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Table 8 Summary of key findings from in-depth interviews

From: Copayment and recommended strategies to mitigate its impacts on access to emergency medical services under universal health coverage: a case study from Thailand

Emerging themes Regulators Private hospital directors, financial staff and ED staffs The clearing house administrators The administrators of the health insurance schemes
Opinions about the policy initiatives 1. The policy maker makes reference to the Sanatorium Act B.E. 2541 under the MOH to recruit the private hospitals into the policy implementation. This is perceived to be a very rare case since the law came into effect over a decade. 1. The policy makers give too short notice for private hospitals to consider whether to participate or not. 2. The single payment rate is considered inappropriate for the cost of provision of EMS which could substantially vary from case to case. 3. The rationale and method used for determining single payment rate are considered unclear. 4. Prior to the policy initiatives, the private hospitals claim of having been providing EMS to any patients in an emergency condition, even free of charge, on ethical ground and as required by the law. Hence the policy requirement is considered redundant. 1. The hectic manner in policy implementation precludes adequate design of payment rate and timely responses from the health insurance schemes in terms of modification of rules and regulations to support the policy requirement (single payment rate and payment mechanism). 1. The policy makers give too short notice for the health insurance schemes to get organize in response to the policy. The single payment rate to private hospitals and the clearing house mechanism are the issues of major concern since there is no the existing rules and regulations to support the scheme compliance to the policy requirement. 2. The UCS administrator advocates for the implemented payment rate out of a concern of financial sustainability since per head budget for the UCS is the lowest among the 3 schemes.
Operational definitions for emergency conditions (EC) and the state of being stabilized enough for inter-hospital transfer. The definition has been used to guide prehospital care ambulance for many years. It was developed based on the U.S. standards. 1. The operational definition of EC is not clear cut hence rendering abuse from some users with non EC. There are examples of users choose to visit a private hospital far away from the scene of emergency event instead of choosing the nearby hospitals. 2. The definition for judging whether a patient is stable for inter-hospital transfer is not available. This induces difficulty in transferring the patients especially CSMBS beneficiaries to other hospitals especially public hospitals in case the patients could not afford the cost of further stay beyond 72 h in the private hospitals. The operational definition for severity classification of EC is too subjective especially for discriminating patients with non-critical conditions. As a result, misclassification of the patients among severity categories could render difficulty in claim approval. 1. SSS beneficiaries with EC who are admitted to hospitals outside the contract are allowed to stay no more than 72 h before transferring to contracted hospitals. Hence the lack of definition on patients being stabilized for inter-hospital transfer is less likely to affect SSS beneficiaries. Similar arrangement like this does not exist in the health insurance system under CSMBS and UCS. However, the UCS beneficiaries are less likely than those of CSMBS to face difficulty in the inter-hospital transfer issue since the formers are registered to certain hospitals whereas the latters are not required to register to any hospitals.
Mechanisms and processes to enhance common understanding and acceptance of the definition among the key stakeholders 1. Formal meetings were held among all relevant stakeholders to inform detailed definition and its implications for service provision. 1. Sensible approach to the adoption of such definition should be based on consultation of providers and professional organizations such as the Royal College of Surgery etc. 1. Apart from a formal meeting to inform providers and the health insurance schemes about the definition, a public telephone number was set up to facilitate clarification of relevant concerns of stakeholders since day one of the implementation. 2. Formal training sessions were organized to assist application of the definition by the private hospitals. 1.A formal meeting was held among the administrators of the health insurance schemes at the commencement of the policy.
Regulatory function and mechanism to enhance provider compliance to the laws 1. Until the present, there has not been any formal mechanisms to keep track on the compliance of private hospitals to the Sanatorium Act. 2. So far based on my experience (a senior health officer) in working in the Health Facility Committee under the Sanatorium Act, there has not been a single case of specific private hospitals being seriously dealt with for misconduct. Not applicable 1. Financial audit of claimed data on case by case basis is mandatory for compensation to the private hospitals. 2. Time limit has been imposed on the process of financial audit in order to avoid unnecessary delay of the compensation to the hospitals. Not applicable
Provision of care and the process of claim submission or claim processing 1. There has not been any concrete information systems to keep track of service provision in private hospitals except for setting up online channel for user complaints. 1. Some security-market registered hospitals describe network of member hospitals with certain degree of differentiated specialization to support patients with specific needs and different level of purchasing power. The network, hence, is in a better position to smoothly handle continuity of care including inter-hospital transfer of patients with diverse needs and purchasing power. In addition, these hospitals also contend that maintaining standby teams of medical specialties for any major emergency cases is costly hence justifying the price setting. 2. A few security-market registered private hospitals show concrete evidence of standard protocols for certain EC like acute abdomen, acute chest pain. 3. It is the duty of a physician in charge of specific patients in EC to do severity classification. Charge processing is the responsibility of financial staffs taking into account the standard claim protocol of the clearing house. 1. A standard online claim protocol is specifically established for the program. According to the protocol, expected timeline for claim processing is set to be completed within a month from the date of claim submission. 2. Only financial audit is conducted to ensure hospital compliance to the protocol. 3. There is no pre-admission authorization for each hospitalized patient. Not applicable
Feedback on the payment and the regulation Volume of prehospital ambulance services by the national lead agency of emergency care system is reported to the high-level decision-making forum on monthly basis. 1. Without acceptable financial compensation to private hospitals, compliance to the law is hardly achievable. 2. The private hospitals proposed revision of the single payment rate to reflect the cost of service provision through participatory approach. 3. Private hospitals set prices to reflect full cost recovery and a surplus of under 15 % per annum 4. Given the fact that a number of patients bypass the hospitals closest to the place of events, it is justified to impose copayment to mitigate this misconduct on the demand side. Monthly feedback to the high-level decision-making forum involves trends of : volume of service, access by health insurance status, number of patients by severity classification, type of hospital visits, findings from periodic telephone surveys, number of participating hospitals, duration of arrangement for inter-hospital transfer of inpatient, copayment 1. It is not clear about the progress on the attempts to make changes in rules and regulations for payment mechanism relevant to the program expectation. 2. CSMBS and SSS administrators concern about potential impacts of the expected changes on all other benefit packages for non-emergency conditions.