การจำลองผลกระทบทางการเงินจากการเปลี่ยนหลักเกณฑ์การเบิกจ่ายค่ายา : กรณีบริการผู้ป่วยนอกในระบบหลักประกันสุขภาพ 3 ระบบหลักของประเทศไทย ในโรงพยาบาลเฉพาะทางจิตเวชแห่งหนึ่ง

Abstract

Objective: This study was aimed to simulate financial impact to health care providers and payers if the existing pharmaceutical reimbursement schemes would be replaced by alternative options of fee for service based reimbursement models which pre-specified reimbursed prices by the buyers. The study would be a piece of information to support decision making in the future. Method: Retrospective secondary data of prescriptions dispensed for outpatient during the fiscal years 2012-2014 at a psychiatric hospital was employed. Descriptive study and model simulation were done comparing financial impact among alternative options of pharmaceutical reimbursement scheme: RP-1: Current pharmaceutical reimbursement with RP-2: Reimbursement prices for pharmaceuticals from the National Health Security Office Region 13 and RP-3: The proposed pharmaceutical reimbursement model being developed for those under the Civil Servant Medical Benefit Scheme by the Health Insurance System Research Office. Result: The study found that disease-specific drug spending per visit under fee for charge based Civil Servant Medical Benefit Scheme (CSMBS) was highest for all groups of diseases comparing to capitation based scheme: Universal Coverage Scheme (UC) and Social Security Scheme (SSS). The average drug spending per visit was found the same direction. CSMBS was the highest. (CSMBS: 4,359.36 Baht/visit, UC: 243.24 Baht /visit, SSS: 472.63 Baht/visit). This implied that drug utilization pattern among health insurance schemes were different, even when controlled for disease. The simulated financial impacts on provider demonstrated decreasing of providers' income but never lower than medicine costs. RP-2 was found highest decreasing providers' income (12.98% from current). On the other side, regarding the financial impacts on payers, it was found that RP-2, 3 model could save drug expenditure only for the CSMBS and SSS scheme. The UC scheme oppositely demonstrated higher spending when RP-2, 3 were simulated to replace the current reimbursement, which draws the payment ceiling at 700 Baht/visit. In addition, majority of prescriptions under the UC scheme are low price items. The alternative reimbursement scheme, RP-2,3 assigned higher rate of %mark-up for low price range, the simulated overall drug expenditure was then grown up. In summary, both alternative reimbursement models demonstrated saving for health care payers, while ensured sufficient income to cover medicine cost for providers.