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Determinants of clinical practice variations and influence of provider

payment methods:

A case study from Thailand Viroj Tangcharoensathien, MD PhD

Phusit Prakongsai, MDSupon Limwattananon, PhD

Chulaporn Limwattananon, PhDWalaiporn Patcharanarumol, MPH

International Health Policy Program (IHPP)Ministry of Public Health, Thailand

Presentation to the 6th IHEA World Congress10 July 2007, Copenhagen

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Outline of presentation• Background information and objectives of

the study• Three tracers for exploring clinical practice

variations:– Cesarean section procedure;– Treatments for acute non-lymphoid

leukemia (ANLL);– Controller medication for chronic asthmatic

patients.• Discussions• Conclusions and policy recommendations

Health care finance and service provisions of the Thai health care system after

implementation of the universal coverage policy

General tax

General tax Standard Benefit

package

Tripartite contributions Payroll taxes

Risk related contributions Capitation

Capitation & global

Co-payment budget with DRG for IP Services

Fee for services Fee for services - OP

Population Patients

Ministry of Finance - CSMBS(6 million beneficiaries)

National Health Insurance Office The UC scheme (48 millions of pop.)

Social Security Office - SSS(7 millions of formal employees)

Voluntary private insurance

Public & Private Contractor networks

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Objectives• To describe variations in clinical practices, costs of

medical interventions, and clinical outcomes among three different health insurance schemes having different provider payment methods.

Health intervention tracers Caesarian section procedure Treatments for acute non-lymphoid leukemia (ANLL) Controller medication for chronic asthmatic patients

Multivariate analysis (controlled for case-mix difference)

Probit and logistic regressions for likelihood of receiving the interventions Weibull regression for patient survival rate

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2004 2005 2006Number of admissionsin total

3,829,533 4,507,724 4,895,136

Number of deliveriesin total 361,426 429,548 441,407

Deliveries as % of total admissions 9.4% 9.5% 9.0%

Caesarean sectionsas % of total deliveries 16.3% 18.3% 20.1%

Hospital Admissions and Deliveries

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Percentage of caesarian section to total deliveries

by health insurance schemes

15.4% 15.9% 16.4% 17.0% 17.2% 17.8% 18.3% 18.9% 19.8% 20.0% 20.0% 20.1%

17.0% 17.3% 16.2% 16.8% 18.4% 20.2% 20.3% 21.6% 20.6% 20.1% 19.3% 19.7%

28.8%

36.3%

30.5%

24.3%

35.9%

42.3%37.7%

41.4%45.6%

40.1%

48.4% 48.1%

9.8%

14.3%

6.0%9.3%

14.0%12.2% 12.7%

18.5%16.4% 16.4%

20.4%

15.1%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

2004Qtr1

2004Qtr2

2004Qtr3

2004Qtr4

2005Qtr1

2005Qtr2

2005Qtr3

2005Qtr4

2006Qtr1

2006Qtr2

2006Qtr3

2006Qtr4

UC SSS CSMBS ROP

Source: Electronic claim database of inpatients from National Health Security Office, 2004-2006 (N=13,232,393 hospital admissions)

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Likelihood of having caesarian section

Logit estimation (N=1,229,458 deliveries)Odds ratio

P-value 95% LL 95% UL

SSS vs. UC 1.04 <0.001 1.02 1.06

CSMBS vs. UC 2.44 <0.001 2.28 2.62

ROP vs. UC 1.06 0.334 0.94 1.19Age 20-35 vs. <20 yr 1.87 <0.00

1 1.84 1.89

Age >35 vs. <20 yr 2.86 <0.001 2.81 2.91

District vs. Other hosp. 0.26 <0.001 0.25 0.27

Provincial vs. Other hosp. 1.62 <0.001 1.58 1.67

Central vs. Bangkok 1.07 <0.001 1.05 1.08

North-East vs. Bangkok 0.95 <0.001 0.94 0.97

South vs. Bangkok 0. 93 <0.001 0.92 0.95

Years 2005 vs. 2004 1.12 <0.001 1.10 1.13

Years 2006 vs. 2004 1.25 <0.001 1.23 1.27

ANLL induction treatment from Adult Hematological Malignancy Registry,

ThailandNumber of patientsN 581

Palliative care/

no chemo RX

ChemotherapyADR+Ara

a IDR+Arab Other M3 Rxc

UC 336 36.9% 22.0% 20.2% 8.3% 12.5%

SSS 66 7.6% 21.2% 47.0% 4.6% 19.7%

CSMBS 119 29.4% 17.7% 30.3% 16.8% 5.9%

ROP 60 31.7% 13.3% 30.0% 11.7% 13.3%

a ADR+Ara: Adriamycin 3 days + Cytarabine 7 daysb IDR+Ara: Idarubicin 3 days + Cytarabine 7 daysc M3 (acute promyelocytic leukemia) Rx: All-trans retinoic acid or AsO3 (+ADR or IDR)

Direct costs of medical treatment forANLL induction treatment* and palliative

careCosts of induction treatment Costs of palliative care

Median(USD)

Quartile 1

(USD)Quartile 3

(USD)Median(USD)

Quartile 1

(USD)Quartile 3

(USD)

UC 3,194 977 7,720 1,026 307 3,053

SSS 8,438 4,833 16,818 1,988 387 3,815

CSMBS 4,937 1,580 11,797 2,007 629 3,690

Rest of pop. 3,593 613 9,409 1,162 656 2,994

* Excluded cost of bone marrow transplant USD 1 = 35.50 Thai Baht

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Survivals of ANLL Patients (N=509 cases)

Number of

patientsN 509

Median survival*(months)

Survival rate*

6-month 12-month 24-month

UC 298 3.45 40.3% 23.6% 4.5%

SSS 59 9.21 62.3% 38.6% 20.5%

CSMBS 108 8.33 58.7% 35.7% 13.9%

Rest of pop. 44 10.34 60.7% 45.5% 42.1%

* Adjusted for age 50 yr

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Relative risk of dying –ANLL patients(N=565)

Relative risk* P-value 95% LL 95% UL

SSS vs. UC 0.61 0.004 0.43 0.85

CSMBS vs. UC 0.65 0.001 0.50 0.83

ROP vs. UC 0.64 0.019 0.44 0.93

Age (1-yr increase) 1.01 0.017 1.00 1.01

Male vs. Female 0.96 0.671 0.79 1.16ADR+Ara vs. No chemo

Rx 0.45 <0.001 0.34 0.61IDR+Ara vs. No chemo

Rx 0.45 <0.001 0.34 0.59Other chemo vs. No

chemo Rx 0.68 0.022 0.49 0.94

M3 Rx vs. No chemo Rx 0.31 <0.001 0.21 0.46

* Time-to-event analysis based on Weibull regression

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Percentage of patients receiving inhaled cortico-steroids

Chronic asthma adults (N=6,176)from 18 provincial hospitalsUC-E*

(N = 2,553)

UC-P**(N = 866)

SSS(N = 624)

CSMBS(N = 1,668)

ROP(N = 465)

Year 2 001 253. % 47.7% 394. % 405. %344. %

Year 2 002 250. % 500. % 393. % 412. % 271. %

* UC-E: UC members exempted from copay per visit** UC-P: UC members required copay per visit

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Odds of receiving inhaled cortico-steriods

Odds ratio* P-value 95% LL 95% ULUC-E vs. SSS 084. 0026. 072 0.98UC-P vs. SSS 147. 000< .

1124 1.73

CSMBS vs. SSS 151 000< .1

129 1.77ROP vs. SSS 093 0492. 076. 1.14Age 36-49 vs. 18-35 yr 101. 0915 088 1.15Age > 50 vs. 18-35 yr 044. 000< .

1039 0.5

Male vs. Female 089. 0009. 082. 0.97Prior admission due to asthma vs. No admission

3 .00 000< .1

257. 3.5

Prior rescue medication vs. No rescue medication

168 000< .1

152. 1.86

Years 2002 vs. 2001 0.78 0.093 0.58 1.04

* Based on logistic regression, adjusted for indicators of 18 study hospitals

20%

30%

40%

50%

60%

70%

80%

2001 2002 2001 2002

Likelihood of receiving inhaled cortico-steroids

Chronic Asthma Adults (N=6,176)

Patients with history of admission due to asthma (N=489)Patients who ever used rescue medication (N=1,512)

CSMBS

CSMBS

UC-P

UC-P

SSS

SSS

ROP

ROP

UC-E

UC-E

Year

Patients with no asthma admissionnor prior rescue medication (N=4,175)

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landDiscussions 1

– Determinants of clinical practice variations• Very complex relationship, whereas provider payment is

one of the determinants • Multiple determinants

– Structural • District hospitals have less Ob-Gyn specialists and

facilities [blood, anaesthesia] for caesarean section than others

• No haematologist in provincial hospitals to initiate chemotherapy for ANLL

• District staff mostly new graduate MD, whereas internal medicine specialists in provincial hospital – competency in application of inhaled cortico-steroid

– Demand side characteristics • Prior exposure to rescue drugs, admission of asthma and

use of inhaled medicines • Older age pregnancy and higher chance for caesarean

section • Patient preference and self demand for caesarean section

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landDiscussions 2

– Insurance status and provider payment methods • Hospital policy

• Variations in drug list – low cost generic versions for capitation model of SHI and UC,

• Original versions and non-ED for fee for services CSMBS and out-of-pocket payment patients

• Clinician prescribing preference • Non-ED and brand drugs for CSMBS

• Being a “Private patients” in public hospitals • Ob-gyn specialists in Thailand are bound to conduct

delivery, time management usually results in medically non-indicated caesarean section [Tangcharoensathien et al 2002]

• Special payment for high cost care such as chemotherapy

• SHI - fee schedule with ceiling at ~870 USD per year• CSMBS - fee for services• UC – central fund using DRG with global budget

payment, and disease management

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Conclusions– Practice variations:

• Determinants are complex and multiple, provider payment is one of the determinants resulting in cost and outcome variations

• Further detail investigations required for each specific tracer. – Caesarean

• Highest rate among CSMBS, plus confounder of “being a private patient” of OBGYN.

– ANLL • Lower access to chemotherapy, poorer survival outcome

among UC patients and in favour of SHI patients • Provider payment, availability of haematologist and clinical

experiences in induction treatment are complex determinants.

– Use of inhaling cortico-steroid in asthma • Severity of disease is important (using admission and use of

rescue drugs as a proxy indicator)• In favour of CSMBS and self pay before UC and UC-P after UC

scheme launched • Not that expensive and not unaffordable, but perhaps

clinician’s awareness of the use of inhaling cortico-steroid

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Policy Recommendations– Minimize practice variations

• Further expansion the coverage of clinical practice guidelines, and advocate their use, e.g. the use of inhaled cortico-steroid,

• Single-out some key interventions from capitation payment with special additional payment e.g. fee schedule with close monitoring e.g. Chemotherapy or additional payments for high cost care

• Adequate payment for high cost and effective intervention, e.g. some curable cancers.

• Monitor and routine report among peers on practice variations, e.g. Caesarean, self control of unnecessary non-clinically indicated Caesarean.

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Acknowledgements• National Statistical Office of Thailand • Ministry of Public Health (MOPH)• Thailand Research Fund (TRF) and Health Systems Research

Institute (HSRI) for institutional grants • Centre for Health Informatics for the dataset of hospital

admissions • Thai Society of Haematology for Leukaemia registry • 18 regional and provincial hospitals of MOPH