Suriyawongpaisal Paibul, Aekplakorn Wichai, Srithamrongsawat Samrit, Srithongchai Chaisit, Prasitsiriphon Orawan, Tansirisithikul Rassamee
Department of Community Medicine, Faculty of Medicine Ramathibodi hospital, Mahidol University, Bangkok, Thailand.
BMC Health Serv Res. 2016 Oct 21;16(1):606. doi: 10.1186/s12913-016-1847-y.
Although bodies of evidence on copayment effects on access to care and quality of care in general have not been conclusive, allowing copayment in the case of emergency medical conditions might pose a high risk of delayed treatment leading to avoidable disability or death.
Using mixed-methods approach to draw evidence from multiple sources (over 40,000 records of administrative dataset of Thai emergency medical services, in-depth interviews, telephone survey of users and documentary review), we are were able to shed light on the existence of copayment and its related factors in the Thai healthcare system despite the presence of universal health coverage since 2001.
The copayment poses a barrier of access to emergency care delivered by private hospitals despite the policy proclaiming free access and payment. The copayment differentially affects beneficiaries of the major 3 public-health insurance schemes hence inducing inequity of access.
We have identified 6 drivers of the copayment i.e., 1) perceived under payment, 2) unclear operational definitions of emergency conditions or 3) lack of criteria to justify inter-hospital transfer after the first 72 h of admission, 4) limited understanding by the service users of the policy-directed benefits, 5) weak regulatory mechanism as indicated by lack of information systems to trace private provider's practices, and 6) ineffective arrangements for inter-hospital transfer. With demand-side perspectives, we addressed the reasons for bypassing gatekeepers or assigned local hospitals. These are the perception of inferior quality of care and age-related tendency to use emergency department, which indicate a deficit in the current healthcare systems under universal health coverage. Finally, we have discussed strategies to address these potential drivers of copayment and needs for further studies.
尽管关于共付费用对总体医疗服务可及性和医疗质量影响的证据尚无定论，但在紧急医疗情况下允许共付费用可能会带来治疗延误的高风险，从而导致可避免的残疾或死亡。
我们采用混合方法，从多个来源获取证据（泰国紧急医疗服务行政数据集的40000多条记录、深入访谈、对用户的电话调查以及文献综述），得以阐明泰国医疗体系中共付费用的存在情况及其相关因素，尽管自2001年以来泰国实行全民健康覆盖。
尽管政策宣称提供免费医疗服务，但共付费用对私立医院提供的紧急医疗服务可及性构成了障碍。共付费用对三大公共医疗保险计划的受益人产生了不同影响，从而导致了医疗服务可及性的不平等。
我们确定了共付费用的6个驱动因素，即：1）认为支付不足；2）紧急情况的操作定义不明确；3）入院72小时后缺乏医院间转诊的合理标准；4）服务使用者对政策导向福利的理解有限；5）监管机制薄弱，表现为缺乏追踪私立医疗机构行为的信息系统；6）医院间转诊安排无效。从需求方的角度，我们探讨了绕过守门人或指定当地医院的原因。这些原因包括对医疗服务质量较低的看法以及与年龄相关的使用急诊科的倾向，这表明在全民健康覆盖下当前医疗体系存在缺陷。最后，我们讨论了应对这些共付费用潜在驱动因素的策略以及进一步研究的需求。
