The Impact of a Billing System on Healthcare Utilization: Evidence from the Thai Civil Servant Medical Benefit Scheme
| Author | Jirawat Panpiemras,Nada Wasi,Wanwiphang Manachotphong |
| DOI | http://doi.org/10.1111/obes.12376 |
| Published date | 01 February 2021 |
| Date | 01 February 2021 |
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©2020 The Department of Economics, University of Oxford and JohnWiley & Sons Ltd.
OXFORD BULLETIN OF ECONOMICSAND STATISTICS, 83, 1 (2021) 0305–9049
doi: 10.1111/obes.12376
The Impact of a Billing System on Healthcare
Utilization: Evidence from theThai Civil Servant
Medical Benefit Scheme
Nada WasiÅ, Jirawat Panpiemras† and
Wanwiphang Manachotphong‡
ÅPuey Ungphakorn Institute for Economic Research, 273 Samsen Rd, Pra Nakorn, Bangkok
10200, Thailand (e-mail: nada.wasi@gmail.com)
†Bangkok Bank PCL, Bangkok, Thailand (e-mail: panpiemras@gmail.com)
‡Department of Economics, Thammasat University, Bangkok,Thailand (e-mail: wanwiphang
@econ.tu.ac.th)
Abstract
This study examines how a new billing process of theThai Civil Servant Medical Benefit
Scheme affects outpatient care utilization. Unlike policy changes considered in most exist-
ing studies, there is no change in cost-sharing for the scheme considered here. Previously,
the beneficiaries had to pay out of pocket and receive their reimbursement later. The new
billing system allows hospitals to charge the government directly. Using patient-level data
from a large hospital, we find that the change affects outpatient utilization through both
visiting rates and treatment intensity.These positive impacts are moderate, but persistent.
The estimates are not sensitive to our choice of a time window, but their magnitudes can
be sensitive to model specifications. Our analysis also suggests that patients with lower
utilization rates (conditional on illnesses) prior to the change in the billing process increase
their healthcare utilization more proportionally.
I. Introduction
The Civil Servant Medical Benefit Scheme (CSMBS) is a comprehensive health insurance
programme in Thailand covering current and retired civil servants and their families. The
scheme is tax-financed and essentially free for their beneficiaries (zero cost-sharing). It
is a fringe benefit to help compensate for low public salary rates. Prior to 2003, CSMBS
outpatients were required to pay medical fees at the time of treatment and submit claims
for reimbursement. While there is no risk of not receiving the reimbursement, some ar-
gue that this procedure may hinder cash-constrained beneficiaries from seeking necessary
care.
JEL Classification numbers: I12; I13; I18; D12.
Billing system & healthcare utilization229
Towards the end of 2003, the government gradually implemented the Direct Billing
Payment (DBP) programme through which healthcare providers directly bill the govern-
ment for outpatient charges incurred by CSMBS patients. Patients who enrol in the DBP
no longer need to pay any fees.After implementation, the outpatient costs of the CSMBS
between 2004 and 2008, sharply increased to a yearly average of 28%, compared with a
yearly average of 16% during the period 1989–2003 (Panpiemras,Wasi and Manachot-
phong, 2013).
While the impact of the DBP is of interest to a wide range of stakeholders, existing
studies on the DBP do not attempt to find precise effects on utilization or address the
distributional issue. In fact, even internationally, we are aware of only one health insurance
study focusing on the effects of a policy change operating through such a purely non-
price mechanism. The change DBP introduced does not resemble anycost-sharing method
discussed in the health literature. It is, however, more similar to the replacement of mail-in
rebates by instant discounts, where the net price and consumers’expected wealth remain
unchanged.
This study investigates the role of the billing process in healthcare utilization using
patient-level panel data from a large public regional hospital inThailand. Our contribution
is twofold. First, weaim to shed some light on the extent to which the increase in outpatient
cost was accounted for by the DBP. Second, we seek to contribute to the health insurance
literature by addressing the effects of a non-price mechanism on care-seeking behaviour.
Existing studies on the consequences of the DBP generally focus on prescription drug
charge and types of drugs prescribed one year before and after the programme was in
place (e.g. Pongchareonsuk and Pattanaprateep, 2009; Dilokthornsakul, Chaiyakunakruk
and Nimpitakpong, 2010). Our study differs from these studies in several dimensions.
First, we decompose the healthcare utilization into the number of visits and charge
per visit. This allows us to examine whether the impacts channel through the extensive
margin (the number of visits) or intensive margin (treatment intensity measured by charge
per visit and share of prescription drug charge to total charge). Second, with the patient-
level panel data, we can control for the time trends as well as unobserved heterogeneity
across patients. A single study (Zhong, 2011) looking into the effect of a reimbursement
approach in China uses cross-sectional data. Finally, we also examine whether the
effects persist over time and whetherthe DBP affects potentially cash-constrained patients
differently.
Our result shows that ceteris paribus, the number of outpatient visits increases among
the enrollees post-DBP. Conditional on visits, treatment intensity also increases. While the
magnitude of the effects is moderate, it is quite persistent. The estimates are not sensitive
to our choices of time window (three- or six-month). However, while they are generally
positive, the magnitudes can be sensitive to model specifications. In addition, we find that
patients with lower utilization than the average patient with the same illnesses pre-DBP
increase their utilization more proportionally.
The next section provides some background on the health insurance system inThailand
and the existing literature. Section III discusses the framework underlying patients’deci-
sions and section IV describes the data. Section V explains the empirical specifications
and presents the main results. The supplementary analyses and a placebo test are provided
in section VI. The last section presents the conclusions and discussion.
©2020 The Department of Economics, University of Oxford and JohnWiley & Sons Ltd
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