Dynamics of Healthcare Utilization under the Civil Servant Medical Benefit Scheme of
Thailand’s Universal Health Coverage
Introduction
Although Thailand is currently one of the few developing countries that achieved the Universal
Health Coverage (UHC), new health systems problems have emerged since the policy was first
implemented in 2001. One of the major concerns for the policymakers is the sustainability of
three major publicly-funded health financing schemes under Thai UHC, namely the Civil Servant
Medical Benefit Scheme (CSBMS), the Social Security Scheme (SSS) and the Universal
Coverage Scheme (UCS). Over the past recent years, healthcare expenditures of the Civil
Servant Medical Benefit Scheme (CSBMS) have been increasing rapidly and disproportionately
when compared to the other two schemes [1, 2]. For instance, research shows different costs of
hospital care across the three health financing systems, with the mean and the median found
highest in the CSMBS (26,668; 10,209 Baht), followed by SSS (21,455; 9,713 Baht) and the UCS
(13,086; 5,246 Baht) [3].
Many strategies aiming to control the CSMBS budgeting have been implemented in the past
decade, including healthcare utilization review, utilization management, and direct electronic
reimbursement. While the success of such policy interventions was limited, those regulations
apparently created a tension between the Central Comptroller's Department (CDG) that
regulates the CSMBS and healthcare organizations nationwide that serve the CSMBS
beneficiaries [4]. It appears that compartmentalized solutions led us to nowhere, as they usually
address existing problems while creating a new one.
The increasing healthcare expenditures are complicated by the country’s epidemiological
transition to non-communicable diseases (NCDs), the rapidly aging populations, and the limited
range of available facilities that can effectively provide chronic care and elderly care [5]. Thus,
besides coping with the rapidly rising cost, improving quality is still the ongoing agenda of
healthcare reforms under Thailand’s UHC. By law, the CSMBS beneficiaries are allowed to
primarily use the outpatient departments (OPD) and the inpatient departments (IPDs) of
hospitals as their main health care facilities without a requirement to consult with primary care
providers. There are no gatekeepers of CSMBS healthcare systems. The existing hospital care,
originally designed to cope with acute illness, however, would unlikely be able to deliver the
desirable outcomes for the growing demands of chronically ill patients and aging CSMBS
beneficiaries. Moreover, Thailand has become an aged society very rapidly [6], and if the
increasing demands for elderly care and long-term care continue to be served by insufficient
hospital services, disadvantaged populations could have more limited access to the existing
healthcare facilities, and consequently worsen health quality and equity.
The burdens of chronic illness in the rapidly aging Thailand can reflect the similar situations in
other lower- and middle-income countries (LMICs). The recommendations of health systems
reforms in dealing with such health burdens include creating effective primary care services
with linkages between the healthcare systems and other community agencies, aligning
incentives for providers, empowering patients to get involved in their own care, and investing in
disease prevention [7]. At the healthcare facilities level, the reorganization of clinical practices
to provide for longer visits needed for patient education and follow-up, the consistent delivery of
evidence-based healthcare, the responsiveness to the needs of patients when seeking lifestyle
and other behavioral changes, and the implementation of supportive information systems are
crucial interventions to cope with chronic illnesses [8]. With limited resources especially the
health workforce in LMICs, however, each intervention could drain resources from one another
and hence create adverse consequences.
Therefore, a comprehensive solution of healthcare reforms that can address multiple factors at
the same time is needed. But the remain questions are how much the investments should be
put into building new models of primary care services to deal with a greater demand of chronic
care, how much the efforts should be put into quality improvement initiatives in existing facilities,
particularly the outpatient departments of hospitals. It is also uncertain how early such systems
interventions must be implemented to make them effective and efficient given the rapidly
increasing health needs of chronically ill and elderly patients over time.
Applications of system dynamics to explore the healthcare utilization problems
Using a system dynamics approach [9], this present study aimed to seek a better
understanding of the current structure and behaviors of stakeholders of Thailand’s healthcare
delivery systems and the complex relationships among the factors related the problems of
healthcare suboptimal quality and inefficiency that potentially contribute to financial
unsustainability of the CSMBS and the UHC of Thailand. The dynamics of healthcare utilization
was explored to see what has contributed to the rapidly increasing healthcare expenditures,
what has caused behavioral change of stakeholders in Thailand’s healthcare delivery systems
over time, and how ones can influence such behaviors.
The group model building [10, 11] was used to collaboratively develop a conceptual model with
the stakeholders. Quantitative data was collected from the CSMBS stakeholders to generate
causal models of the problems using semi-structured interviews and focus groups. The
ethnographic methodology was used as the protocols to interpret the qualitative data and to
incorporate this information into the modeling process [12]. After conducting a review of related
literature and engaging with the CSMBS stakeholders, the explicit assumptions were made and
the hypotheses of why the burdens of rapidly increasing healthcare expenditures of the CSMBS
are still persisting have been identified. A casual loop diagram (CLD) was created to
demonstrate how the CSMBS beneficiaries, the healthcare providers and other stakeholders
interacts in the existing healthcare delivery systems of Thailand.
Availability of Sees
Hospital Care Sovees
Availability of aN Productivity of
Hospital Care sores Hospital Management
FTEs of Hosptial Care
Providers
a Emerging Technology for
Accessibility of “toatl Care Graduates Choosing Hospital Management
Hospital Care Services Workforce” Hosptial Care Specialties
Size of Labor Market for
Hosptial Care Services
. Utilization of Oy Healthcare
Hospital Care Services. Expenditures
.. (OPDs, IPDs, EDs) bs
Population Strucutre of
Aging Society
wu! Size of Labor Market for
‘Hospital Care Non-Hosptial Care Services
(Acute Care)"
Emerging Health
Information Technology (R2) ‘
. Investment on
* ‘Healthcare ‘Hospital Care
fmt Health Needs Infrastruture”
(Acute & Chronic llinesses) Da ce
Health Literacy Utilization of Pressure to Improve Non-Hospital Care Services Graduate Choosing
and | Self -care Non-Hosptial Care Services (Primary Care, Intermediate Care, Long-term Care,/ Non-Hospital Care Specialties
Palliative Care, Hospice Care)
(B3) (B2) Investments on Primary Care ,/ (R3)
"Self-Care" Nob: ospitel Care and Co-ordination "Non-Hospital Care
(Non-Acute Care)" among Care Models Workforce”
Accessibility of
Non-Hospital Care Services
Productivity of
Non-Hospital Care Management FTES tees eee Care
Availability of Public
Non-Hospital Care Servi
Effectiveness of Chronic Care
and Preventive Medicine
Emerging Technology for
Availability of Privat
ices AR Nat Managment of Non-Hospital Care
Non-Hospital Care Services
Figure 1 Causal loop diagram (CLD) demonstrating the shifting of the burdens of primary care
to hospital care
The root causes of the CSMBS's rapidly and persistently increasing healthcare expenditures
can be more clearly understood by walking through the hypothesized feedback loops as shown
in Figure 1. Overall, it appears that the rising cost of care was a result of the shifting of the
burdens of cheaper primary care services to more expensive hospital care over time.
— Loop B1 and B2 show how the demands generated by unmet health needs of the
CSMBS beneficiaries should lead to utilization of primary care services. With effective
primary care services, health needs of the beneficiaries would be met. Moreover,
chronic disease management by primary care providers could prevent costly
complications and unnecessary utilization of healthcare services later on.
— Loop B3 shows that prevention measures and health promotion practices of primary
care providers could also improve the health literacy of the beneficiaries, which can lead
to a better self-care and less utilization of hospital care. As a result, there would be not
much pressure to change the practices or systems of the existing primary care.
— Loop R1 reveal the facts that most health needs of the CSMBS beneficiaries are unmet,
as there is adequate availability of primary care services or lacking of primary care
services trusted by the beneficiaries. Hence, those chronically ill patients could bypass
primary care services to see providers at the outpatient departments (OPDs) of
hospitals, and patients with more complex illnesses would also receive healthcare at the
inpatient departments (IPDs) of hospitals. When their health needs are met after
receiving a costlier hospital care, there would be no incentives for the beneficiaries to go
back and utilize a less costly primary care.
— Loops R1 show the size of labor market for hospital care is continuously increasing, as a
result of an attempt to address the increasing demands for hospital care. Thus, the
newly graduate health professionals are incentivized to working in hospital settings more
than working in other care models.
— Loops R2 and R3 show that, because the hospital care usually costs more than primary
care, an extensive utilization of healthcare at the OPDs and at the IPDs of the hospitals
will have a direct impact on the rapidly increase of the total CSBMS expenditures.
Moreover, the more resources are spent as healthcare expenditures, the less resources
are left for research and development, particularly investments on innovative primary
care models, policies and management practices that could prevent the unnecessary
utilizations of hospital care from the beginning. Along the same lines, the newly graduate
health professionals are incentivized to not working in primary care and other non-acute
care settings compared to working in hospitals.
Next steps toward a formulation of policy interventions
To help the decision-making process of the policymakers, a system dynamics modeling to
quantitatively explore the consequences of behavioral changes in Thailand's healthcare delivery
systems over the period of 20 years will be built. Then, policy options on comprehensive
strategies to strengthen healthcare delivery systems for CSMBS will be developed. The
preliminary data from the existing literature [3] and from the expert's opinions were used to build
a stock and flow diagram (SFD) as shown in Figure 2. Although further research with an
updated and validated data sets is still needed for building a more accurate system dynamics
model, the preliminary analysis reveals that strategies for budget controlling such as healthcare
utilization review and management show a limited success, while the implementation of
integrated primary care systems effectively dealing with the progress of chronic illnesses of the
beneficiaries appears to be a fundamental solution.
The root causes of subpar quality and inefficiency of care under the governance of CSBMS
apparently are derived from the stakeholders' behaviors embedded in the current systems
structure that primary care, chronic care and long-term care are too dominated by hospital
care. With extensive investments on primary care development, the cost of hospital care would
be better controlled as shown by the preliminary results in Figure 3. This is consistent with the
findings of Homer, Hirsch and Milstein (2007), as a lack of focus on primary care can lead to
missing “upstream” interventions of managing risk factors and preventing illness onset of the
chronic illness, while no “downstream” interventions focusing only at the currently over-utilized
hospital care can solve the problems of an underperforming and expensive healthcare delivery
systems [13, 14].
Scaling up the integrated primary care systems that can better coordinate with hospital care, as
well as other care models such as long-term care for the elderly, is crucial to solving this
persistent problem of rising cost of total healthcare expenditures. One of the policy implications
is that the policymakers should emphasize on building a comprehensive strategy rather than a
compartmentalized one—both upstream and downstream interventions are required. The
downstream interventions alone such as controlling a resource utilization in hospital care are
definitely not enough to cope with the feedback loops of increasing healthcare expenditures.
With more insights of the stakeholders' behaviors embedded in the current systems structure,
policy options can be developed based on comprehensive strategies to strengthen healthcare
delivery systems for the CSMBS beneficiaries and other people living under the Thailand's UHC
policy. This knowledge gained could benefit not only the policymakers of the CSMBS or
Thailand’s UHC, but also the policymakers of healthcare reforms in LMICs during the
epidemiological transition and the population aging as well.
_avarage cost per
Investment in pe pe vist complex
ulation management eacivenor oop
ization management
‘average cost per
base average cost “Sag wat sone,
total opd sim,
new benafiianes
base incidence rate base moray rate complx P
tgiaheathcare
expenditures
Figure 2 Stock and flow diagram (SFD) of disease progression and healthcare utilization of the
CSBMS beneficiaries
Number of OPD Visits by Simple Patients Number of OPD Visits by Complex Patients
20M aM
2 1m 2 25m
& =
> $
° ™
2018 2018 2028 2028 2033 2018 2018 2028 2028 2033
years years
— pd visits simple — pd visits complex
Number of Hospital Admissions CSMBS Healthcare Expenditures
300k
g
5
B 200%
=
5
2
years
100% — total healthcare expenditures
2018 2018 2028 2028 2033 ~~ total opd simple expenditures
years total opd complex expenditures
— ipd admissions ~ ~ - total ipd expenditures
Figure 3 Preliminary findings from the system dynamics modeling of future CSMBS healthcare
utilization
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