Orathai Khiaocharoen

Rehabilitation service development for Sub-Acute and Non-Acute Patient (SNAP) under universal coverage scheme in Thailand

The need of rehabilitation in sub-acute and non-acute patients has been continuously increased. Rehabilitation services in Thailand are considered only as part of acute care so that the providers are not motivated to provide intensive services to patients because the payment based on diagnosis related group focuses on acute phase. This study aimed to develop an appropriate model for SNAP Casemix including in-patient, out-patient, and home based care in 4 groups of patients: stroke, brain dysfunction (traumatic and non-traumatic), spinal cord dysfunction (traumatic and non-traumatic) and major multiple trauma. The expected results are improvement of accessibility, continuity, quality of care as well as the proper payment and information of activities, unit costs. Fifty five hospitals in five provinces were recruited voluntarily to develop rehabilitation services both facility-based and home-based care, referral system, structure, payment, information system etc. Three development steps were set up as follows: 1) setting the new desirable system, 2) implementation of the new system (according to context of each province) and 3) evaluation. The effectiveness will be assessed through functional status and quality of life gained compared to set target. The efficiency studies consist of cost per patient, cost per DRG and cost recovery. Barthel Index (assessment of 10 functions: feeding, transfer, grooming, toilet use, bathing, mobility, stairs climbing, dressing, bowels, and bladder) and EQ5D (Assessment of quality of life in 5 dimensions including: mobility, self-care, usual activities, pain/discomfort and anxiety/depression) will be used for functional assessment. The study will go on for 18 months.

Economic Evaluation of Rehabilitation Services for Inpatients with Stroke in Thailand: A Prospective Cohort Study

OBJECTIVE Rehabilitation can restore function and prevent permanent disability in patients with stroke. There is, however, only one study on cost-effectiveness of rehabilitation in Thailand. Our objective was to evaluate the cost-utility of rehabilitation for inpatients with stroke under Thai settings. METHODS This was a prospective observational cohort study with a 4-month follow-up in two regional hospitals. The sample consisted of 207 first-episode stroke inpatients divided into rehabilitation and unexposed groups. Rehabilitation services during the subacute and nonacute phase were the intervention of concern. Main outcomes were patients Barthel index for functional status and the EuroQol five-dimensional questionnaire as utility scores. A microcosting approach was employed considering a societal perspective. Effectiveness was defined as the improvement in functional status and quality-adjusted life-year (QALY). We used a longitudinal logistic model and multiple regressions. Cost-effectiveness ratios per QALY gained were presented. A probabilistic sensitivity analysis was conducted to estimate the uncertainty range. RESULTS Compared with the unexposed group, the Barthel index and QALY of patients with rehabilitation were significantly improved (P < 0.010). The incremental cost-effectiveness ratio of rehabilitation services for patients with stroke was 24,571 baht per QALY. Cost-effectiveness acceptability curves suggested that the rehabilitation services were likely to represent good value for money at the ceiling ratio of 70,000 baht per QALY (compared with the threshold of 1 time per-capita gross domestic product per QALY gain or 100,000 baht per QALY). CONCLUSION The rehabilitation services for stroke survivors were cost-effective under the Thai health care setting.

Patient-level costing for the Thai Diagnosis Related Group in Thailand: a micro-costing approach

Cost estimation is important in assessing a health system’s performance. However, most of the costing system that presently exists presumes that all patients consume exactly the same amount of resources, and little attention is paid to costs at the patient level. Thailand has used Thai DRG for the prospective payment of inpatient care with a closed end, but there is a growing need to have patient-level cost data to calculate relative weight. This report presents a brief summary of the technical details involved in patient-level costing for Thai DRG version 5. Cost methodology focused on a provider perspective, and cost data were collected from nine hospitals in the North, Central and Northeast of Thailand. These comprised two medical school hospitals, three community hospitals, two provincial hospitals, and two regional hospitals. The primary data collected included the proportion of working time to apportioned labour cost, patient demographic characteristics, and medical data from 349,275 inpatients. Secondary data included hospital expenditures and the total number of medical services provided by each hospital unit in the fiscal year 2009. Cost analyses consisted of four major processes. First, hospital cost was analysed using a standard top-down approach. Cost centre identification, direct, indirect, and total cost determination for 14 chargeable service units were examined. Second, the cost-to-charge ratio (RCC) was calculated by dividing the total cost by the total charge for each of 14 service groups. Third, a micro-costing method was employed for patient-level costing. To determine cost, the charge of each service group was converted to a cost by multiplying the charge by the corresponding RCC. This was then summed up to derive the total cost for each patient. Finally, all patient data were grouped into Thai DRG version 5, and then the average cost per admission, average cost per DRG, and RW were calculated.