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SHORT COMMUNICATION  
Year : 2021  |  Volume : 46  |  Issue : 2  |  Page : 295-299
 

Self-referral to the university hospital resulting in unnecessary patient expenses: A prospective descriptive study in a super-tertiary hospital


Department of Community Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand

Date of Submission31-May-2020
Date of Acceptance29-Jan-2021
Date of Web Publication29-May-2021

Correspondence Address:
Dr. Varisara Luvira
Department of Community Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen
Thailand
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijcm.IJCM_422_20

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   Abstract 


Context: Thailand subsidizes health-care costs, allowing citizens access to health care without out-of-pocket expenses. However, some citizens still spend large amounts of money on treatment provided at tertiary care hospitals. Aim: To identify the proportion of patients whose visits are not covered by national health insurance at the tertiary hospital and their reasons for visiting. Settings and Design: Prospective, descriptive study in patients visiting Srinagarind hospital outpatient department from July to September 2019. Subjects and Methods: We gathered and analyzed the data regarding demographics, hospital visits, and illness severity using a questionnaire. Statistical Analysis Used: Descriptive analyses and logistic regression were performed as appropriate. Results: Of the 700 participants, 40% (95% confidence interval 36.3–43.7) was not covered for their visits. The three common reasons visiting this hospital were desire of treatment from a specialist (42.9%), the reputation of the hospital (31.4%), and service satisfaction (26.6%). Conclusions: Although the national health-care system provides a gratis service pathway, some people still pay out-of-pocket unnecessarily. Officials should work to better raise the level of public confidence in the primary and secondary care units.


Keywords: Community medicine, general practice, health insurance, self-referral, tertiary care


How to cite this article:
Phankitiya S, Luvira V. Self-referral to the university hospital resulting in unnecessary patient expenses: A prospective descriptive study in a super-tertiary hospital. Indian J Community Med 2021;46:295-9

How to cite this URL:
Phankitiya S, Luvira V. Self-referral to the university hospital resulting in unnecessary patient expenses: A prospective descriptive study in a super-tertiary hospital. Indian J Community Med [serial online] 2021 [cited 2021 Jun 20];46:295-9. Available from: https://www.ijcm.org.in/text.asp?2021/46/2/295/317064





   Introduction Top


Unnecessary expenses for medical issues, is the one of problem in the developing country, which indicates social disparity. The people living in remote area, who usually have lower income, need to pay more expense for their illness. Decentralization in the health-care system is the one of the strategy to decrease these disparities and increase the quality of life of the people who live in the remote area.

Thailand had been listed as one of the most wealth inequality countries. There are many strategies to reduce this gap, including government-provided health insurances. Although Thailand is one of many countries that subsidizes health care for its citizens, many Thai citizens pay for health-care services out-of-pocket unnecessarily. Currently, most of the Thai population has health insurance provided by the government under the Universal Health Coverage Scheme (UCS), Social Health Insurance Scheme (SHI), and Civil Servant Medical Benefit Scheme (CSMBS).[1] In order to be covered under the UCS and SHI, patients are obliged to visit the primary or secondary care unit of an affiliated hospital before referral to a tertiary care unit if the disease progresses beyond center capability.[2] The CSMBS covers the full cost of any public hospital visit, excluding those of any unnecessary investigations or drugs not included in the National List of Essential Medicines (NLEM). The Thai public health system encourages patients to visit a primary care unit first. Then, if the patient's condition does not improve, to be transferred to a secondary and tertiary care unit, as appropriate. No payment is required for patients who seek treatment through this referral system (besides the drug and unnecessary treatment exceptions mentioned above).

Northeast Thailand is the region with the country's largest population, which has the lowest average income. The largest health-care provider in this region is Srinagarind Hospital in Khon Kaen Province. Srinagarind Hospital is a tertiary care unit, where expected to take care only the patients who require the specialists, still has walk-in patients who do not require a specialist. However, patients there not covered under the CSMBS must pay out of pocket.

Since this hospital is a tertiary care medical school with many specialists and access to a large amount of medical equipment, it attracts patients from provinces throughout the Northeast, many of whom could have been treated at their local affiliated health-care unit. This results in hospital overcrowding, which increases the risks of infection and mortality, dissatisfaction with the service provided, medical error, health-care provider burnout, and most importantly, unnecessary expenses of the poor patients.[3] The factors found to be associated with patient self-referral in other countries are desire of treatment by a specialist, treatment quality (including drugs and laboratory investigation),[4],[5],[6] and the perception of severe illness progression.[7] This study was thus conducted to identify the reasons patients present at the Srinagarind hospital outpatient department and visit the hospital from out of province to establish the development process of primary and secondary care providers and to reduce the disparities in our region as a final goal.


   Subjects and Methods Top


This was a prospective, descriptive study in patients who visited the Srinagarind hospital outpatient department from July to September 2019. We gathered data regarding demographics, hospital visits, and illness severity using a self-administered questionnaire. Patients over 18 years of age who willing to participate in the study and could read and write in Thai. Emergency patients and those unable to answer the questionnaire were excluded. Patients were enrolled in the study after providing written consent. This study was approved as exemption review by the Khon Kaen University Center for Ethics in Human Research (HE 621100).

In this study, the definition of “payment requires” was the expense in patients without CSMBS health insurance, Srinagarind Hospital UCS and SHI.

Statistical analysis

The power calculation was based on the primary outcome, the proportion of the patients whose visits are not covered by national health insurance at the tertiary hospital. Assuming the proportion of 42.4%, a total of 653 participants were required to detect a relevant difference of 10% with a significance α = 5% and a power of (1−β) = 80%.

Descriptive analyses were performed as appropriate. All analysis was conducted using IBM SPSS 19 (IBM Corp. Released 2010. IBM SPSS Statistics for Windows, Version 19.0. Armonk, NY: IBM Corp). Data were summarized as the nominal variables by expressing their frequency and percentage and numerical variables as mean and standard deviation or median and range. Logistic regression was used to computed the odd ratio and 95% confidence interval (CI).


   Results Top


Demographic data

Of the 700 participants enrolled in this study, 69.3% were female, 44.7% were from Khon Kaen province, and 52.9% had no underlying disease. The mean age was 45.36 ± 17.7 years.

Hospital visit data

Most patients had visited Srinagarind hospital in the past (76.5%), and 32.3% were covered by the CSMBS. Of the 280 patients (40%: 95% CI 36.3–43.7) whose visits were not covered. Of these, 163 (58.2%) indicated that they misunderstood that they visit affiliated hospital according to their health insurance.

The reasons for visiting the Srinagarind hospital outpatient department were desire of treatment from a specialist (42.9%), the reputation of the hospital (31.4%), and satisfaction with the service provided (26.6%). These factors did not differ by province of residence or health-care coverage status. Anyway, patients living in the province gave nearby hospital as the second reason [Table 1].
Table 1: Reasons visiting the Srinagarind hospital outpatient department

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In terms of perceived illness severity, patients mostly thought that their symptoms indicated a nonemergency (50.9%) and were moderate in severity (49.6%). Four hundred and forty-two patients (63.1%) thought that their local health-care provider would not be able to treat their symptoms. These factors did not differ by province of residence or health-care coverage status [Table 2].
Table 2: Perception of illness severity in patients visiting the Srinagarind hospital outpatient department

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Factors related to interprovincial visits to the Srinagarind hospital outpatient department

The reasons for patients from other provinces visiting the Srinagarind hospital outpatient department differed from those of patients residing in Khon Kaen. These included desire of treatment by a specialist, (odds ratio [OR] 2.11; 1.55–2.88), having received ineffective treatment from another health-care provider (OR 2.23; 1.2–4.12), having been recommended by a friend or family member (OR 2.75; 1.54–4.94), and the perception that their local health-care provider would not be able to treat their illness (OR 1.85; 1.35–2.54) [Table 3]
Table 3: Factors related to interprovincial visits to the Srinagarind hospital outpatient department

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   Discussion Top


We found that 40% of patients visiting the Srinagarind hospital outpatient department were paying out of pocket. The most common reasons were desire of treatment from a specialist, the reputation of the hospital, service satisfaction, having received ineffective treatment from another health-care provider, having been recommended by a friend or relative, and the perception that their local healthcare provider would not be able to treat their illness. However, more than half of these patients believed that their visit would be covered by the national health-care services.

Surprisingly, more than half of the patients visiting the Srinagarind hospital outpatient department did not know about their government-provided health insurance. This may have resulted from misunderstanding in the term of health insurance between the patients and medical personnel. In medical personnel, health insurance according to the Thai public health system means that there is no payment need in patients visiting health-care provider. However, in some patients, hospital cost to pay also means that they have the hospital's health insurance. This kind of misunderstanding can lead to hospital visits that are not covered by the patient's insurance. This issue is simply solved by extensively provide the corrected information regarding health care insurance.

Most patients, regardless of coverage status or place of residence, visited Srinagarind hospital because they desire of treatment by a specialist. This finding is consistent with those of a previous descriptive study, which found that self-referral patients bypassed primary care facilities due to distrust in the medical personnel/equipment at the primary facilities, high illness expectation more than the primary care can handle,[6] and their perceptions of their diseases/symptoms. However, patient perception of illness often does not correspond with reality. A previous study suggested that patients tend to evaluate their necessity to undergo examination higher than physicians do.[8] Patients visiting the outpatient department are generally patients without emergency conditions and who are not in need of a specialist. Despite this, many of these patients seek out treatment facilities in which specialists are available, possibly as a result of anxiety[9] or wrongly estimating the emergency level of their disease.[10]

Patients who resided outside of Khon Kaen had different reasons for visiting Srinagarind Hospital than those living within the province. The reasons for interprovincial visits were requiring treatment by a specialist, having received ineffective treatment from another health-care provider, having been recommended by a friend or relative, and the perception that their local health-care provider would not be able to treat their illness. These reasons demonstrated an attitude to the health-care provider and confidence in the treatment of tertiary care from patients and people around. Although the illnesses of many patients in this study could have been treated by a local health-care provider, the patients spent the additional time and money required to receive treatment at the tertiary hospital. This finding was consistent with those in previous reports, which have suggested that patients have a low level of confidence to primary care units.[11],[12],[13] These support the decentralization of health-care system, which is in the part of reduction of the social disparity, to distribute more specialist to the primary and secondary care.

A strength of this study was that it was prospectively conducted in the largest medical school hospital in the region with the largest and poorest population, so the results will likely apply to any country with a similar health-care system and demography. However, this study has some limitations, (i) it relied on a self-assessment questionnaire with no tracking of patients after visiting the outpatient department, so there was no information about subsequent treatment or specialist referral and (ii) this study did not explore about the expenses of the participants. Although average income in the region is low, residents spend a large amount of money on unnecessary health-care costs due to their attitudes regarding tertiary care hospitals, their overestimating the severity of their illness, and misunderstandings with regard to the national health-care schemes. These problems can be solved through proper education with regard to health-care provider services and health insurance and by working to raise peoples' level of confidence in primary and secondary care units.


   Conclusions Top


The hospital visits of 40% of patients in the outpatient department were not covered by national health insurance. More than half of these patients understood that they visit affiliated hospital according to their health insurance. The most common reasons were desire of treatment from a specialist, the reputation of the hospital, and service satisfaction. The factors associated with interprovincial visits were requiring treatment by a specialist, having received ineffective treatment from another health-care provider, having been recommended by a friend or relative, and the perception that their local health-care provider would not be able to treat their illness.

Acknowledgments

The authors thanks (a) the staff at the Srinagarind Hospital outpatient department for assistance with data collection; (b) all of the participants for their willingness to attend this project; and (c) Mr. Dylan Southard for assistance with the English-language presentation under the aegis of the English consultant KKU, Thailand.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Tangcharoensathien V, Patcharanarumol W, Kulthanmanusorn A, Saengruang N, Kosiyaporn H. The political economy of UHC reform in Thailand: Lessons for low- and middle-income countries. Health Syst Reform 2019;5:195-208.  Back to cited text no. 1
    
2.
Tangcharoensathien V, Witthayapipopsakul W, Panichkriangkrai W, Patcharanarumol W, Mills A. Health systems development in Thailand: A solid platform for successful implementation of universal health coverage. Lancet 2018;391:1205-23.  Back to cited text no. 2
    
3.
Virtanen M, Pentti J, Vahtera J, Ferrie JE, Stansfeld SA, Helenius H, et al. Overcrowding in hospital wards as a predictor of antidepressant treatment among hospital staff. Am J Psychiatry 2008;165:1482-6.  Back to cited text no. 3
    
4.
Okoli H, Obembe T, Osungbade K, Adeniji F, Adewole D. Self-referral patterns among federal civil servants in Oyo state, South-Western Nigeria. Pan Afr Med J 2017;26:105.  Back to cited text no. 4
    
5.
Abdi WO, Salgedo WB, Nebeb GT. Magnitude and determinants of self-referral of patients at a general hospital Western Ethiopia. Sci J Clin Med 2015;4:86-92.  Back to cited text no. 5
    
6.
Koce F, Randhawa G, Ochieng. Understanding healthcare self-referral in Nigeria from the service users' perspective: A qualitative study of Niger state. BMC Health Serv Res 2019;19:209.  Back to cited text no. 6
    
7.
Siddiqi S, Kielmann A, Khan M, Ali N, Ghaffar A, Sheikh U, et al. The effectiveness of patient referral in Pakistan. Health Policy Plan 2001;16:193-8.  Back to cited text no. 7
    
8.
Barry DW, Melhado TV, Chacko KM, Lee RS, Steiner JF, Kutner JS. Patient and physician perceptions of timely access to care. J Gen Intern Med 2006;21:130-3.  Back to cited text no. 8
    
9.
Kraaijvanger N, Rijpsma D, Willink L, Lucassen P, van Leeuwen H, Edwards M. Why patients self-refer to the emergency department: A qualitative interview study. J Eval Clin Pract 2017;23:593-8.  Back to cited text no. 9
    
10.
Bianco A, Pileggi C, Angelillo IF. Non-urgent visits to a hospital emergency department in Italy. Public Health 2003;117:250-5.  Back to cited text no. 10
    
11.
Becker J, Dell A, Jenkins L, Sayed R. Reasons why patients with primary health care problems access a secondary hospital emergency centre. S Afr Med J 2012;102:800-1.  Back to cited text no. 11
    
12.
Pillay I, Mahomed OH. Prevalence and determinants of self referrals to a district-regional hospital in KwaZulu Natal, South Africa: A cross sectional study. Pan Afr Med J 2019;33:4.  Back to cited text no. 12
    
13.
Visser CA, Marincowitz GJ, Govender I, Ogunbanjo GA. Reasons for and perceptions of patients with minor ailments bypassing local primary health care facilities. S Afr Fam Pract 2015;57:333-6.  Back to cited text no. 13
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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