Mixed Payment:

What We Can Learn from Thai’s Experience

Andreasta Meliala
andremeliala@ugm.ac.id
The Aim of Proper Payment System

• To compensate the hospital for any resource that has been utilized to
serve the patient
• To motivate the provider to serve passionately
Thai’s learning curve

• Long loop of learning process (1975 till now)

• Incrementally developed (DRG’s version changed every 2 years 1999-
2003; and every 4-5 years in 2003-2012)
• Contextualization of the system (Thai DRG)
Attractive Points
Collaboration among researcher, practitioner, and regulators

Openess
Quantitative analysis
Gaps: Cost Structure & Pricing

Practical Normative

? Investment Gaps Investment Gaps

BPJS Operation Gaps OperationGaps

?

? Maintenance Gaps Maintenance Gaps

? Reinvestment
Gaps Reinvestment Gaps
Accommodative model to accept case & site variations
Cost in Health Service Level
Tertiary Hospital
• Located in major province
• Advanced HR & medical devices Cost
weight?
Secondary Hospital
• Located in District & Municipality FORMULA?
• Apply minimum service standard
REFERRAL level &
COST

Primary care level Cost

• Located in sub district
weight?
• Mainly to conduct public
health services

RANGE OF CASES
Combination of indemnity and managed care model

• Managed
• Indemnity: care
• Cap • SOP
• Output- • Process
unrelated oriented
Multi-payor model for specific group &
specific hospital type

CSMBS
UCS

TAKEN INTO ACCOUNT:

Regional basis SSS
Referral system
Teaching hospital

Equity & Efficiency

Hybrid System

Payor
Global Budget

Hospital
Fee for Service

Professional
What is (still) missing?
• Clinical outcome of the treatment (comparison among those 3
schemes)
• Physician’s opinion and change management
• Patient satisfaction measurement
• Hospital manager’s opinion
• Sustainability of the program
Establishment of current payment mechanism

Paradigma
Dokter Paradigma JKN
(established)

Retrospective
Prospective
Payment /Fee
Payment
for Service

Structured
Clinical
Clinical
Liberty
Guideline
UHC di mata Tenaga Kesehatan: Thailand
• Persepsi tenaga kesehatan terdapap penerapan UHC:
• Terjadi peningkatan beban kerja (27%)
• Kualitas pelayanan menurun dan tidak memadai untuk semua
kasus (karena kurangnya budget)
• Pasien menjadi tidak rajin merawat kesehatan
• Pasien menjadi “manja” dan meminta pelayanan berlebihan
• Terjadi ketegangan dalam system rujukan (tarik-ulur)
• Terjadi kecemburuan regional dan inter-sector (public & private)

Thoresen, S.H., Fielding, A. 2011. Universal health care in Thailand: Concerns among
the health care workforce. Health Policy 99 (2011) 17–22
Cycle of Payment System & Health Status

Health
Financing

Health Access &

status Utilization

Hospital
readiness
Trend-Watching: Normal Cycle
Health
Financing

Health Access &

status Utilization

Hospital
readiness
Trend-Watching: Circulus Vitiosus
Health
Financing

Health Access &

status Utilization

Hospital
readiness
Terima Kasih