1. Impacts of Direct Fee-For- Service Payment Insurance on Access and Use of Drug: An Interrupted Time Series Study on Diabetic Care Inthira Kanchanaphibool, PhD and Sanita Hirunrassamee, PhD

2. Health Insurance in Thailand  Outpatient care – 3 major schemes  Some people who do not use their insurance  paid Out-Of-Pocket (OOP) – FFS payment Health InsuranceBeneficiary Payment to hospital Civil Servant Medical benefit Scheme (CSMBS) Government officersFee-For- Service (FFS) Universal Coverage (UC)Low income peopleCapitation Social Security Scheme (SSS)EmployeesCapitation

3. Direct Payment Policy – CSMBS Outpatient Care  Former payment:  Advance paid by officers, and then reimbursed from the government  A policy change since July, 2006:  Direct-FFS payment from the government to hospitals  To reduce a financial burden of beneficiaries  To obtain e-health care utilization data submitted from hospitals for reimbursement Do the change in the reimbursement policy affect the consumption of healthcare resources?

4. Objectives  To determine access and use of drugs before and after the implementation of direct-FFS payment for CSMBS beneficiaries to the hospital  To compare these changes over time with other health insurance schemes Tracer  Diabetes outpatient care (chronic disease)

5. Methods  Longitudinal quasi-experimental analysis with an interrupted time series design  A 1,200-bed public hospital with tertiary care services  All diabetic outpatients with antidiabetic drugs during 2005 – 2009 (5 years) from e-prescription database  Outcome measurements - before and after the direct-FFS payment policy implemented  Number of patients accessed to antidiabetic drugs  Average charge of antidiabetic drugs/patient/month  Segmented regression analysis: levels and trends

6. Number of patients accessed to antidiabetic drugs Direct-FFS

7. Average charge of antidiabetic drugs per patient (Baht) per month Direct-FFS

8. Average charge of high cost antidiabetic drugs per patient (Baht) per month Direct-FFSPetition to ban rosiglitazone

9. Summary  The direct FFS payment to hospitals for CSMBS outpatient care seems to  Extensively increase health care expenditure  Provide no changes in access to care  Discrepancies of average charge of antidiabetic drug among schemes  Inequalities  Possibility to be irrational use over- or under-used???

10. Policy Implications  The policy of health insurance payer in reducing burden of advance payment by CSMBS patients may increase drug utilization  The hospital should consider coexisting strategies to ensure rational uses of drug needed to contain drug costs and to secure quality of care, for example  Standard treatment guidelines, medical record review, etc.