Financial Impact Simulation of Changing Pharmaceutical Reimbursement Method for Outpatient Care among Major Health Insurance Schemes: Case of a General Hospital

Abstract

Objective: To simulate the financial impacts on the payers and providers if the developed pharmaceutical reimbursement schemes were implemented by comparing with those of the present reimbursement schemes for outpatients of Civil Servant Medical Benefit Scheme (CSMBS), Universal Coverage Scheme (UC) and Social Security Scheme. Methods: The study employed secondary data of outpatient prescribing in a general hospital during October 1, 2013 to September 30, 2014. Subsequently, the simulation of financial impact was conducted using 3 alternatives for pharmaceutical reimbursement i.e., RP-1 (Comptroller General’s Department’s pricing scheme), RP-2 (pharmaceutical reimbursement pricing employing by the National Health Security Office of Bangkok area and RP-3 (pharmaceutical reimbursement pricing scheme developed by the Health Insurance System Research Office). Results: The RP-2 scheme saved drug cost for payers more than any other schemes while still able to cover the cost of medicine for health care provider. However, changing from capitation based payment for drug in for the UC scheme to item based fee would benefit in case of outpatients registered with the studied hospital with service utilization rate not higher than 66% and proportion for drug spending not less than 68%of capitation rate.Conclusion:All alternative pharmaceutical reimbursement methods in this study could save drug expenditure for CSMBS comparing to the current fee for charge based reimbursement scheme. Capitation based health insurance scheme or UC showed differential results depending on the payment ceiling level per utilization, proportion of beneficiary utilizing services, proportion of capitation rate available for medicine spending, and amount of drugs used by patients.