การจำลองผลกระทบทางการเงินหากมีการปรับเปลี่ยนวิธีการเบิกจ่ายค่ายาสำหรับผู้ป่วยนอกของ 3 ระบบประกันสุขภาพหลัก : กรณีศึกษาโรงพยาบาลทั่วไปแห่งหนึ่ง

Abstract

Objective: This study was aimed to simulate the financial impacts on the health care purchaser and providers perspective comparing among options of pharmaceutical reimbursement pricing scheme. development were actually used by comparing with the present reimbursement in the case of the outpatient of Civil Servant Medical Benefit Scheme, Universal Coverage Scheme and Social Security Scheme. Method: Retrospective secondary data of outpatient prescriptions since 1* October 2013 to 30th September 2014 was employed. The simulation of financial impact was done for 3 options of pharmaceutical reimbursement pricing scheme. Those are RP- 1: Comptroller General's Department's pricing scheme, RP-2: pharmaceutical reimbursement pricing employing by National Health Security Office of Bangkok area and RP-3: pharmaceutical reimbursement pricing scheme developed by the Health Insurance System Research Office (HISRO). The current pharmaceutical reimbursement scheme of 3 major social health insurance were simulated to be replaced by these reimbursement options. Results: This study found that health care payers are demonstrated to gain most saving by RP-2 reimbursement pricing scheme comparing to other options, in spite of this model using the public maximum purchasing price for marking up to be reimbursement prices. RP-3 which was developed by HISRO demonstrated higher saving than CGD pricing scheme. These schemes differ from the RP-3 as they use the actual purchasing price for marking up to be reimbursement price. The drug groups by therapeutics accounted for high spending are closely corresponding to drug price. The study found RP-3 tend to save more from expensive drugs, while assigned higher mark up to the cheaper drugs comparing to RP-2 model. When considering of each health insurance scheme separately, the study found all reimbursement models simulated in this study could decrease payers' expenditure, while still able to cover cost of medicine for health care provider. However, for the universal coverage health insurance scheme, changing from capitation based payment for the drug to fee for item based would be benefit only in case the service utilization rate was not higher than 66% and the proportion for drug spending was not less than 68% of capitation rate. Under UC scheme, considering only outpatient refer cases, the hospital has been paid lower than its cost of medicine. Per case basis with the ceiling 200 baht was not enough to cover the medicine cost, this payment mechanism needed to be reconsidered to decrease the hospital's financial burden. Conclusion: All alternative options of pharmaceutical reimbursement pricing scheme simulated in this study could save drug expenditure for CSMBS comparing to the current fee for charge based reimbursement scheme. For capitation based health insurance scheme, UC, was found uncertain benefit depending on the payment ceiling level for refer case, service utilization rate, proportion of capitation rate available for medicine spending, and also medicine cost and amount using.