation payment with special additional payment e.g. fee schedule with close monitoring e.g. Chemotherapy or additional payments for high cost care • Adequate payment for high cost and effective intervention, e.g. some curable cancers. • Monitor and routine report among peers on practice variations, e.g. Caesarean, self control of unnecessary non-clinically indicated Caesarean.

19. Acknowledgements • National Statistical Office of Thailand • Ministry of Public Health (MOPH) • Thailand Research Fund (TRF) and Health Systems Research Institute (HSRI) for institutional grants • Centre for Health Informatics for the dataset of hospital admissions • Thai Society of Haematology for Leukaemia registry • 18 regional and provincial hospitals of MOPH