international health policy program -thailand determinants of clinical practice variations and...
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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 Congress10 July 2007, Copenhagen
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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
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
Population Patients
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
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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
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2004 2005 2006
Number of admissionsin total
3,829,533 4,507,724 4,895,136
Number of deliveriesin total
361,426 429,548 441,407
Deliveries as % of total admissions
9.4% 9.5% 9.0%
Caesarean sectionsas % of total deliveries
16.3% 18.3% 20.1%
Hospital Admissions and Deliveries
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Percentage of caesarian section to total deliveries
by health insurance schemes
15.4% 15.9% 16.4% 17.0% 17.2% 17.8% 18.3% 18.9% 19.8% 20.0% 20.0% 20.1%
17.0% 17.3% 16.2% 16.8% 18.4%20.2% 20.3% 21.6% 20.6% 20.1% 19.3% 19.7%
28.8%
36.3%
30.5%
24.3%
35.9%
42.3%
37.7%41.4%
45.6%
40.1%
48.4% 48.1%
9.8%
14.3%
6.0%
9.3%
14.0%12.2% 12.7%
18.5%16.4% 16.4%
20.4%
15.1%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
2004Qtr1
2004Qtr2
2004Qtr3
2004Qtr4
2005Qtr1
2005Qtr2
2005Qtr3
2005Qtr4
2006Qtr1
2006Qtr2
2006Qtr3
2006Qtr4
UC SSS CSMBS ROP
Source: Electronic claim database of inpatients from National Health Security Office, 2004-2006 (N=13,232,393 hospital admissions)
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Likelihood of having caesarian section
Logit estimation (N=1,229,458 deliveries)Odds ratio
P-value
95% LL 95% UL
SSS vs. UC 1.04<0.00
11.02 1.06
CSMBS vs. UC 2.44<0.00
12.28 2.62
ROP vs. UC 1.06 0.334 0.94 1.19
Age 20-35 vs. <20 yr 1.87<0.00
11.84 1.89
Age >35 vs. <20 yr 2.86<0.00
12.81 2.91
District vs. Other hosp. 0.26<0.00
10.25 0.27
Provincial vs. Other hosp. 1.62<0.00
11.58 1.67
Central vs. Bangkok 1.07<0.00
11.05 1.08
North-East vs. Bangkok 0.95<0.00
10.94 0.97
South vs. Bangkok 0. 93<0.00
10.92 0.95
Years 2005 vs. 2004 1.12<0.00
11.10 1.13
Years 2006 vs. 2004 1.25<0.00
11.23 1.27
ANLL induction treatment from Adult Hematological Malignancy Registry,
Thailand
Number of patientsN 581
Palliative care/
no chemo RX
Chemotherapy
ADR+Araa IDR+Arab Other M3 Rxc
UC 336 36.9% 22.0% 20.2% 8.3% 12.5%
SSS 66 7.6% 21.2% 47.0% 4.6% 19.7%
CSMBS 119 29.4% 17.7% 30.3% 16.8% 5.9%
ROP 60 31.7% 13.3% 30.0% 11.7% 13.3%
a ADR+Ara: Adriamycin 3 days + Cytarabine 7 daysb IDR+Ara: Idarubicin 3 days + Cytarabine 7 daysc M3 (acute promyelocytic leukemia) Rx: All-trans retinoic acid or AsO3 (+ADR or IDR)
Direct costs of medical treatment forANLL induction treatment* and palliative
careCosts of induction treatment Costs of palliative care
Median(USD)
Quartile 1
(USD)
Quartile 3(USD)
Median(USD)
Quartile 1
(USD)
Quartile 3(USD)
UC 3,194 977 7,720 1,026 307 3,053
SSS 8,438 4,833 16,818 1,988 387 3,815
CSMBS 4,937 1,580 11,797 2,007 629 3,690
Rest of pop.
3,593 613 9,409 1,162 656 2,994
* Excluded cost of bone marrow transplant
USD 1 = 35.50 Thai Baht
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Survivals of ANLL Patients (N=509 cases)
Number of
patientsN 509
Median survival*(months)
Survival rate*
6-month 12-month 24-month
UC 298 3.45 40.3% 23.6% 4.5%
SSS 59 9.21 62.3% 38.6% 20.5%
CSMBS 108 8.33 58.7% 35.7% 13.9%
Rest of pop. 44 10.34 60.7% 45.5% 42.1%
* Adjusted for age 50 yr
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Relative risk of dying –ANLL patients(N=565)
Relative risk*P-
value95% LL 95% UL
SSS vs. UC 0.61 0.004 0.43 0.85
CSMBS vs. UC 0.65 0.001 0.50 0.83
ROP vs. UC 0.64 0.019 0.44 0.93
Age (1-yr increase) 1.01 0.017 1.00 1.01
Male vs. Female 0.96 0.671 0.79 1.16
ADR+Ara vs. No chemo Rx
0.45 <0.001 0.34 0.61
IDR+Ara vs. No chemo Rx
0.45 <0.001 0.34 0.59
Other chemo vs. No chemo Rx
0.68 0.022 0.49 0.94
M3 Rx vs. No chemo Rx 0.31 <0.001 0.21 0.46
* Time-to-event analysis based on Weibull regression
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Percentage of patients receiving inhaled cortico-
steroids
Chronic asthma adults (N=6,176)
from 18 provincial hospitals
UC-E*
(N = 2,553)
UC-P**
(N = 866)
SSS
(N = 624)
CSMBS
(N = 1,668)
ROP
(N = 465)
Year
2 001253. % 47.7% 394. % 405. %344. %
Year
2 002250. % 500. % 393. % 412. %271. %
* UC-E: UC members exempted from copay per visit
** UC-P: UC members required copay per visit
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Odds of receiving inhaled cortico-steriods
Odds ratio* P-value 95% LL 95% UL
UC-E vs. SSS 084. 0026. 072 0.98
UC-P vs. SSS 147. 000< .1
124 1.73
CSMBS vs. SSS 151 000< .1
129 1.77
ROP vs. SSS 093 0492. 076. 1.14Age 36-49 vs. 18-35 yr 101. 0915 088 1.15
Age > 50 vs. 18-35 yr 044. 000< .1
039 0.5
Male vs. Female 089. 0009. 082. 0.97Prior admission due to asthma vs. No admission
3 .00 000< .1
257. 3.5
Prior rescue medication vs. No rescue medication
168 000< .1
152. 1.86
Years 2002 vs. 2001 0.78 0.093 0.58 1.04
* Based on logistic regression, adjusted for indicators of 18 study hospitals
20%
30%
40%
50%
60%
70%
80%
2001 2002 2001 2002
Likelihood of receiving inhaled cortico-steroids
Chronic Asthma Adults (N=6,176)
Patients with history of admission due to asthma (N=489)
Patients who ever used rescue medication (N=1,512)
CSMBS
CSMBS
UC-P
UC-P
SSS
SSS
ROP
ROP
UC-E
UC-E
Year
Patients with no asthma admission
nor prior rescue medication (N=4,175)
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ndDiscussions 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
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– 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
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ndConclusions
– 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
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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.
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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