Mortality and treatment costs of hospitalized chronic kidney disease patients between the three major health insurance schemes in Thailand

Thailand implemented healthcare reforms in 2002 to ensure universal healthcare provision [1]. The 4 national healthcare insurance schemes include: (i) the Universal Coverage Scheme (UCS) provides free medical care for persons without any other insurance (i.e., > 70% of the population: the majority of farmers, low-income persons, and the unemployed); (ii) the Civil Servant Medical Benefit Scheme (CSMBS) provides free medical care for government employees and their dependents; (iii) the Social Health Insurance (SHI) scheme for private sector employees; and, (iv) private insurance. The first 3 schemes cover > 96% of the population [2].

The level of healthcare in Thailand depends on the particular hospital type and location. Community hospitals principally provide primary care and have limited resources for treating complex illnesses. Patients from the latter are sent to general (secondary) and tertiary hospitals, as appropriate. The distribution of hospitals in turn depends on economics and geography. The central region—where the capital is located—has the highest gross domestic product (GDP) per capita (~158% of national GDP). By comparison, the respective proportion of national GDP of the Northeast and North is 34 and 45% [3].

Previous reports—comparing the fairness of healthcare provision among the 3 main healthcare schemes—were mainly on the provision of medication for cancers and HIV/AIDS [4‐8]. To our knowledge, there has been no report comparing the different healthcare schemes vis-à-vis chronic diseases (i.e., chronic kidney diseases – CKD) that require medicine, special care teams, special medical equipment, and hospitalization.

Since CKD patients have an increased rate of hospitalization and a high risk for death [9, 10], we evaluated the nationwide healthcare data of hospitalized CKD patients in fiscal year 2010 for practice outcomes of healthcare among the 3 main health insurance schemes. Our particular focus was on differences in (i) clinical outcomes, (ii) access to special care and equipment (notably dialysis), and (iii) budgeting.

The data analyzed were from (i) the in-patients total medical expense forms from the UCS fiscal year 2010 from the National Health Security Office; (ii) the in-patient data from the CSMBS from the Comptroller General’s Department; and, (iii) the in-patient data from the SHI from the Social Security Office. The variables included: sex, age, occupation, address, type of hospital, health insurance scheme, co-morbidities, length of hospital stay (days), complications, treatment, clinical outcomes, and medical expenses (costs charged). Additional information obtained from the Nephrology Society of Thailand, the National Statistical Office, and the Office of the National Economic and Social Development Board, Office of the Prime Minister included: ratio of nephrologists to dialysis units/regional population and end-stage renal disease (ESRD) patients, and the reimbursement of renal replacement therapies among the different healthcare schemes.

The in-patient data were first checked for accuracy by examining for (i) overlapping information (ii) visit dates (iii) missing items (iv) incorrect coding and (v) the correct fiscal year. CKD patients were identified in either the primary diagnosis (CKD-primary) or secondary diagnosis (CKD-secondary) as code N18 of the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) [11]. Hemodialysis and peritoneal dialysis were identified as code 39.95 and 54.98, respectively (ICD-9-CM 2010 classification of procedures) [12]. The data were analyzed not only on the basis of health insurance scheme but also on the level of care provided (i.e., community/primary, general/secondary or tertiary hospital or private hospital) in order to assess accessibility to appropriate care.

CKD is defined as abnormalities in the kidney structure or function and/or a decreased glomerular filtration rate for more than 3 months (GFR < 60 ml/min/1.73 m²) [14]. Code N18 in the ICD-10 represents an older nomenclature for chronic renal failure as a decrease in GFR comparable to stage 3a-5 CKD patients (estimated GFR < 60 ml/min/1.73 m²). Our study revealed that 45–60% of admitted CKD patients also had hypertension and diabetes. The co-morbidities associated with mortality and high hospital charges were sepsis, pneumonia, respiratory failure followed by cardiovascular diseases and AKI on pre-existing CKD. This finding agrees with previous studies that demonstrated the severity of CKD increased in-hospital mortality among patients with acute coronary syndrome [15‐20], heart failure [21‐23], cardiac surgery [24], and stroke [25]. Early optimum therapeutic interventions and appropriate medications might improve clinical outcomes and reduce the cost of hospitalization.

After the Thai healthcare reforms were implemented in 2002, the poor indeed had wider access to medical services. Equity of health financing, health workers and healthcare infrastructure have been studied and an improving trend in equity was reported [26‐29]. Notwithstanding, differences in access to hospital types persist among the 3 insurance schemes. The population under UCS must be registered at a community hospital near home. When necessary, there is a line of referrals. Any patient who does not follow the referral process and attempts to go directly to a tertiary care center will have to pay all costs by themselves. By comparison, under the CSMBS, a government employee can register at any public hospital according to their preference [2] while an employee covered by SHI must register at the contracted public or private hospital [30]. If a referral is required, the employee must go to one of the hospitals in the designated network. Only in an emergency may persons covered by SHI or UCS be exempted from paying; however, they must be transferred to their registered hospital as soon as possible. These vagaries in regulations provide an explanation as to why those on UCS go to community hospitals and government employees go to tertiary care hospitals [2]. Since the UCS group comprises a higher proportion of low socio-economic patients, mainly located in rural region, they experience delayed hospital accessibility. Furthermore, our study revealed differences in clinical outcomes of hospitalized CKD patients that might represent residual inequality that needs addressing.

Mortality rates of hospitalized CKD patients differed among the 3 insurance schemes: the crude odd ratios revealed the highest mortality under the CSMBS. Patients admitted under the CSMBS had more severe or complicated disease than the other schemes; as indicated by the highest (i) percentage of life-threatening co-morbidities, (ii) length of stay, and (iii) hospital charges. After adjusting for biological and economic geographic variables, the multivariable analysis demonstrated that the UCS group had the highest risk of in-hospital death while the SHI group had the lowest mortality. The explanation may be related to the limited health care benefits under the UCS compared to the CSMBS and SHI. Table 6 presents a comparison of the health policies among the 3 schemes. The CSMBS appears to have better benefits than the other schemes; such as free access to specialist care, free service without capitation, and better chances of getting kidney replacement therapy (either hemodialysis or CAPD) for ESRD patients. Furthermore, the ratios of population and ESRD patients per nephrologist and dialysis unit were the best in Bangkok and the central region: that is, the regions where a higher proportion of patients are under either the CSMBS or SHI. On the other hand, in the other regions where most patients are under the UCS, poorer ratios prevail. The insufficiency of medical personnel and equipment might be the reasons for higher CKD complications and less dialysis treatment in the UCS group. Previous studies confirmed that remote CKD patients were less likely to receive specialist care, to receive laboratory testing, and to get appropriate medications, and were more likely to die or be hospitalized compared with those living closer to a nephrologist [31, 32].

Improving CKD care might be achieved by implementing policies that ensure fairness by providing a comparable budget allocation among the healthcare schemes. The “PD First” policy in Thailand launched in 2008 initiated CAPD as renal replacement therapy for ESRD patients under the UCS [33]. This policy represents an effective strategy for correcting the inadequate distribution of hemodialysis machines and insufficient numbers of nephrologists in rural areas and to underprivileged groups.

Anemia is one of the complications seen in CKD patients, and this can be corrected by injection of erythropoiesis stimulating agent (ESA). ESA is relatively costly and is only reimbursed during the pre-dialysis period under the CSMBS scheme. Our data revealed that there was a lower proportion of patients with anemia requiring blood transfusion under the CSMBS than the UCS or SHI groups. More intensive, high-cost medication support by the 3 main health schemes might reduce morbidity and hospitalization.

The strength of this study is that almost all of the subjects were hospitalized adult, Thai, CKD patients. The results, therefore, provide a clear overview of the situation vis-à-vis these adult patients; however, some limitations existed. Lack of a registered nationwide laboratory system means that there is no standardized staging of CKD patients, which might influence the clinical outcomes. The present study analyzed the administrative claim data, therefore socio-economic status of patients was not available. In addition, we are not able to generate an area locator as a proxy for socio-economic status of individual patients due to lack of data. Insufficient data of these demand-side characteristics observed at the individual level made some limitations in comparison of equity among the three health insurance schemes. The record of charges for each group represents an average and this might not wholly characterize the severity of individual patients nor include details of the procedures and medical instruments needed for each patient. Moreover, the mortality focused in this study was outcome at discharge which may be different with mortality after discharge because some patients died at home.

Concerning the treatment of hospitalized CKD patients, the UCS group had the poorest healthcare benefits compared to the other healthcare schemes—e.g., less budget for hospital care (charge cost), poorer access to specialist care, and treatment options that depended on variable healthcare policies. These might explain the greater mortality rate of those under the UCS compared to those under the CSMBS or SHI. In order to improve health outcomes among hospitalized CKD patients, new healthcare policies are needed to improve budget allocations, accessibility to specialist care, and distribution of resources.