Thursday, October 15, 2009

Is it possible that Thailand is ahead of the US when it comes to health care?

This trip home and a talk with local authorities in Thailand's health care system got me thinking - Thailand is still considered to be a developing country, but when it comes to health care, I'd like to suggest that the citizens of Thailand might be better off than the Americans. This is a big statement to make, but to substantiate it I will start off with the explanations of how the Thai health care system works. Then I will go over the problems within the Thai system, after which I will make an amateur guess on where our system is going compared to the US. This is when you can decide if we are indeed in a better position.

How does the system work?
Thailand consists of 70 or so provinces - Bangkok is one of them. In each province, the smallest unit is called "Tumbol," where local health care centers are run by trained community health workers who are fully integrated into the community. These health care centers are low-capacity clinics without admission capability, and there just simply aren't enough doctors/nurses to staff all these rural clinics. The health workers (the good ones anyway) know their communities in and out, they draw from resources to solve all types of problems affecting the community (income generation, sanitation), and they focus on prevention and disease detection (they use simple symptom-based algorithms to arrive at possible diagnoses and preliminary instructions on how to deal with the illness).
When things get too complicated for the health workers to handle, they refer patients to "Amphur" hospitals, which take care of "Tumbol" health clinics in their areas. Amphur hospitals can take care of simple cases and admit a few patients. They are staffed by a few senior doctors who are also CEOs of the hospitals, and the day-to-day work is handled by new graduates from gov't medical schools who rotate out to these facilities to pay back their tuition before they can move on to residency (gov't medical schools are better than private ones, and the tuition is cheap because the gov't reaps its human investment through these post-graduation rotations). Most graduates consider this to be a great clinical experience, while others who loathe the rural area have to pay a ridiculous sum of money to avoid it.
For patients who are too sick, they are transferred to big provincial hospitals, which are responsible for Amphur hospitals in their jurisdiction. Provincial hospitals have full capacity similar to that of big shiny hospitals in Bangkok. They are staffed by a number of physicians, many of whom are specialists.
To recap: Tumbol health clinics --> Amphur small hospitals --> Provincial big hospitals

How do we pay for it?
Before 2001, most people did not have insurance - they pay out of pocket. The lucky few to have insurance were government workers (gov't insurance), the poor (Medicaid-like insurance), social security (this has a different meaning than social security in the US - in Thailand it means insurance for retired people who contributed to the fund during their lifetime), and the rich (private insurance-very small %, insurance wasn't and isn't big in Thailand).
In 2001, the gov't introduced the 30-Baht program - everyone can get comprehensive care at participating hospitals (all gov't hospitals and some private) for a co-payment of 30 Baht (it's so puny you can maybe buy just a meal with it - after a while this co-payment was canceled and people can get care even if they forgot their wallet at home). People can pick any hospital as their "starting point," where ideally they will have primary care doctors who then refer patients to specialists anywhere when needed. Each hospital gets capitation (per head) payment based on the number of people who signed up, and that's all the money they get no matter how sick their patients are. Patients can get care outside their starting point only in emergency situation. When patients are stabilized, they can be transferred back to the starting point, or if the base hospital refuse to take their patients back, the "emergency" hospital can collect money from the base hospital based on Diagnosis-Related Group (DRG) rates.
As for the fate of other programs: Medicaid was eradicated. The rich continued to pay out of pocket at private hospitals to avoid the now much longer lines at participating hospitals. Old gov't workers can keep their gov't insurance, but the new ones will only get the 30-Baht program (most gov't institutions are now "leaving" the gov't systems to become private-like entities - the gov't still controls the policies, but to encourage efficiency, the management will resemble that of private entities and the gov't worker benefits will no longer be offered). People getting social security refused to let their program and their hard-earned savings vanish, so they get to keep social security if they want to. However, if they choose social security (usually with better benefits), they are not eligible for the 30-Baht program.
And that's where we stand now: the system remains fragmented, but arguably anyone in the country, regardless of ability to pay, will now be able to get health care.

What are our problems? - Find out in part 2!

1 comment:

  1. Let's see the next one, long way to go.

    Nice thoughts though.