Transcript Hospital Beds

Thai Contracting Case
Siripen Supakankunti
Chantal Herberholz
Faculty of Economics
Thailand: Per Capita GDP
Per Capita GDP
140,000
120,000
100,000
THB
80,000
60,000
40,000
20,000
0
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Year
Nominal
Real
Data source: NESDB web site (accessed on June 18, 2010)
Population Characteristics
Source: Health Policy in Thailand, MoPH, 2009
Burden of Disease
Source: Thailand Health Profile 2005-2007, MoPH, Wibulpolprasert (ed.), 2008
Hospital Beds
(By agency and region, 2005)
Source: Thailand Health Profile 2005-2007, MoPH,
Wibulpolprasert (ed.), 2008
Bed-occupancy rates
(By agency, 2003-2005)
Source: Thailand Health Profile 2005-2007, MoPH,
Wibulpolprasert (ed.), 2008
Health Manpower
Proportion of doctors by region, 2005
Source: Thailand Health Profile 2005-2007, MoPH,
Wibulpolprasert (ed.), 2008
Public Health Insurance Schemes
Source: Universal Health Care Coverage Through Pluralistic Approaches, Sakunphanit, 2006
Public Health Insurance Schemes
Source: Universal Health Care Coverage Through Pluralistic Approaches, Sakunphanit, 2006)
Health Expenditures
Source of spending
Public sector
MoPH
Other ministries
CSMBS
SOEBS
WCS
SSS
Total
Private sector
Private health insurance
Households and employers
Total
Other
International financial aid
Total (%)
Overall health expenditure (THB million)
in % of GDP
Population (million)
Per capita expenditure
1980
1990
2000
2005
17.76
8.73
2.61
0.44
0.40
0
29.94
12.95
3.64
3.44
0.58
0.35
0
20.96
21.02
2.07
5.69
0.54
0.42
3.21
32.95
19.75
1.40
6.66
0.86
0.35
4.04
33.06
0.88
67.75
68.63
1.12
77.77
78.89
2.43
64.60
67.03
3.19
63.57
66.76
1.44
0.15
0.02
0.18
100
100
100
100
34,916 111,635 172,671 224,213
3.82
5.74
6.09
6.14
46.45
56.34
61.77
62.20
752
1,981
2,795
3,605
Data source: Thailand Health Profile 2005-2007, MoPH, Wibulpolprasert (ed.), 2008
Harding-Montagu-Preker Framework: Overview
Goal
Assessment
Focus
Private
Sector
Strategy
PHSA
•Gather available
information
Grow
•Identify additional needs
•In-depth studies
•Distribution
Activities
(equity)
• Hospitals
• PHC
• Diagnostic labs
• Producers / Distributors
•Efficiency
•Quality of Care
Harness
Convert
Ownership
• For-profit corporate
• For-profit small business
• Non-profit charitable
Public
Sector
Formal/ Informal
Source: Adapted from Harding & Preker, Private Participation in Health Services, 2003.
Restrict
Policy Tools
• Goal: Improve quality of care
• Instrument selected: Contracting
• Contracting options employed:
– Procurement of drugs and food
– Lease or rental agreements for capital-intensive
equipment
– Contracting-in
• Drug stores
• Administration
– Contracting-out
• Clinical laboratory services
• Selected hospital services
3 Models
• Model I: Rural model
– Initiator: public sector
– Goals:
• To increase availability of operating rooms
• To increase availability of beds for postoperative
recovery of patients
– Selection of provider: based on personal relations
– Target group:
• CSMBS-insured patients
– Elective
• Patients who pay OOP
– Elective
3 Models
• Rural model (continued)
– Services:
• Operating rooms
• Hospital inpatient care (simple illness types)
– Payment strategy:
• Patients register at private hospital
– Operations
» Private hospital pays public doctors a doctor fee
– Inpatient care
» DRG (MoF) or FFS
– Bed
» Fixed rate
• Subject to administrative provisions of insurance scheme
and agreement between the parties
– Problem: regulatory framework
– Implementation: pending
3 Models
• Model II: Urban model
– Initiator: public sector
– Goals: to increase availability of beds for
postoperative recovery of patients and chronic
care
– Selection of providers: NHSO recommendation
• Private hospital A
– Interested; located in different zone
• Private hospital B
– Denied; UCS capitation too low
• Private hospital C
– Not feasible; too small
– Target group:
• UCS-insured patients
– Elective
3 Models
• Urban model (continued)
– Services:
• Hospital inpatient care
– Selected illness types
– Payment strategy:
• Patients register at public hospital
– NHSO pays fixed rate for inpatient service to private
hospital
• Subject to administrative provisions of
insurance scheme
– Problems:
• Lack of support at public hospital due to
negative impact on payment mechanism
• Liability
• Regulatory framework
– Implementation: pending
3 Models
• Model III: Urban model with university
teaching hospital
– Public teaching hospital:
• 1,500 beds (common ward and private beds)
• Mostly CSMBS patients
• High average occupancy
– Private hospital:
• 550 beds
• Mostly OOP patients or patients covered by
private health insurance
• Initially low average occupancy
3 Models
• Urban model with university teaching
hospital (continued)
– Initiator: public sector
– Goals: to increase availability of beds for
postoperative recovery of patients
– Selection of provider: based on personal
relations
– Target group:
• CSMBS-insured patients
– Elective
– Services:
• hospital inpatient care (10 beds)
• Selected illness types
3 Models
• Urban model with university teaching
hospital (continued)
– Payment strategy:
• Patient registers at public hospital
– Inpatient care
» DRG (MoF)
» Medication sent from public to private hospital
– Bed – Example:
» Private hospital charges public hospital 3,000 baht;
usually sells for 5,000 baht
» Patient pays 3,500 baht for bed at private hospital
» Patient can reimburse 800 baht from MoF; copayment 2,700 baht
• Subject to administrative provisions of insurance
scheme and agreement between the parties
3 Models
• Urban model with university teaching
hospital (continued)
– Negotiations:
• Started 4 years ago; 3 phases
– Phase I
» Private hospital reserved 10 beds, but these
were not all used by public hospital
– Phase II
» Private hospitals did not reserve 10 beds, but
sold these elsewhere
– Phase III
» MoU signed
» Private hospital reserves 10 beds
• Transaction costs?
3 Models
• Urban model with university teaching
hospital (continued)
– Liability:
• Private hospital responsible for stabilizing patient
in case of emergency
• Patient and responsibility subsequently transferred
back to public hospital
– Problems:
• Lack of responsibility and accountability at public
hospital
• Lack of marketing skills at public hospital
• Regulatory framework
Concluding remarks
• There is no “one-size-fits-all” approach
– All 3 models come with different features
• Involving all stakeholders matters for successful
hospital contracting
–
–
–
–
Public and private providers
Health insurers
Regulator
Consumers
• Hospital contracting can be a powerful tool for
harnessing the private sector
Discussion
• What do you think about contracting with
private hospitals as a way to solve bed
shortages at public hospitals?
• What are the risks transferred to the
private hospital under the 3 models?
• Can you identify any action items to
achieve a more effective solution?