คณะสังคมสงเคราะห์ศาสตร์และสวัสดิการสังคม ม.หัวเฉียวเฉลิมพระเกียรติ

Mechanism and process for handling complaints and extending primary assistance in Thailand’s health insurance systems 

Dr.Thipaporn Portawin

                                                                          Dr. Jaturong Boonyarattanasoontorn           

1. Preface

        Objectives of this study on the mechanism and process for handling complaints and extending primary assistance in Thailand’s health insurance systems are to study (1) the very mechanism and process for handling complaints and extending primary assistance to patients, (2) their efficiency and effectiveness, (3) impacts from mistakes made in providing medical treatment in the systems to service providers, service receivers and the society, and (4) operation of, and problems and obstacles faced by, people’s health insurance coordinating centers in terms of their participation in development of the health insurance systems and being an independent body of the people sector working together with local administrative organisations in health management at local community level in long term.

      Methodologies used in this study are documentary research and field research which consist of both quantitative survey, collecting data from sample of 3,015 persons who register with the three health insurance systems, and qualitative survey, conducting an in-depth interview of 59 key informants and 5 case studies. 

2. Importance of the mechanism and process for handling complaints and extending primary assistance in the health insurance systems

      2.1 Complaining is a right eligible to patients in the health insurance systems. Rights of patients is a starting point, an issue that patients use to lodge their complaints when they feel that they are neglected or ignored, do not enjoy their fair rights. If it is proofed that their cases of complaint are within patients’ rights, agency or person that is the subject of complaint must show responsibility to provide primary assistance and show additional responsibilities depending on each case. 

      2.2 Treatment of complaints from, and extending primary assistance to, patients in the health insurance systems must be based on protection of rights, enhancement of good governance and constructive conflict resolution.

        1) Protection of rights and enhancement of good governance. The concept of protection of rights and enhancement of good governance can be used to analyse complaints and extend primary assistance to patients in the health insurance systems whether or not a patient should decide to lodge a complaint to protect his/her right, whether or not a patient has relationship with formal and informal institutes in any way that play a role to empower them and if so, how much.  Providing information, giving opportunities to participate, check and form group are processes that the government must facilitate for patients, so that they would enjoy their rights and receive services that are up to the standards. 

         2) Good governance. Analysis and assessment is needed to see whether or not medical service and public health care provided to complainers are consistent with the good governance principles, that are ethical principle, moral principle, transparency, participation, responsibility and cost effectiveness, and if so, how much.

      3) Constructive conflict resolution.  Concept of constructive conflict resolution can be used as a framework to study a process for handling complaints and extending primary assistance whether or not it is consistent with this concept, and what should be improved?

     2.3 Role of the people sector and its participation in the health insurance systems. An objective of this research is to assess capacity and success of people’s health insurance coordinating centers in term of their participation in development of the health insurance system and being an independence body of the people sector together with local administrative organisations in health management at local community level in long term. This study should therefore find out whether or not the coordinating centers take part in actions to create health insurance for the people, and if so, how much? 

3. Situation of the mechanism and process for handling complaints and extending primary assistance in the health insurance systems

      Results of a study on situation of the mechanism and process for handling complaints and extending primary assistance in the health insurance systems are as follows:

      3.1 Mechanisms for handling complaints in the health insurance systems at present are all different from each other.

         (1) The Universal Health Insurance System.  Mechanisms for handling complaints consist of several agencies, that are National Health Insurance Office (NHIO), area branches of the National Health Insurance Office (13 branches all over the country), Provincial Public Health Offices, complaints unit in hospitals, the Gold Card Hotline 1330, National Public Health Service Standards and Quality Control Committee, sub-committees appointed by the Public Health Service Standards and Quality Control Committee to work as assigned, committees or working groups under the complaints handling structure in hospitals, and people’s health insurance coordinating centers.

            (2) The Social Security System. Complaints handling mechanisms consist of the Social Security Office, district social securiry offices, provincial social security offices, social security hotline, Medical Coordination Division, the Medical Committee and sub-committees appointed by the Medical Committee to work as assigned.  Mechanism to handle complaints related to medical treatment in the Social Security System, on the other hand, is a committee of physicians consisting of a chairperson and other committee members altogether no more than 16 persons appointed by the minister with a representative of the Social Security Office acting as its committee member and secretary. This committee has authority to check and make decisions, including proposing penalties for wrong-doers. The social security office has a clear complaint and compensation system. Channels for making complaints are district social security offices in Bangkok and provincial social security offices with registration and medical coordination section to receive complaints related to medical service.

            (3) Welfare system on medical treatment of government officials and state enterprise officials. Complaints handling mechanism is the Comptroller General’s Department in the Ministry of Finance.  In case that a private hospital or clinic is the subject of complaint by a government official or state enterprise official, the Finance Ministry has authority to give name of the hospital/clinic to other government agencies, so that they would not reimburse medical expenses to that hospital/clinic, except it is necessary to receive medical treatment from the hospital/clinic in emergency case. In case that the subject of complaint is a state hospital/clinic, the Comptroller General’s Department has no authority whatsoever apart from referring the complaint to the higher authority of that hospital/clinic to deal with the case.

      Mechanisms in all these three systems to protect health insurance consumers have weaknesses that need to be improved.  Considering Thailand’s current situation, an idea that these three systems should have the same standards may be difficult to materialize.  However, as Article 50 of the Constitution of the Kingdom of Thailand B.E. 2550 (AD 2007) states that “…Persons have equal right to receive public health care service that is up to acceptable standards…”, having different standards provided by the three health insurance systems is therefore against the current constitution. 

      3.2 The currently existing processes for handling complaints and extending primary assistance are different in the three systems as follows:

            (1) The Universal Health Insurance System has a system to handle complaints from, and pay compensation to, patients clearly stated in the National Health Insurance Act B.E. 2545 (AD 2002).  At present, mechanisms and process for handling complaints at national, regional, provincial and hospital level have been developed to be able to receive complaints and solve incurring problems till the end.

            (2) Social Socurity System has a clearly-defined process to handle complaints, that is when an employee/insured faces a medical service related problem, he/she can lodge a complaint or ask for advice through several channels, such as make a complaint by oneself, send a complaint letter by mail, submit a complaint in website of the Prime Minister Office or Ministry of Labour or Social Security Office, and complain through various media, including a hotline 1506. 

      When a complaint is made, a district social security office or provincial social security office would first make a phone call or send a letter to the concerned hospital to seek negotiation and reconciliation, including looking for primary facts.  If the complaint is about medical treatment standards, the concerned hospital and related hospitals would be asked to send medical records to medical advisors of the Social Security Office. If the case could not be determined at this stage, it would be referred to a medical sub-committee on medical treatment standards of the Medical Committee. If the insured does not satisfy with a verdict of this sub-committee, he/she can appeal to an appeal committee, and if the insured still does not satisfy with verdict of the appeal committee, he/she can bring the case to the Labour Court.

      In case that the Medical Committee sees that the concerned hospital did not take care of the affected insured according to medical treatment standards, the hospital would be asked to be responsible for incurring expenses.  If the concerned hospital does not comply, the Social Security Office would deduct these expenses from medical service fees given to the hospital. At the same time, a punitive measure would be imposed by deducting the quota of insureds given to the concerned hospital or ultimately taking the hospital out of the social security project.

            (3) Welfare system on medical treatment of government officials and state enterprise personnel has limited channels for making complaints and lacks mechanism to handle complaints, resulting in those who try to use their right in this system when they face any problem from the welfare system on medical treatment need to resort to the judicial procedure.

      Results from the qualitative study indicates that there exists a process to handle complaints from patients who receive service in all the three health insurance systems concretely at provincial and hospital level. 

      At provincial level, provincial public health office acts as coordinator compiling information about all complaints in the province.

      At hospital level, there exists a centre to receive complaints and opinion boxes.  Service receivers can lodge their complaints through the provincial channel or through the Public Health Ministry to the Prime Minister Office.  In the first stage, Director of the hospital concerned would be fair to both sides because none of them had intention to cause problem. As for establishment of a mechanism to receive complaints in hospital, consumers’ right defenders see that there should be a complaint-receiving organisation that is really independent.  Having a complaint receiving system located in hospital seems to make it a center of the hospital itself that tries to talk service receivers to agree with the hospital, turning it to be a center to protect interest of the hospital. 

      Primary assistance or compensation that needs no investigation should be widely publicised.  In practice, such cases should be clearly separated from cases that a complaint needs to be made before any action can be taken because any complaint make the two concerned sides feel bad, especially those being accused. Physicians and nurses are very much afraid of complaints because they must write a report in response.

      At present, it is easy for a patient to lodge a complaint.  However, an impact on those who are complained at is that they feel despair and do not want to do any work that has a risk of being complained.  Patients therefore would be referred to a hospital that has modern equipment, causing over-crowding in large hospitals.   

4. Findings from this study

      4.1 Efficiency and effectiveness of the process to extend primary assistance to patients in the health insurance systems

      Results of this study on efficiency and effectiveness of the process to extend primary assistance to patients in the three health insurance systems are as follows:

      (1) Steps, methods, conditions and timeframe as required in the National Health Insurance Act B.E. 2549 (AD 2006), Social Security Act B.E. 2533 (AD 1990), Finance Ministry’s regulation on welfare concerning medical treatment for government officials B.E. 2545 (AD 2002) and other laws related to handling of complaints and extending primary assistance to patients in the health insurance systems have been observed.  A mechanism established to handle complaints in hospitals and at Khon Kaen, Samut Prakarn and Nakhonping (Chiang Mai) provincial public health offices has a process that clearly defines steps to be taken and timeframe for handling complaints.

      (2) There exists measures to prevent reoccurrence of damages in all the three health insurance systems that are implemented at hospital level.  Results of concrete implementation of these measures, however, could not be assessed.

      (3) Hospitals at present manage to prevent and deal with complaints in form of a risk management committee.

      (4) In term of results of concerned practices in the three health insurance systems, the Universal Health Insurance System is a good system, being able to protect the people, providing information, giving right to make complaints and extending primary assistance to patients who receive damages without having to proof right or wrong.  Shortcomings of this system is that it did not raise awareness of its service receivers to take care of themselves and to correctly follow rules and regulations in claiming their right and seeking assistance, resulting in additional burden.  Physicians need to work hard and increase their carefulness in providing treatment. Relationship between patients and service providers is declining.

      The Social Security System, on the other hand, has a good mechanism to receive complaints, but extending assistance to damaged insureds is still complicated and cumbersome, making its protection of insureds inefficient.  Finally, the welfare on medical treatment for government officials and state enterprise personnel begins to have problems, including limitations of treatment and medicine available in the medicine list, unclear policy and ineffective provision of information.

      (5) Service receivers have moderate satisfaction towards behaviours of service providers, process for handling complaints on health insurance, process for handling complaints related to hospital, channels for making complaints, and speed of actions in each step.

      Moreover, it is found that there have been attempts to apply the participation principle, which is a part of the good governance principles, in administration of the process for handling complaints.  This can be clearly seen in the Universal Health Insurance System.  People’s Health Insurance Coordination Center was established as an important mechanism to receive complaints in the Universal Health Insurance System, becoming a strength of this system.

      As for the welfare on medical treatment for government officials and state enterprise officials and the Social Security System, good governance principles are clearly used as a framework for operation.  Payment of medical fees to right users in both systems has regulations and is strictly checked.  However, both systems are managed as bureaucracy that follows certain regulations and steps, making them inefficient and having weakness in term of participation of right users that need to be improved.

            4.2 Mistakes from past operation and impacts on service providers, service receivers and society as a whole.

      Results of this study on mistakes from past operation and impacts on service providers, service receivers and society as a whole are as follows:

      (1) The sample group very much agree on three groups of issues that lead to complaints, that are service providing behaviours, treatment by physicians and deprivation of right.  The top three service providing behaviours that lead to complaints are 1) care, 2) conversation, and 3) confidence on safety a hospital provides to service users.  The top three treatment by physicians that lead to complaints are 1) services that cause damages, 2) mistakes in diagnosis of illness and medical treatment, and 3) patients not receiving clear advice and explanation about medical treatment from service providers.  The three top deprivation of right that lead to complaints are 1) deprivation of right, 2) hospital’s lack of attention to deal with problems, and 3) being required to pay service fees while in fact the hospital has no right to ask for payment. 
 
 

      (2) Most of the sample groups do not know agencies in the health insurance systems.  The National Health Insurance Office and Social Security Office are agencies that are known and not known at nearly the same proportion, while provincial public health office, provincial social security office and the Gold Card Hotline 1330 are known and not known by the sample groups at a much different proportion.

      (3) The sample groups express moderate satisfaction towards behaviours of service providers, process for handling complaints in the health insurance systems, handling of complaints by hospital, channels for complaints and speed that action is taken in each step. The three top satisfaction towards behaviours of service providers are 1) knowledge and capacity of concerned officials, 2) care taken by officials, and 3) conversation of officials in the agencies being complained. The three top satisfaction towards process for handling complaints in the health insurance systems are 1) services provided according to their rights, 2) arrangement of complaint receiving unit by hospital, and 3) advice and instruction by officials. The three top satisfaction towards handling of complaints by hospital are 1) operation of hospital, 2) negotiation to look for solution to a problem, and 3) attention given in handling problems by hospital. The three top satisfaction towards channels for complaints are 1) channel for self-complaint, 2) channel for complaints by phone, and 3) channel for complaints through the hotline.  The three top satisfaction towards speed that action is taken in each step are 1) negotiation that takes into consideration damages occurred to all parties concerned, 2) primary assistance, and 3) continuous follow-up to actions being taken.

      (4) Impacts from complaints.  This study finds that complaints cause moderate impacts on service receivers and service providers.  The three top impacts towards service receivers are 1) waste of time to earn a living, 2) waste of their own expenses, and 3) waste of their family’s expenses, while three top impacts towards service providers are 1) stress and worry, 2) reputation of service providers, and 3) relationship between service providers and patients and their family.

      Qualitative study, on the other hand, finds that after the Universal Health Insurance System was put into effect in 2001, hospitals and clinics have to bear more burden in providing medical treatment to patients.  In addition, there are also more complaints from patients about damages that occured when they went to receive medical treatment. Moreover, many hospitals have to bear a burden giving medical treatment to more people than in quota assigned to them because there are many non-residence population living in the area, resulting in work load being unproportionate to number of existing personnel.

      A tendency is that there would be more complaints, resulting in hospitals adjusting their operational structure to cope with this new situation, so that their personnel would be able to work.  This is seen by service providers as an increase of work load where there is no change in human power.  Some hospitals then organise to have a risk management system which consists of a risk monitoring committee and a complaints receiving and handling committee.  A point in risk management policy of these hospitals is that creation of safety for patients receiving their medical treatment service is considered as prevention against complaints.

      Social impacts from complaints are both positive and negative.  Positively, they have raised awareness in development of the health insurance systems in term of quality, resulting in people’s having more confidence towards the systems.  The people are given more opportunities to use their rights; they have more opportunities to take part in checking and controlling service providing units and networks by promoting more operation of the people’s health insurance coordination center.  Local administrative organisations begin to play a role and involve in operation related to protection of public health service quality and standards in committees, sub-committees and working groups at provincial level.

      Negative impacts, on the other hand, are created by dissemination of complaint cases in the mass media, resulting in decline of people’s trust towards physicians’ morality and ethics and decline of their trust towards systems, mechanisms and process for extending primary assistance, including compensation for damages occurred to right users in the health insurance systems, especially the Social Security System that draws wide criticisms from workers and academics.  Case studies in this research reveal strict and rigid interpretation of regulations concerning payment to the insureds to an extent that humanitarian principle is overlooked.

      4.3 Successes of the people’s health insurance coordination centers

      A survey on opinions of the sample groups reveals that they have moderate satisfaction towards the successes with three top ratings go to (1) bringing people who have no Gold Card to apply for one, (2) coordination with tambon administrative organisations in the area in administration and management of  the tambon-level health insurance fund, and (3) advocating local administrative organisations to participate in development of the health insurance systems in the local area.

      Qualitative research data from group discussion with committees and coordinators of the people’s health insurance coordination centers in Bangkok and in Chiang Mai, Khon Kaen and Songkhla provinces indicates that operation of the centers is successful only to a level because they still depend on financial supports from the government.  Operation according to their mission incurs rather high costs.  The center in some provinces need to insert activities to create understanding about health insurance in communities in other activities that have existing budget, resulting in health insurance work cannot be fully carried out.  

5. Ways to improve mechanisms and process for extending primary assistance to patients in the health insurance systems

      This study reveals that the sample groups very much agree with 4 broad ways for improvement, that are 1) supporting consumers to be able to protect their rights, 2) allowing every party involved to take part in preventing and solving mistakes in services, 3) improving hospitals’ service methods, and 4) informing results of consideration on the cases of complaint. 

6. Recommendations on development of mechanisms and process for handling complaint and extending primary assistance in case that service receivers face damages from receiving medical treatment in each of the health insurance systems

      6.1 Effectiveness of the Universal Health Insurance System should be developed.

            (1) The Universal Health Insurance System should be developed to be more effective by improving and developing quality of services to prevent mistakes and impacts on service receivers, service providers and society.

            (2) The government should promote improvement of mechanisms and process for extending primary assistance to patients in the Universal Health Insurance System that would help service providers and service receivers to be treated fairly and can live happily together in four areas, that are 1) supporting consumers to be able to protect their rights, 2) allowing every party involved to take part in preventing and solving mistakes in services, 3) improving hospitals’ service methods, and 4) effectively informing results of consideration on the cases of complaint.  

      6.2 Effectiveness of the Social Securtity System should be developed in the following areas:

               (1) A process to select members of various committees in the Social Security System, so that there would be representatives really selected and recognised by the insureds.

      (2) Regulations on limit of compensation for damages in case that the insureds face damages to an extent that they cannot work anymore should be changed by increasing payment for medical treatment costs, unemployment compensation and cost of living appropriately so that the damaged parties can maintain their living.

      (3) Regulations concerning payment for lost interests and compensation money to employees who face damages should be improved so that work to assist the insureds and employees who face damages can be smoothly and quickly done.

      (4) A process for investigating facts when compensation is requested should be improved by taking into consideration rights of the insureds as guaranteed by law. For instance, there should be enough officials in the area of service or area under responsibility, so that they can immediately visit to examine the place of incidence or  use other information in their consideration and can make their consideration with transparent reasons.  There should also be committee members from other sectors, such as representatives of insurers and representatives of labour union, for example, to take part in the investigation.

          (5) The Social Security Office as the principal agency responsible for administration of the Social Security System should improve its operation procedure in its investigation or fact finding and interpretation in consideration of complaints and payment of compensation for insurers and employees being harmed in their work that is apppropriate and consistent with reality, so that insurers and employees being harmed in their work are faily protected.  It should improve its investigation, finding more facts to be enough for consideration and interpretation, and should widely interpret or consider information based on reality.  It should consider other work related factors that may cause insurers to lost their life; not that lost of life has to happen while they perform their duties in order that insurers would be eligible to receive compensation. 

      6.3 Effectiveness of welfare system on medical treatment for government officials and state enterprise personnel

                  (1) Improving effectiveness of the existing channel to receive complaints in the welfare system on medical treatment for government officials and state enterprise personnel (hotline 1689) and increase more diverse channels to receive complaints as alternatives.

                  (2) Promoting participation of government officials and state enterprise personnel in policy making and works related to the welfare system on medical treatment for government officials and state enterprise personnel.

      6.4 Capacity of the people’s health insurance coordination centers should be developed in terms of participation in development of the health insurance systems and their being a people sector’s independent body together with local administrative organisations in health management at local community level in long term.

      6.5 The government should have a clear direction to provide financial supports necessary for operation of the people’s health insurance coordination centers so that the centers would be able to function continuously and sustainably as channels for complaints easily accessed by the people or patients.  

      6.6 The National Health Insurance Office should issue clear rules and regulations to recognise existence of the people’s health insurance coordination centers in all areas, so that role and duties of the centers are accepted.  

      6.7 The National Health Insurance Office should publicise or inform medical personnel about roles and duties of the people’s health insurance coordination centers because it is found that many medical personnel still do not know and do not understand roles and duties of the people’s health iunsurance coordination centers.  

     6.8 A research should be conducted in the future about development of the health insurance systems for handling complaints and process for extending primary assistance to patients in the health insurance systems.  

      (1) A study should be conducted on forms, components of committee, roles, duties, operational process and financial sources appropriate for an independent body for protection of people facing damages in the three health insurance systems.

      (2) A study should be conducted on participation of government officials and state enterprise personnel in policy making and operation related to welfare system on medical treatment for government officials and state enterprise personnel.  
 
 

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