Healthcare utilization (outpatient services).

Objectives Universal population coverage for healthcare was achieved in several countries, including Thailand, while retaining fragmented health insurance schemes. Fragmentation in health financing has been debated since it can exacerbate inequalities, especially when health systems are under stress due to a public health emergency. This study examines whether the type of public health insurance affects outpatient healthcare utilization and out-of-pocket expenditure in Thailand before and during the coronavirus pandemic. Methods Using the 2019 and 2021 waves of the nationally representative Health and Welfare Survey and a repeated cross-sectional design, logit and multinomial logit models are estimated to investigate the effect of health insurance type on outpatient healthcare utilization (n=10,220), while two-part and Tobit models are employed as alternative models for the analysis of out-of-pocket expenditure (n=12,014). For both healthcare utilization and out-of-pocket expenditure, the study also explores models with and without interactive terms between insurance coverage type and a dummy variable capturing the COVID-19 period. Results Type of health insurance is found to impact provider choice (i.e., designated versus non-designated providers) rather than outpatient care utilization per se. Insignificant interaction effects indicate further that the relationship between health insurance type and outpatient care utilization is not affected by the pandemic. The regression results also show that health insurance type is associated with out-of-pocket expenditure (separated into medical and transportation spending) but the magnitude of the effect is relatively small, pre- and peri-pandemic. High-need persons with, for example, chronic conditions, however, face a higher out-of-pocket burden in terms of medical and transportation spending. Conclusion Overall, the results suggest that Thailand’s universal health coverage system has continued to live up to its promise of access and financial protection in the face of COVID-19, despite existing fragmentation. Notwithstanding, this study highlights that universal health coverage is an ongoing effort that requires careful monitoring, inter alia to mitigate undesirable consequences of fragmentation and to ensure that high-need and other vulnerable persons are not left behind.研究目标：包括泰国在内的多个国家已实现全民医保（universal health coverage），但同时保留了碎片化的医疗保险制度。医保筹资的碎片化问题长期以来备受争议，因其可能加剧医疗不公平，尤其是在公共卫生紧急事件导致医疗系统承压的情况下。本研究旨在检验新型冠状病毒肺炎（COVID-19）大流行前后，泰国的公共医疗保险类型是否会影响门诊医疗服务利用与自付支出（out-of-pocket expenditure）。 研究方法：本研究采用具有全国代表性的2019年与2021年健康与福利调查（Health and Welfare Survey）数据，结合重复横截面研究设计。针对门诊医疗服务利用情况（样本量n=10220），本研究使用Logit模型与多项Logit模型评估医疗保险类型对其的影响；针对自付支出（样本量n=12014），则采用两部分模型与Tobit模型作为备选分析方法。此外，针对医疗服务利用与自付支出两类指标，本研究还分别构建了包含与不包含“保险覆盖类型”与“新冠疫情时期”虚拟变量（dummy variable）交互项的模型进行对比分析。 研究结果：结果显示，医疗保险类型主要影响就诊机构选择（即定点与非定点医疗机构），而非门诊医疗服务利用本身。交互项效应不显著进一步表明，医疗保险类型与门诊医疗服务利用之间的关联并未受到新冠疫情大流行的影响。回归结果还显示，无论在疫情前还是疫情期间，医疗保险类型均与自付支出（分为医疗费用与交通费用两类）存在关联，但效应幅度相对较小。然而，存在慢性疾病等医疗需求较高的人群，其医疗与交通相关的自付负担更高。 研究结论：总体而言，尽管泰国的医疗保险体系仍存在碎片化问题，但其全民医保制度在新冠疫情大流行期间仍切实履行了保障就医可及性与财务安全的承诺。尽管如此，本研究强调，全民医保是一项持续推进的工作，需要开展细致的监测工作，尤其要缓解碎片化带来的不良后果，并确保高医疗需求人群与其他弱势群体不会被排除在保障体系之外。