Health Insurance Schemes and Their Influences on Healthcare Variation in Asian Countries: A Realist Review and Theory’s Testing in Thailand

Document Type : Review Article

Authors

1 Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK

2 International Health Policy Program, Ministry of Public Health, Nonthaburi, Thailand

3 Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK

4 London School of Hygiene & Tropical Medicine, London, UK

Abstract

Background 
Various features in health insurance schemes may lead to variation in healthcare. Unwarranted variations raise concerns about suboptimal quality of care, differing treatments for similar needs, or unnecessary financial burdens on patients and health systems. This realist review aims to explore insurance features that may contribute to healthcare variation in Asian countries; and to understand influencing mechanisms and contexts.
 
Methods 
We undertook a realist review. First, we developed an initial theory. Second, we conducted a systematic review of peer-reviewed literature in Scopus, MEDLINE, EMBASE, and Web of Science to produce a middle range theory for Asian countries. The Mixed Methods Appraisal Tool (MMAT) was used to appraise the methodological quality of included studies. Finally, we tested the theory in Thailand by interviewing nine experts, and further refined the theory.
 
Results 
Our systematic search identified 14 empirical studies. We produced a middle range theory in a contextmechanism-outcome configuration (CMOc) which presented seven insurance features: benefit package, cost-sharing policies, beneficiaries, contracted providers, provider payment methods, budget size, and administration and management, that influenced variation through 20 interlinked demand- and supply-side mechanisms. The refined theory for Thailand added eight mechanisms and discarded six mechanisms irrelevant to the local context.
 
Conclusion 
Our middle range and refined theories provide information about health insurance features associated with healthcare variation. We encourage policy-makers and researchers to test the CMOc in their specific contexts. Appropriately validated, it can help design interventions in health insurance schemes to prevent or mitigate the detrimental effects of unwarranted healthcare variation.

Keywords

References

  1. Appleby J, Raleigh V, Frosini F, Bevan G, Gao H, Lyscom T. Variations in Health Care: The Good, the Bad and the Inexplicable. London: The King’s Fund; 2011. https://www.kingsfund.org.uk/sites/default/files/Variations-in-health-care-good-bad-inexplicable-report-The-Kings-Fund-April-2011.pdf. Accessed October 12, 2022.
  2. Wennberg JE. Time to tackle unwarranted variations in practice. BMJ. 2011;342:d1513. doi:1136/bmj.d1513
  3. Johnson A, Stukel TA. Medical Practice Variations. 1st ed. Boston: Springer; 2016. doi:1007/978-1-4899-7603-1
  4. Wennberg JE. Forty years of unwarranted variation--and still counting. Health Policy. 2014;114(1):1-2. doi:1016/j.healthpol.2013.11.010
  5. Public Health England. The NHS Atlas of Variation in Healthcare Reducing Unwarranted Variation to Increase Value and Improve Quality. London: Public Health England; 2015. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwjVooK5oJz1AhVtILcAHXVnDzgQFnoECAwQAQ&url=https%3A%2F%2Ffingertips.phe.org.uk%2Fdocuments%2Fatlas_2015%2520compendium.pdf&usg=AOvVaw0bT4n5XbQLNKcPTPZWOuXc.
  6. Public Health Scotland. Scottish Atlas of Healthcare Variation | Introduction. https://www.isdscotland.org/products-and-services/scottish-atlas-of-variation/introduction/. Accessed January 7, 2022.
  7. Health Quality & Safety Commission. New Zealand. Atlas of Healthcare Variation. https://www.hqsc.govt.nz/our-programmes/health-quality-evaluation/projects/atlas-of-healthcare-variation/. Accessed January 6, 2022.
  8. Australian Commission on Safety and Quality in Health Care. The Fourth Australian Atlas of Healthcare Variation. Sydney: Australian Commission on Safety and Quality in Health Care Sydney; 2021. https://www.safetyandquality.g ov.au/sites/default/files/2021-04/the_fourth_australian_of_atlas_healthcare_variation_2021.pdf. Accessed January 7, 2022.
  9. Deuning C. The Dutch National Atlas of Public Health and Health Care. 2014. https://pdfs.semanticscholar.org/db3a/415ef49fedd3c33c2d19ea00df572598b01b.pdf. Accessed January 7, 2022.
  10. Kim Y, Kim AM, Kang M, Cho JM, Kim H. Health Atlas as a Policy Tool: How to Investigate Geographic Variation and Utilize the Information for Decision-Making. 2015. https://documents1.worldbank.org/curated/en/539331530275649169/pdf/Colombia-Health-Atlas-Methodology.pdf. Accessed January 7, 2022.
  11. Corallo AN, Croxford R, Goodman DC, Bryan EL, Srivastava D, Stukel TA. A systematic review of medical practice variation in OECD countries. Health Policy. 2014;114(1):5-14. doi:1016/j.healthpol.2013.08.002
  12. Feufel MA. How to uncover sources of unwarranted practice variation: a case study in emergency medicine. Qual Health Res. 2018;28(9):1486-1498. doi:1177/1049732318774322
  13. Mercuri M, Gafni A. Medical practice variations: what the literature tells us (or does not) about what are warranted and unwarranted variations. J Eval Clin Pract. 2011;17(4):671-677. doi:1111/j.1365-2753.2011.01689.x
  14. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care. Ann Intern Med. 2003;138(4):273-287. doi:7326/0003-4819-138-4-200302180-00006
  15. Wennberg J, Gittelsohn A. Variations in medical care among small areas. Sci Am. 1982;246(4):120-134. doi:1038/scientificamerican0482-120
  16. Din JN, Snow TM, Rao SV, et al. Variation in practice and concordance with guideline criteria for length of stay after elective percutaneous coronary intervention. Catheter Cardiovasc Interv. 2017;90(5):715-722. doi:1002/ccd.26992
  17. MacLean LC, Richman A. Physician practice style variations. Socioecon Plann Sci. 1989;23(6):361-371. doi:1016/0038-0121(89)90004-9
  18. Panczak R, Luta X, Maessen M, et al. Regional variation of cost of care in the last 12 months of life in Switzerland: small-area analysis using insurance claims data. Med Care. 2017;55(2):155-163. doi:1097/mlr.0000000000000634
  19. Wentz AE, Wang RRC, Marshall BDL, Shireman TI, Liu T, Merchant RC. Variation in opioid analgesia administration and discharge prescribing for emergency department patients with suspected urolithiasis. Am J Emerg Med. 2020;38(10):2119-2124. doi:1016/j.ajem.2020.07.016
  20. Ulyte A, Wei W, Dressel H, et al. Variation of colorectal, breast and prostate cancer screening activity in Switzerland: Influence of insurance, policy and guidelines. PLoS One. 2020;15(4):e0231409. doi:1371/journal.pone.0231409
  21. Organization for Economic Co-operation and Development (OECD). Proposal for a Taxonomy of Health Insurance. OECD; 2004. https://www.oecd.org/els/health-systems/31916207.pdf. Accessed February 11, 2022.
  22. Cuadrado C, Crispi F, Libuy M, Marchildon G, Cid C. National Health Insurance: a conceptual framework from conflicting typologies. Health Policy. 2019;123(7):621-629. doi:1016/j.healthpol.2019.05.013
  23. Tangcharoensathien V, Srithamrongsawat S, Pitayarangsarit S. Overview of health insurance systems. In: Pramualratana P, Wibulpolprasert S, eds. Health Insurance Systems in Thailand. Nonthaburi: Health Systems Research Institute (HSRI); 2002:28-39. http://ihppthaigov.net/DB/publication/attachbook/73/chapter3.pdf.
  24. Patcharanarumol W, Panichkriangkrai W, Sommanuttaweechai A, Hanson K, Wanwong Y, Tangcharoensathien V. Strategic purchasing and health system efficiency: a comparison of two financing schemes in Thailand. PLoS One. 2018;13(4):e0195179. doi:1371/journal.pone.0195179
  25. Limwattananon C, Limwattananon S, Sakulpanit T, Greetong T, Mills A, Tangcharoensathien V. Different Provider Payment Methods: Variation in Clinical Practice, Lessons from Thailand. http://ihppthaigov.net/DB/publication/attachresearch/259/chapter1.pdf.
  26. Limwattananon C, Limwattananon S, Pannarunothai S, Tangcharoensathien V. Analysis of Practice Variation Due to Payment Methods Across Health Insurance Schemes. Nonthaburi: International Health Policy Program; 2009.
  27. Hirunrassamee S, Ratanawijitrasin S. Does your health care depend on how your insurer pays providers? Variation in utilization and outcomes in Thailand. Int J Health Care Finance Econ. 2009;9(2):153-168. doi:1007/s10754-009-9062-6
  28. Tangcharoensathien V, Prakongsai P, Limwattananon S, Limwattananon C, Patcharanarumol W. Determinants of Clinical Practice Variations and Influence of Provider Payment Methods: A Case Study from Thailand. 2007. https://slideplayer.com/slide/7061096/.
  29. Thammatacharee J. Variations in the Performance of Three Public Insurance Schemes in Thailand [dissertation]. London School of Hygiene & Tropical Medicine; 2009. doi:17037/pubs.04646540
  30. Siwachat S, Lertprasertsuke N, Tanatip N, et al. Effect of insurance type on stage at presentation, surgical approach, tumor recurrence and cancer-specific survival in resectable non-small lung cancer patients. Risk Manag Healthc Policy. 2020;13:559-569. doi:2147/rmhp.s244344
  31. Suriyawongpaisal P, Aekplakorn W, Tansirisithikul R. Does harmonization of payment mechanisms enhance equitable health outcomes in delivery of emergency medical services in Thailand? Health Policy Plan. 2015;30(10):1342-1349. doi:1093/heapol/czv005
  32. Tatsanavivat P, Thavornpitak Y, Pongchaiyakul C. Comparative effectiveness of three national healthcare schemes in Thailand: in-hospital medical expenses for diabetes and hypertension in 2010. J Med Assoc Thai. 2012;95 Suppl 7:S254-S261.
  33. Reungjui S, Anunnatsiri S, Limwattananon C, Thavornpitak Y, Pukdeesamai P, Mairiang P. Health insurance system and healthcare provision: nationwide hospital admission data 2010. J Med Assoc Thai. 2012;95 Suppl 7:S240-S253.
  34. Mulyanto J, Kunst AE, Kringos DS. Geographical inequalities in healthcare utilisation and the contribution of compositional factors: a multilevel analysis of 497 districts in Indonesia. Health Place. 2019;60:102236. doi:1016/j.healthplace.2019.102236
  35. Xu J, Wang J, King M, et al. Rural-urban disparities in the utilization of mental health inpatient services in China: the role of health insurance. Int J Health Econ Manag. 2018;18(4):377-393. doi:1007/s10754-018-9238-z
  36. Shi J, Chen N, Liu N, et al. Options for care of elderly inpatients with chronic diseases: analysis of distribution and factors influencing use of care in Shanghai, China. Front Public Health. 2021;9:631189. doi:3389/fpubh.2021.631189
  37. Kazungu JS, Barasa EW, Obadha M, Chuma J. What characteristics of provider payment mechanisms influence health care providers' behaviour? A literature review. Int J Health Plann Manage. 2018;33(4):e892-e905. doi:1002/hpm.2565
  38. Berg R, Nanavati J. Realist review: current practice and future prospects. J Res Pract. 2016;12(1):1-28
  39. Wong G, Greenhalgh T, Westhorp G, Buckingham J, Pawson R. RAMESES publication standards: realist syntheses. J Adv Nurs. 2013;69(5):1005-1022. doi:1111/jan.12095
  40. Wong G, Greenhalgh T, Pawson R. Internet-based medical education: a realist review of what works, for whom and in what circumstances. BMC Med Educ. 2010;10:12. doi:1186/1472-6920-10-12
  41. Rycroft-Malone J, McCormack B, Hutchinson AM, et al. Realist synthesis: illustrating the method for implementation research. Implement Sci. 2012;7:33. doi:1186/1748-5908-7-33
  42. United Nations Statistics Division. Standard Country or Area Codes for Statistical Use (M49). https://unstats.un.org/unsd/methodology/m49/. Accessed December 25, 2021.
  43. World Health Organization (WHO). The World Health Report 2010: Health Systems Financing: The Path to Universal Coverage. Geneva: WHO; 2010. https://www.who.int/publications/i/item/9789241564021.
  44. Mendeley Ltd. Mendeley Desktop (Version 1.19.8). https://www.mendeley.com/reference-management/reference-manager.
  45. QSR International Pty Ltd. NVivo (Release 1.6.1). QSR International Pty Ltd; 2020.
  46. Wong G, Westhorp G, Pawson R, Greenhalgh T. Realist Synthesis: RAMESES Training Materials. In: The RAMESES I; 2013. https://www.ramesesproject.org/media/Realist_reviews_training_materials.pdf.
  47. Dada S, Dalkin S, Gilmore B, Hunter R, Mukumbang FC. Applying and reporting relevance, richness and rigour in realist evidence appraisals: advancing key concepts in realist reviews. Res Synth Methods. 2023;14(3):504-514. doi:1002/jrsm.1630
  48. Hong QN, Pluye P, Fàbregues S, et al. Mixed Methods Appraisal Tool (MMAT), Version 2018. User Guide; 2018. http://mixedmethodsappraisaltoolpublic.pbworks.com/. Accessed October 25, 2021.
  49. Tangcharoensathien V, Witthayapipopsakul W, Panichkriangkrai W, Patcharanarumol W, Mills A. Health systems development in Thailand: a solid platform for successful implementation of universal health coverage. Lancet. 2018;391(10126):1205-1223. doi:1016/s0140-6736(18)30198-3
  50. The Government Gazette. National Health Security Act B.E. 2545 (A.D. 2002). Vol 2545. National Legislative Assembly; 2002. https://www.nhso.go.th/eng/files/userfiles/file/2018/001/Thailand_NHS_Act.pdf.
  51. Constitution Drafting Commission. The Constitution of the Kingdom of Thailand, B.E.2560 (2017) - Unofficial Translation. Bangkok: Constitution Drafting Commission; 2018. https://cdc.parliament.go.th/draftconstitution2/ewt_dl_link.php?nid=1460&filename=index.
  52. National Health Security committee. Draft Appointment of Subcommittees Under the National Health Security Board. https://www.nhso.go.th/storage/downloads/boardresolution/1297/132400409238019088_Board6_15มิยpdf. Published 2020. Accessed September 2, 2021.
  53. Feldhaus I, Mathauer I. Effects of mixed provider payment systems and aligned cost sharing practices on expenditure growth management, efficiency, and equity: a structured review of the literature. BMC Health Serv Res. 2018;18(1):996. doi:1186/s12913-018-3779-1
  54. Glassman A, Giedion U, Sakuma Y, Smith PC. Defining a health benefits package: what are the necessary processes? Health Syst Reform. 2016;2(1):39-50. doi:1080/23288604.2016.1124171
  55. Linden M, Gothe H, Ormel J. Pathways to care and psychological problems of general practice patients in a "gate keeper" and an "open access" health care system: a comparison of Germany and the Netherlands. Soc Psychiatry Psychiatr Epidemiol. 2003;38(12):690-697. doi:1007/s00127-003-0684-6
  56. Lagarde M, Powell-Jackson T, Blaauw D. Managing Incentives for Health Providers and Patients in the Move towards Universal Coverage. Montreux: London School of Hygiene & Tropical Medicine; 2010. https://www.hsr-symposium.org. Accessed July 16, 2021.
  57. Seyedjavadi M, Jafari M, Ravaghi H, Aryankhesal A. Study of ambulatory care supervision mechanisms in health systems: a comparative study. Med J Islam Repub Iran. 2020;34:148. doi:34171/mjiri.34.148
  58. Asadi-Lari M, Packham C, Gray D. Need for redefining needs. Health Qual Life Outcomes. 2003;1:34. doi:1186/1477-7525-1-34
  59. Li X, Zhang W. The impacts of health insurance on health care utilization among the older people in China. Soc Sci Med. 2013;85:59-65. doi:1016/j.socscimed.2013.02.037
  60. Fu X, Sun N, Xu F, et al. Influencing factors of inequity in health services utilization among the elderly in China. Int J Equity Health. 2018;17(1):144. doi:1186/s12939-018-0861-6
  61. Chen R, Li NX, Liu X. Study on the equity of medical services utilization for elderly enrolled in different basic social medical insurance systems in an underdeveloped city of Southwest China. Int J Equity Health. 2018;17(1):54. doi:1186/s12939-018-0765-5
  62. Sparrow R, Budiyati S, Yumna A, Warda N, Suryahadi A, Bedi AS. Sub-national health care financing reforms in Indonesia. Health Policy Plan. 2017;32(1):91-101. doi:1093/heapol/czw101
  63. Fu XZ, Wang LK, Sun CQ, et al. Inequity in inpatient services utilization: a longitudinal comparative analysis of middle-aged and elderly patients with the chronic non-communicable diseases in China. Int J Equity Health. 2020;19(1):6. doi:1186/s12939-019-1117-9
  64. Huang Y, Li J, Hao H, Xu L, Nicholas S, Wang J. Seasonal and monthly patterns, weekly variations, and the holiday effect of outpatient visits for type 2 diabetes mellitus patients in China. Int J Environ Res Public Health. 2019;16(15):2653. doi:3390/ijerph16152653
  65. Fang H, Meng Q, Rizzo JA. Do different health insurance plans in China create disparities in health care utilization and expenditures. Int J Appl Econ. 2014;11(1):1-18.
  66. Hartwig R, Sparrow R, Budiyati S, et al. Effects of decentralized health-care financing on maternal care in Indonesia. Econ Dev Cult Change. 2019;67(3):659-686. doi:1086/698312
  67. Kim DH, Roe JR. The effect of coverage structure of private health insurance on physician visits between conventional and traditional medicine. Orient Pharm Exp Med. 2019;19(3):323-329. doi:1007/s13596-019-00366-0
  68. Mukem S, Meng Q, Sriplung H, Tangcharoensathien V. Low coverage and disparities of breast and cervical cancer screening in Thai women: analysis of national representative household surveys. Asian Pac J Cancer Prev. 2015;16(18):8541-8551. doi:7314/apjcp.2015.16.18.8541
  69. Kim H, Cheng SH, Yamana H, et al. Variations in hip fracture inpatient care in Japan, Korea, and Taiwan: an analysis of health administrative data. BMC Health Serv Res. 2021;21(1):694. doi:1186/s12913-021-06621-y
  70. Crowson MG, Ryan MA, Rocke DJ, Raynor EM, Puscas L. Variation in tonsillectomy rates by health care system type. Int J Pediatr Otorhinolaryngol. 2017;94:40-44. doi:1016/j.ijporl.2017.01.014
  71. Casparie AF. The ambiguous relationship between practice variation and appropriateness of care: an agenda for further research. Health Policy. 1996;35(3):247-265. doi:1016/0168-8510(95)00787-3
  72. Wennberg JE. Unwarranted variations in healthcare delivery: implications for academic medical centres. BMJ. 2002;325(7370):961-964. doi:1136/bmj.325.7370.961
  73. Mercuri M, Gafni A. Examining the role of the physician as a source of variation: are physician-related variations necessarily unwarranted? J Eval Clin Pract. 2018;24(1):145-151. doi:1111/jep.12770
  74. Harrison R, Manias E, Mears S, Heslop D, Hinchcliff R, Hay L. Addressing unwarranted clinical variation: a rapid review of current evidence. J Eval Clin Pract. 2019;25(1):53-65. doi:1111/jep.12930
  75. Komaromy M, Lurie N, Osmond D, Vranizan K, Keane D, Bindman AB. Physician practice style and rates of hospitalization for chronic medical conditions. Med Care. 1996;34(6):594-609. doi:1097/00005650-199606000-00009
  76. The Center for the Evaluative Clinical Sciences. Preference-Sensitive Care. A Dartmouth Atlas Project Topic Brief. Illinois: CECS; 2007. https://www.dartmouthatlas.org/downloads/reports/preference_sensitive.pdf.
  77. McIntyre D, Garshong B, Mtei G, et al. Beyond fragmentation and towards universal coverage: insights from Ghana, South Africa and the United Republic of Tanzania. Bull World Health Organ. 2008;86(11):871-876. doi:2471/blt.08.053413
  78. Bazyar M, Rashidian A, Kane S, Vaez Mahdavi MR, Akbari Sari A, Doshmangir L. Policy options to reduce fragmentation in the pooling of health insurance funds in Iran. Int J Health Policy Manag. 2016;5(4):253-258. doi:15171/ijhpm.2016.12
  79. Bazyar M, Yazdi-Feyzabadi V, Rashidian A, Behzadi A. The experiences of merging health insurance funds in South Korea, Turkey, Thailand, and Indonesia: a cross-country comparative study. Int J Equity Health. 2021;20(1):66. doi:1186/s12939-021-01382-w
  80. Meng Q, Fang H, Liu X, Yuan B, Xu J. Consolidating the social health insurance schemes in China: towards an equitable and efficient health system. Lancet. 2015;386(10002):1484-1492. doi:1016/s0140-6736(15)00342-6
  81. McIntyre D, Ranson MK, Aulakh BK, Honda A. Promoting universal financial protection: evidence from seven low- and middle-income countries on factors facilitating or hindering progress. Health Res Policy Syst. 2013;11:36. doi:1186/1478-4505-11-36
  82. Maeda A, Araujo E, Cashin C, Harris J, Ikegami N, Reich MR. Universal Health Coverage for Inclusive and Sustainable Development: A Synthesis of 11 Country Case Studies. Washington, DC: World Bank; 2014. https://documents.worldbank.org/en/publication/documents-reports/documentdetail/575211468278746561/universal-health-coverage-for-inclusive-and-sustainable-development-a-synthesis-of-11-country-case-studies.
  83. Wang X, Zheng A, He X, Jiang H. Integration of rural and urban healthcare insurance schemes in China: an empirical research. BMC Health Serv Res. 2014;14:142. doi:1186/1472-6963-14-142
  84. Thomson S, Foubister T, Mossialos E. Financing Health Care in the European Union: Challenges and Policy Responses. Copenhagen: WHO Regional Office for Europe; 2009. https://apps.who.int/iris/handle/10665/326415.
  85. Kwon S. Thirty years of national health insurance in South Korea: lessons for achieving universal health care coverage. Health Policy Plan. 2009;24(1):63-71. doi:1093/heapol/czn037

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History

  • Receive Date: 09 January 2023
  • Revise Date: 26 January 2024
  • Accept Date: 13 February 2024
  • First Publish Date: 17 February 2024

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