'Emergency care' definition causes clash with health funds
The government should replace the term "emergency" with "critical" when defining medical conditions that require urgent attention, as the definition has caused confusion among both healthcare providers and patients while making private hospitals reluctant to provide life-saving treatment for state-sponsored patients, health experts say.
"There's no authority that can identify which diseases or conditions are eligible for 'emergency' medical services," Dr Samrit Srithamrongsawat, director of the Health Insurance System Research Office (HISRO), said recently.
Samrit was on a research team that evaluated the government's plan to merge its three main medical care schemes, which cover unlimited emergency medical treatment. The team studied 7,805 cases of private hospitals admitting patients for emergency medical services and receiving reimbursement from a state health agency.
He found that in 90 per cent of the cases, the emergency care patients were required to pay their medical bills themselves at full prices, then asked to check with their state health insurance providers about eligibility for reimbursement. If approved, the hospital would refund the reimbursable amounts to the patients and charge for only the excess costs.
"They are not confident that they will get full repayment from the government, so they charge patients with the full price of treatment and get reimbursed later" he added.
On April 1 last year, the government's policy went into effect to give citizens free access to emergency medical services from any hospital, no matter which national healthcare scheme they belonged to - the National Health Security Fund (NHSF), Social Security Fund (SSF) or Civil Servant Medical Benefit Fund (CSMBF).
This plan was supposed to protect people with an unexpected critical condition or severe injury in an accident, especially during festive seasons such as New Year's, which this year killed 365 and injured 3,329.
In principle, citizens just need to show their national identification card to receive emergency medical services at the nearest hospital. They would be treated until they recover and the NHSF would pay the hospital directly for their medical charges.
Emergency conditions are divided into three colour-coded categories. Red refers to a critical condition that needs emergency life-saving medical treatment. Yellow is for an acute condition that can wait a few hours before emergency treatment. Green designates moderate symptoms that can wait for medication.
However, sometimes a private hospital would categorise a patient's case as red or yellow, but when it sought reimbursement, the NHSF would categorise the case as green and not follow the hospital's request. This is why private hospitals need to charge patients the full price first, Samrit said.
According to the NHSF's report, as of November 30, 12,845 patients had received emergency medical services under this scheme at 239 private hospitals nationwide. The NHSF had paid Bt205 million to the private hospitals that joined the scheme.
However, Prof Paibul Suriyawong-paisal of Ramathibodi Hospital, head of the research team, said some people did not go to a private hospital to receive emergency medical services, as they were afraid of being charged.
But the directors of private hospitals said some of those patients had decided to go to another private hospital located far from their home instead of the nearest.
Dr Chalerm Harnpanich, chairman of the Private Hospital Association, said he wants the government to hold a meeting to discuss the problem and find a solution soon.
Dr Varunee Jinarat, director of Rajavithi Hospital, said some patients had admitted to her medical staff that they were confused about the definition of emergency medical services. However, she allowed them to receive the treatment first then request reimbursement later.
Dr Surasak Leela-Udomlipi, director of Ramathibodi Hospital, said he had instructed his staff to clearly explain to patients the medical conditions that are categorised as critical or acute. If they do not qualify, staff will advise them to go the hospital that they are registered with under their health scheme.
Samrit said the government should set up a neutral agency to point out at the first step of treatment which diseases or conditions are classified as emergencies.
Dr Winai Sawasdivorn, secretary-general of the National Health Security Office, said his office is making a proposal to the NHSO's board and the government to improve the emergency medical policy, but acknowledged that there's still uncertainty over what constitutes an emergency.
To help clear up the situation, Winai will ask the government to set up a middleman to inform private hospitals and patients which medical conditions are listed as critical, acute or moderate.
Source: The Nation 14 January 2013
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