Government Health Insurance

[citizen33]

What you need to understand is how the "Social Security system" work?

Once you are a member of this program, a small portion of money is deducted from your monthly salary -together with some from your employer. The Government will assign you to a hospital in the program where the Gov will pay Max 35,000 Baht (actual number is much less, depends on category of illness), and Max 200,000 Baht for operation.

I thought I had some basic understanding of how the SSS worked but am having difficulty in matching my understanding with this.

The SSS uses a public contracting model based mainly on capitation funding. This is different from say a US-style private insurance plan that may reimburse hospitals for treatment up to specfied cost maxima, and leaves the patient to pick up the difference if the hospital charge is higher. Under capitation funding a public or private hospital contracts with the SS Office to provide treatments in the pre-specified package in return for an agreed annual payment per member. The capitation payment was about 700 baht when the SSS started in 1991 and has now risen to about 2000 baht. This is paid whether or not a patient needs treatment, so that private hospitals entering the scheme need to calculate whether the total capitation allocation received for all registered members will cover the cost of treating those who actually present for care. Fee-for-service only comes in at the margin for a few services and medical appliances - it accounts for well under 10% of total SSS expenditure and is not payable by patients. Where the hospital of registration needs to refer a case on for tertiary treatment (to a tertiary hospital within the SSS) it will be responsible for making a transfer payment. This is where ceilings on what will be paid come into play but this should not result in any cost to the patient. To sum up, patients requiring a treatment not excluded under the SSS should not have to make any direct payments, and hospitals must treat these patients irrespective of whether the cost exceeds their capitation income. The possible downside with capitation funding is that hospitals have an incentive to under-treat. There is evidence that patients treated under the SSS have shorter average length of stay and less spent on drugs than patients treated under the Civil Service Scheme (CSMBS, which uses only public hospitals but pays fee-for-service). There is a long-term drive to 'harmonise' the three main Thai health schemes - the SSS, the CSMBS and the Universal Coverage Scheme (the former 30 baht project), but at the moment they do not provide equal care. Incidentally a Thai national who can't get SSS coverage is likely to be reliant on the last of these (which covers about 75% of the population).

[pakorn8000]

Under capitation funding a public or private hospital contracts with the SS Office to provide treatments in the pre-specified package in return for an agreed annual payment per member. The capitation payment was about 700 baht when the SSS started in 1991 and has now risen to about 2000 baht. This is paid whether or not a patient needs treatment, so that private hospitals entering the scheme need to calculate whether the total capitation allocation received for all registered members will cover the cost of treating those who actually present for care.

The fact is the SS office pays a capitation sum per an individual, but will pay extra to certain criteria/cases. For instance,

Hemodialysis = actual, max = 3,000 (not exceeding 60 day treatment period)

Peritoneal Dialysis = actual, max = 500 (not exceeding 60 day treatment period)

Chemotherapy and Radiotherapy Chemotherapy= actual, max = 50,000/year

Implantation of Prosthesis and Instrumentation = actual, but limited with remarks*

Brain operation = max 30,000 /case

Balloon Embolization = max 30,000 /case

Stereotactic Radiosurgery = max 50,000 /case

Open Heart Surgery = actual, max = 100,000 /case

And the list goes on ...

To sum up, patients requiring a treatment not excluded under the SSS should not have to make any direct payments, and hospitals must treat these patients irrespective of whether the cost exceeds their capitation income. The possible downside with capitation funding is that hospitals have an incentive to under-treat.

This is the case, Terry. No matter how often we change the hospital, but poor treatment is at our risk. Some has been treated by SSO program, the young doctor did not advise this lady to treat high blood pressure, after a few years this led to poor lady's heart problem. All these because budget limitation.

And in case there is emergency, the contracted hospital may make it difficult for local hospital at scene to treat the symptom sufficiently (of course, they want to do their own, they think it should be cheaper to do in-house)

P.S. I did skip some this important info about capitation funding, my apology.

[citizen33]

The fact is the SS office pays a capitation sum per an individual, but will pay extra to certain criteria/cases.

As in many public health insurance schemes around the world there is a mechanism for extra payments from the SSO for high-cost treatments. As mentioned, more than 90% of the funding is allocated via capitation. However, I stick to my point that this is different from the arrangement in private insurance plans where the scheme pays up to X and the patient pays the difference. In the public scheme the intention is to pool risk for high-cost treatments (so that costs don't fall unfairly on particular providers) and also contain costs in the system by limiting what will be paid to providers who contract with the SSO (they don't have to). Once hospitals sign the contract the theory is that they have to do the treatments in the package. That is how capitation funding works - the hospital can't say halfway through the year it doesn't want the complex cases. Some main contractors use utilisation review and it would be very interesting to investigate how far this may exclude some candidates for certain treatments. Incidentally the SSO does not assign the hospital (patients have a limited choice). At the same time, most main contractor hospitals will have a subcontractor network, so that the patient may then go to a provider selected by the main contractor.Subcontractors are paid in various ways including fee-for-service, per diem and per visit by the main contractor, but this should not result in any payment by the patient

[pakorn8000]

Your point taken, but i did not mention that the patient has to pay the exceeding margin.

[TerryLH]

"Incidentally the SSO does not assign the hospital (patients have a limited choice)."

This may be so, in theory. In a practical sense, it has been my experience that often it is someone other than the patient that is making the choice. In many cases I've seen it was office staff doing the paperwork who chose the hospital, based on either their own personal preference, or on what they thought the patients might want.

Most often it was based on what hospital was closest to work.

[citizen33]

"Incidentally the SSO does not assign the hospital (patients have a limited choice)."

This may be so, in theory. In a practical sense, it has been my experience that often it is someone other than the patient that is making the choice. In many cases I've seen it was office staff doing the paperwork who chose the hospital, based on either their own personal preference, or on what they thought the patients might want.

Most often it was based on what hospital was closest to work.

Yes, that may be the case, but the blanket statement that patients are assigned to a hospital as a feature of the scheme is untrue. As you say in an earlier post, you chose your private hospital from the list provided and in theory that is indeed how it should work.

[samran]

"Incidentally the SSO does not assign the hospital (patients have a limited choice)."

This may be so, in theory. In a practical sense, it has been my experience that often it is someone other than the patient that is making the choice. In many cases I've seen it was office staff doing the paperwork who chose the hospital, based on either their own personal preference, or on what they thought the patients might want.

Most often it was based on what hospital was closest to work.

Yes, that may be the case, but the blanket statement that patients are assigned to a hospital as a feature of the scheme is untrue. As you say in an earlier post, you chose your private hospital from the list provided and in theory that is indeed how it should work.

from the list provided...provided it isn't 'full'. That is why you get three choices when you fill in your form to chose a hospital.

[TerryLH]

When I moved to this province I went to the soc sec office to change my sos sec to here.

They gave me a list of available (I assumed) hospitals. I chose one, they said OK, and then it was just a matter of waiting for my new card.

I know that today the list is shorter than it was several years ago.

"That is why you get three choices when you fill in your form to chose a hospital."

Can I safely assume that's the way it's normally done when the employer fills out/submits the paperwork? That would make sense.

[on-on]

I can only comment on my current experience at Kluaynamthai. I chose that hospital from my employer who offered me to choose. A previous employer apparently chose for me, but without malice, just filling out paperwork. I think the assumption was that farangs never use it anyway, heh. During the recent change I made sure to specify.

On a little side note, since I might as well post somewhere, Kluaynamthai is clean to the naked eye and a bit older. Staff are friendly and helpful. The doctors speak plenty of English in any case. I went in today, filled out a small form, presented them my SS card and answered a few questions about my problem and history. They sat me down and a minute later I was in my consultation. Ten minutes of back and forth and being poked and prodded by the friendly doctor and I was scheduled for surgery. The surgeon was busy today (it's not a super-serious problem), so they scheduled it for tomorrow morning. In and out in about 20 minutes total, give or take. The staff were helpful and friendly and challenged me with questions to make sure they had the details right, which is sometimes a problem here. I heard a lot about waiting and waiting from Thais and farangs (most of whom hadn't used the program), but my experience was much quicker than my paid experiences at BNH and others (not to mention back in The States).

If they cut my penis off tomorrow instead of yanking the cyst out of my back my opinion may sour, but so far it's been a pretty dear experience for an American to just be able to walk into a place, walk out of a place and not have to worry about arguing with someone for months about coverage and pre-existing conditions and co-pays and such. I can afford alternatives, work in a related industry and have always used other hospitals (BNH, Yanhee, Samitivej, etc), but I'm very appreciate of the opportunity I've been given by the gummint here and was, frankly, interested to see what my emotional reaction would be to the affair. Still, that's no reason for the rest of humanity to care, just my personal opinion.

[on-on]

Just a quick rejoinder. Appeared this morning for my 9:30 appointment, had a consultation with the surgeon followed by a sonogram and a final consultation on the results. All told about a half hour waiting up front and an hour of work. Surgery was scheduled for 2PM today. I went back at 2PM, was processed quickly and put in the gown and taken to the OR. It's more casual than an OR back in the states for sure and I'd have to say a little dirtier, but everything seemed quite professional. Waited on the table for about 20 minutes, surgery took about 45 minutes and I was processed out in about 15 minutes. They even offered to help pay for a taxi to take me back and forth to have my dressing changed for the week when they misunderstood one of my questions. I received the usual mountain of prescriptions one receives in Thailand and what not and was explained to clearly how to take them, when and in what dosage. All covered by social insurance.

All told I spent maybe 3 hours and 30 minutes to 4 hours between registration, processing, arbitrage, consultation, diagnosis, surgery and processing out along with a couple of stints on the couch and talking over appointments. Everything was covered by social insurance. The only papers I was asked for were my SS card (that has the hospital on it) and my passport (since that's my form of ID). I was called handsome and told I speak very good Thai a number of times, neither of which is true, heh. Anyway, there's my very summary trip report of using the Thai social insurance at Kluaynamthai if anyone wonders what it's like.

[Martian]

Your point taken, but i did not mention that the patient has to pay the exceeding margin.

Are you saying that if a treatment exceeds what the government will compensate the hospital, the patient has to pay the difference?

If so, this is news to me and where in the SSI information is this stated?

It is/was my understanding that any "covered" incident is 100% paid for under the SSI program.......am I wrong?

Thank you,

Martian

[citizen33]

Your point taken, but i did not mention that the patient has to pay the exceeding margin.

Are you saying that if a treatment exceeds what the government will compensate the hospital, the patient has to pay the difference?

If so, this is news to me and where in the SSI information is this stated?

It is/was my understanding that any "covered" incident is 100% paid for under the SSI program.......am I wrong?

Thank you,

Martian

No you aren't wrong: that is the misleading inference from earlier posts that I was trying to correct. In essence the SSO tries to get the best price it can from hospitals by specifying maximum rates payable, but in agreeing to enter the scheme the hospitals are agreeing to those conditions. So once the patient registers with a hospital in the scheme, that hospital and its contractor network are obligated to provide the treatments in the SSS package with no charge to the patient. Many private hospitals as well as public hospitals have entered the scheme. I'm afraid some of the earlier posters think in terms of US-style private insurance markets and cannot get their heads around the workings of a public SHI scheme.

[PattayaParent]

What you need to understand is how the "Social Security system" work?

Once you are a member of this program, a small portion of money is deducted from your monthly salary -together with some from your employer. The Government will assign you to a hospital in the program where the Gov will pay Max 35,000 Baht (actual number is much less, depends on category of illness), and Max 200,000 Baht for operation. Thus, the pro is "cost" for sure, but the con are as follows:

1. Gov hospital problems:

- crowded

- exhausted personal to due to traffic daily

- control of infection is still not very good (you might end up infected worse than what you went in for in the first place)

2. Private hospital problems:

- must be one in the program, and must be one you are assigned to.

- if you encountered serious illness in a place far away. For instance, you need an immediate brain/heart operation. This will be a problem. Because the hospital close by is not the one got paid. So, why treat you at best? !!

- private hospital runs a business. Hence, new/inexperience/careless doctor or low grade medical possible (and seen in many cases) due to budget constrain.

- Serious or High cost operation/treatment ... forget it!!

- Remember poor or careless treatment usually cost your health. Maybe even more serious llness might follow

It is your health that counts, make your own decision. Maybe the welfare is adequate - maybe not.

That's the UK medical service you're describing, with the addition that your private medical insurer will pay you not to use their private hospital but to remain on the government waiting list

[citizen33]

What you need to understand is how the "Social Security system" work?

Once you are a member of this program, a small portion of money is deducted from your monthly salary -together with some from your employer. The Government will assign you to a hospital in the program where the Gov will pay Max 35,000 Baht (actual number is much less, depends on category of illness), and Max 200,000 Baht for operation. Thus, the pro is "cost" for sure, but the con are as follows:

1. Gov hospital problems:

- crowded

- exhausted personal to due to traffic daily

- control of infection is still not very good (you might end up infected worse than what you went in for in the first place)

2. Private hospital problems:

- must be one in the program, and must be one you are assigned to.

- if you encountered serious illness in a place far away. For instance, you need an immediate brain/heart operation. This will be a problem. Because the hospital close by is not the one got paid. So, why treat you at best? !!

- private hospital runs a business. Hence, new/inexperience/careless doctor or low grade medical possible (and seen in many cases) due to budget constrain.

- Serious or High cost operation/treatment ... forget it!!

- Remember poor or careless treatment usually cost your health. Maybe even more serious llness might follow

It is your health that counts, make your own decision. Maybe the welfare is adequate - maybe not.

That's the UK medical service you're describing, with the addition that your private medical insurer will pay you not to use their private hospital but to remain on the government waiting list

Only problem - as we have said - is that the quoted post is written by somebody who doesn't understand how the funding system works and got several details wrong. There are arrangements for emergency care anywhere in Thailand and the cost maxima do not stop patients from getting treatment for any of the covered conditions. If it is the job of private insurance salemen to sow disinformation, this guy seems to have done a very effective job in misleading readers.

[elruliano]

"You can't take the coverage with you if you leave your participating employer."

I'll politely disagree with that part of your otherwise right-on post.

If, for whatever reason, you are no longer in the system through work you can enroll yourself. You have 6 months to re-sign up, during which time you can still take advantage of the coverage.

I recently did this and now pay 432 baht per month. I did this at my local SS office. It was a routine task for them.

I was asked if I wanted the same hospital provider, or if I wanted to choose a different one.

I think if you do this in a differnt province there may be a several month waiting period while the paperwork gets processed and a new card issued, but I'm not positive about that part of it.

Same benefits as before, so far.

What kind of coverage can I get if I enroll with Social Security (IPD, ER, OPD per day) ?

[Sateev]

Your point taken, but i did not mention that the patient has to pay the exceeding margin.

Are you saying that if a treatment exceeds what the government will compensate the hospital, the patient has to pay the difference?

If so, this is news to me and where in the SSI information is this stated?

It is/was my understanding that any "covered" incident is 100% paid for under the SSI program.......am I wrong?

Thank you,

Martian

Don't know where in the SSS information it says so, but I had to pay for the difference in price between a medicine-coated stent and a plain one, when I had an angioplasty under the Thai Social Security coverage.

I also had to negotiate the price while under mild sedation, laying on the Cardiac Cath Lab table! Amazingly, I bargained hard, and had the cardiac interventionist on the phone to the hospital admin, as well as the stent salesman, before we agreed on a price. Then, at discharge time, the price magically inflated by 40%! I refused to pay it, and got them to reinstate the agreed upon price.

I guess they didn't use enough Versed to make me forget...

In fairness, though, after firing one cardiologist, the department head was superb, as was the nursing staff.

And I'm here to post about it!

All this from a well-known hospital at the Saphan Kwai BTS station...

Sateev

[citizen33]

The negotiation in the cath lab shouldn't have happened, which, of course, is not the same as saying things like this never happen. It is true that the drugs/prostheses available under the SSS may not be the most expensive. Another example may help readers understand how the payment mechanism is supposed to work. Brits will be familiar with the NHS in England (now not the same as Wales, Scotland, or N. Ireland). In England, free NHS treatments may be provided in either NHS or private hospitals, and are reimbursed by government according to national PbR tariffs (i.e. the maximum price that will be paid for a given HRG-based procedure - HRGs are similar to DRGs). Private hospitals only contract to do this work because they believe it will be profitable, but the NHS tariff will be below the provider's published schedule of prices used for private work. Usually these contracts are agreed for a tranche of patients over a year, rather than case by case. Having agreed to a price the hospitals cannot pick and choose by excluding more complex cases within the agreed categories. For these NHS patients, it does not make much sense to talk about the 'exceeding margin', when the issue is simply the difference between the standard price and the NHS price. Actually some larger private buyers entering contracts with private hospitals will also get a cheaper price because they can use their market power, so the very idea of a standard price is questionable. In the NHS system it is not permissible for the patient to 'pay the difference' and be treated as a private patient where any difference in NHS and private treatment exists (some private providers use separate treatment pathways, some do not). Probably this is the only scenario where the idea of the exceeding margin would be meaningful. The Thai SSS is similar. Now it seems that informally some hospitals have been encouraging some patients to 'pay the difference', but to the best of my knowledge this is not how the system is intended to work. If the treatment is in the core package, there should be no extra charge.

[nickcar]

Hi

not having read all the posts in detail, I may be repeating someone but I though it worhtwhile to mention a couple of things.

1 - Social Security will cover the costs of regular dialysis which I have never seen in a normal health insurence.

2 - Paying a little extra for a private room is tsandard practice in most Thai hospitals that treat ssc and 30 naht.

3 - I certainly intend to keep my ssc going when i retire in a few weeks becuase for so little a month it is a good backup and who knows if I will be able to afford insurence in the future.

cheers

Nick

[cihan]

Sorry, taking the thread a little off course, but still on the same topic. Anybody know how a self-employed Thai (very small, non registered business)[as yet] would go about joining the government scheme?

Hi TVI.

How can a Thai National obtain "social security health cover", if they don't have formal employment?

is there anyone who can answer these questions? can a thai national join the social security without having a work?

[TerryLH]

"can a thai national join the social security without having a work?"

No, it's through employment that you become eligible for Thai Social Security.

If you obtained coverage in the past, no longer work, but kept your coverage by paying yourself, you could stay in the system.

If not working, the 30baht/Gold Card system is the plan that you could get in.

[hereforgood]

After an unsuccessful forum search for answers to my questions I want to ask those with knowledge about the government health coverage available through your employer.

I am a Farang and considering a teaching job at a government school in my Thai hometown and they say after 3 months I can have the "social security health coverage at ****** hospital". The designated hospital is the usual one I go to so I am ok with that but what I am asking is this:

As a member of the program, are all medical costs (IP & OP) covered without any deductibles, co-pays or maximums? What are the terms of the program? Dental and/or vision included?

Thank you,

Martian

Suggest you look here for the information :

http://www.sso.go.th/english/faq.php?menu_...;content_id=350

Please note however this is very low coverage and should not be relied on – certainly not if one wants to use the better private/international hospitals

"Please note however this is very low coverage and should not be relied on – certainly not if one wants to use the better private/international hospitals"

That's a pretty self serving statement from a competing ins broker/salesperson.

In case I'm wrong, can you give an explanation of what you mean by low coverage and why it shouldn't be relied on?

Thanks

Terry

Very simple, the amount payable under this scheme will not be sufficient to pay for the treatment in the private/international hospitals

I have been working here in Pattaya for 5 years and as on the Thai SS plan my company pays all my taxes for me and I am insured. I had a double hip replacement at a goverment hospital is Sri Ratcha at zaero cost was covered 100% as is all my follow up visits. The care was second to none. Bumrungrad in Bangkok quoted me 1 Million Baht for the same Plus extra for meds after the Op.

The Doctor that did my replacement told me he may well have been the one doing it at Bumrungrad as well as he works at hospitals all over the area. Been 1 year since it has been done and I fel great ! At zero cost so don't let the fact that it's a goverement hospital scare you away.