Simulation of Financial Impact from Changing Pharmaceutical Reimbursement Method for Outpatient Services among Three Major Health Insurance Schemes: A Case Study of a Psychiatric Hospital

Abstract

Objective: To simulate financial impact in the perspectives of health care providers and payers if the existing pharmaceutical reimbursement schemes would be replaced by alternative options of fee for service based reimbursement models. Method: The research was a descriptive study with simulation using retrospective secondary data on amount and cost of drugs prescribed for outpatients in the fiscal years 2014 at a psychiatric hospital. Two alternative options of pharmaceutical reimbursement scheme included reimbursement prices for pharmaceuticals from the National Health Security Office Region 13 (RP-2) and the proposed pharmaceutical reimbursement model being developed by the Health Insurance System Research Office (RP-3). Result: Disease-specific drug spending per visit under fee for charge based Civil Servant Medical Benefit Scheme (CSMBS) was highest for all groups of diseases comparing to capitation based scheme under Universal Coverage Scheme (UC) and Social Security Scheme (SSS). The same pattern was found in the average drug spending per visit (CSMBS: 4,359.36 Baht/visit, UC: 243.24 Baht /visit, SSS: 472.63 Baht/visit), implying differential pattern of prescribing for patients in different health insurance schemes. The simulated financial impacts on providers if implementing proposed reimbursement prices demonstrated decreasing of providers’ income or lowering the gap between revenues from reimbursement and drug cost, but revenues were never lower than medicine costs. On the other side, regarding the financial impacts on payers, it was found that RP-2 and 3 models could save drug expenditure only for the CSMBS and SSS scheme. On the contrary, the models resulted in a higher spending in the UC scheme than that in the current reimbursement method, which drew the payment ceiling at 700 Baht/visit. In addition, majority of prescriptions under the UC scheme were low price items. The alternative reimbursement scheme, RP-2,3 assigned higher rate of %mark-up for medications in a low price range than those in a higher price range, leading to an inability to save for payers under the UC scheme. Conclusion: Alternative reimbursement schemes for medications in this study could save drug expenditures compared to the current schemes for outpatients in the CSMBS and SSS health schemes.