Enrollment systems and eligibility checking mechanism in Thailand Netnapis Suchonwanich National Health Security Office 31 May 2013
National Health Insurance Framework National policy Scheme policy regarding target population set by country Data provides policy guidance • Benefit package • Formulary Provider rates • Eligibility requirements • Provider policy setting • Premium setting Fundamental system Analyzing performance 6. Care management 7. Utilization management 8. Provider quality management Rules Data & feedback change mgmt 1. Beneficiary management 2. Provider management 3. Premium collection 4. Claims management 5. Accounting
Core businesses in UHC Beneficiary enrollment Fund Management Health Service Quality Control Data, Information IT Infrastructures, Applications Consumer protection Customers Strategic Planning Health Service Provider Registration
From cradle to the grave newborn childhood Working age Elderly
why civil registration ? n Civil registration is the continuous, permanent , compulsory and universal recording of the occurrence and characteristics of vital events - live births - deaths - fetal deaths - marriages and divorces - other civil status events provided by decree or regulation, in accordance with the legal requirements in each country
Minimum core set : Person race gender nationality Given name Citizen identification Home town address person Birth date prefix Middle name family name
Reuse of minimum core set of person race gender nationality Given name Citizen identification person Middle name Home town address Birth date prefix family name Edu : Student person Social Security : Health : Doctor benefitiary person cccc aaaa bbbb Work : employee person aaaa bbbb cccc
Civil registration Local administraion
The evolution of national indentification card in Thailand
National ID just began in the year 1988 13 digits
MOI’s Main System for issuing the National ID Card Central Card Control Khonthai CA Khonthai. com Public Officer • Data Reading • Data Read/Update Initial Participation Agencies Internet CPD Central Population Database • 2, 002 Health care • 274 Social Security • 1, 282 Hospital Central Registration Bureau PDS Population Data Subset Oversea Registration Offices PC ICR • Data Updatin People House Owner Database at Regional center Data Communication Network 9 Regional Centers Population Data Subset at agency Participation Agencies 47 MOU Agencies 100, 000 Multi-Purpose machine 257 Personnel Divisions 72, 000 Villages 76 Provincial Offices 876 District Offices 201 Major Local Offices 980 Minor Local Offices Kiosks 6, 744 Sub-district Authorities • Data Read/Update ICR - IC Reader • Data Read/Update • Applying for card • Data Read/Update
Dead Dynamic of health insurance status in Thailand Civil Servant Medical Benefits Scheme Social security Scheme (CSMBS) (SSS) Work in Formal sector Quit Fired retired Dead Quit Fired retired Become gov. officer มง Stateless people Universal coverage Scheme (UC) Dead
Beneficiary enrollment System EAI ata d th ) day) a de day (every – Centralized th ery e data Ministry of Interior database Bir (ev anc SS Sm em be Members data Immigration Department ur ns hi alt He NHSO Enr ollm Veda ent rifi a te dat d a t en llm ro ta a ( En da at d ) ied me rif ti Ve real r (e Bir ve ry th 2 w Social Security ee (ev – de ks Office ( ery ath mo da nth ta ) y 2 r (ever be BS mem s) CSM week (every n ig h data e Deat th)for mon n Civil Servant i e ries liv nt e u pl co o Pe Internet State enterprise, local administration Registration Data from provincial Offices ( Batch online) Registration Data from Other registration units (online)
Card ID , Purchase province Eligibility primary care unit, Referral hospital , start date, Expiry date transdate
Health Service Providers registration Primary care unit n All of the health service providers in UC have to be registered and approved for the quality assurance before becoming the contracting units in the UC scheme. n Every provider must be assigned the unique hospital code related to the bank account number in order to automatically link to the payment system accurately. Community hospital
NHSO Data Center
Network architecture NHSO Leased line Domestic 60 Mbps Internet 5 Mbps Telecom. 512 Kbps 75 Provinces NHSO Branches NHSO Branches Leased line Branches 2 Mbps (Tele conference) 5 Mbps (Data transfer) High speed Internet (256 -512 Kbps) 1000 Hospitals
Mod. 1 Mod. 2 Mod. 3 Mod. 4 Providers Beneficiaries Med. Rec. Providers Register Medical Records Mod. 5 Mod. 6 Mod. 7 Claim Processing Finance Call Center MIS&EIS Data accounting Claim Processing Centralized Database Mod. 8 Call MIS Center EIS
Concurrently get data from 2 remote sites for the updated information Information from Ministry of Interior MOI NHSO (สปส ช(. Benefit Scheme
Personal data retrieved from smart card xxxxxxx
How to identify the beneficiaries at the provider’s site Website Kiosk
1330 Interactive voice recognition (24 hrs. service) 22
Decrease in beneficiary enrollment errors from 2002 -2005
NEWBORN
The Development of UC Coverage YEAR 25 20 12 %
Reimbursement system
Fund management cash Material (medicine, instrument)
The former EPI vaccines distribution channel Imported vaccines Disease Control Dpt. airport Local produced vaccine ( Red Cross, GPO etc) Regional Provincial Health Office Disease Control Primary care unit Provincial Hospital
The current distribution channel under GPO- VMI Imported vaccines airport GPO Local produced vaccine ( Red Cross, GPO etc) VMI Contracting hospitals VMI Primary care unit
Decreasing the purchasing budget for EPI vaccines after new warehouse designed (million Bht(. New system began in the yr 2010
The wasted OPV from the GPO’ logistics
e-Claim System NHSO Health Service Provider Decryption Internet Medical Record Database - Scheme Verification - DRG Grouping, Data Validation - Deny, Warning, Report (approx. IP : 5, 500, 000 records/year OP(HC, AE) : 600, 000 records/year) Data Validation Reimbursement Database - Verification according to Payment Rules - How much to reimburse ? - Reports on website Encryption Bank
Individual records in NHSO OP, IP data disease management 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Leukemia Lymphoma Haemophilia Heart surgery Epilepsy Cataract Cleft palate HIV Diabetes Mellitus hypertension & dyslipidemia TB Stroke Prevention & Promotion 1. 2. 3. 4. 5. 6. 7. 8. 9. Screening for metabolic syndromes (sss, csmbs) Screening for stroke Thalassemia Vaccine Thyroid Screening for CA cervix Disabilities Sealant Denture in elderly Emergency care 1. 2. 3. 4. Pre-hospital care (EMS) Trauma Poisoning Stroke
Extended Utilization of National Citizen ID Number
Citizen Profile Concept n n Using PID as main linkage-key Individual records were stored in the servers. Retrieving individual health data from various databases Chronologically Rearrangement of data to create individual citizen profile that can describe full history of the patient possessing this PID
Consolidation of the citizen profiles IP individual hospital OP individual PP individual Ministry of Public Health Universal Coverage Registration Specific Disease Registration Screening data NHSO’s server DMIS AIDS& TB Population database
The integration to the health services
Medical record history date Hospital diagnosis medicine Vaccination profile vaccine date Primary care unit
Security Requirement for access citizen health profile Security Requirement Compliance 1. Authentication 2. Authorization and Entitlement 3. Auditability and Traceability 4. Data Integrity 5. Data Confidentiality 6. Non-repudiation 7. Availability and Service Continuity 8. Single Sign-on and Delegation 9. Identity and Policy Management 10. Security Interoperability
Birth registry Birth defect registry
Newborn Outside hospital No Delivery certificate No Birth certificate Around 7 % (50, 000 -60, 000 cases/yr) 41 700, 000 -800, 000 newborns/year In Hospital Delivery certificate Birth certificate Local administration (MOI )
The implementation of seamless operation for birth registry in Thailand n In the year 2011, the collaboration among the Ministry of interior (MOI), UNICEF, MOPH and NHSO were taken place for establishing of birth registry by linking the birth data from hospital’s delivery room to MOI’s database. The data will be further prepared for issuing the national ID and birth certificate later. 42
Process of birth registry Local administrative organization Hospital Print out Key in delivery record delivery certificate 1. Through HIS 2. upload the birth data (complied with standard data structure) from the Delivery delivery room to MOI database for preparing the national ID and birth certificate. . certificate Issue Birth certificate Get 13 digits
The data included in birth registry 1. General data for Newborn 2. Family status 3. Doctor /nurse information 4. Add on some more details involving the abnormal newborn 5. 44 Mother’ s illness
Single window for Birth Defect registry Birth defect database 1. Since the time of birth : connected the delivery records from hospital directly to MOI database for further issuing the birth certificate at the local 2. Add on with health services data : administrative organization Retrieving the healthcare services data from inpatient & outpatient databases with matched ICD codes begin with “Q” 3. Birth Defect Registry website : If new case is founded, the health worker can register via “ the birth defect registry website”.
Health Service Quality Control n n n According to The National Health Security Act, there is a board called the “Standard and Quality Control Board”. Duties of the board : - Prescribe measurement to control health service quality - Monitor the health service quality All registered providers must be accredited by national organizations of accreditation. 46
Information usage for Health service quality control Population Data Hospital Profile Medical Records : OP Medical Records : PP Medical Records : IP Processing Medical Records : DMIS Quality Audit Reports Detections of suspected inferior quality 47
Evidences of Inferior Quality High incidence of re-admission in certain groups of patients n Abnormally high incidence of certain diseases, conditions or complications n Abnormally high incidence of certain operations n Unacceptable infantile morbidity / mortality n …. n 48
NHSO Data Architecture Operational Part Analytical Part Warehouse Data Mart Business Intelligent Tools Data Warehouse Beneficiary enrollment Claim Hospital profiles Medical records Accounting Call Center 49
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