Does harmonization of payment mechanisms enhance equitable health outcomes in delivery of emergency medical services in Thailand?

摘要

There are different reimbursement rates by the various insurance schemes in Thailand, which include the Universal Coverage scheme (UCS), civil servant medical benefit scheme (CSMBS) and social security scheme (SSS). Hence, there are concerns about inequitable care standards. Harmonization of the rates of emergency medical services has been started since April 2012. This study analyzed the impact of harmonization on clinical outcomes in private hospitals. Analysis of 22 900 records of the dataset accrued from April 2012 to June 2013 using multiple logistic modelling revealed that beneficiaries under UCS were the worst off [Odds ratio 2.56 95% of confidence interval: 2.35 to 2.80 for non-trauma and 2.19 (1.59-3.0) for trauma, corresponding to 21.26 and 25.09% of bad outcomes, respectively] in terms of not improved or dead outcomes at discharge compared with those under the CSMBS (8.45 and 12.78%, respectively) controlling for age, sex, hospital location, triage priority code, length of stays and adjusted Relative weight (RW) score. Using propensity score, matching analysis found the outcome rates of not improved including dead were highest in UCS 26.27% for trauma and 21.26% for non-trauma patients. Payment mechanism alone is inadequate to ensure equitable distribution of health outcomes in provision of emergency medical care by private providers in urban settings across the country. A secondary finding was that patients accessing hospital services directly showed better improvement or lower in-hospital mortality compared with access through formal pre-hospital means (P < 0.001). Plausible explanations have been discussed with policy implications and recommendations for further studies.