Questions/Answers

The Universal Coverage for Emergency Patients or UCEP is a compulsory Thai government policy that entitles the rights to all emergency patients in Thailand to access safe and high-quality life-saving emergency medical care for up to 72 hours at any hospitals, applicable both private and public, without having to pay service fee in advanced. Hospitals will apply a single medical criterion called Emergency Severity Index (ESI) through Pre-authorization (PA) program, and deliver appropriate emergency medical care without asking for the patients’ ability to pay from any healthcare schemes or insurances. After the patients are discharged or transferred to hospitals under each of their scheme, hospitals would reimburse the service fee from the three main public healthcare schemes of the country (Universal Healthcare Coverage scheme, Civil Servant Medical Benefit Scheme, Social Security Scheme) under the price of a regulated fee for service (fee schedule). Before UCEP was introduced in April 2017, equity gap persisted among the three public healthcare schemes. Apart from the fact that each of these schemes has coverage differences, the concept also couldn’t be applied to emergency patients whose conditions require urgent medical attention at the nearest hospitals which may or may not be registered with their respective healthcare schemes. As a consequence, service fee will be charged on the patients in which they may be or may not be affordable. UCEP was introduced to reduce and eradicate this equity gap in the healthcare coverage of Thailand. It was also designed to help increase the accessibility to compulsory life-saving emergency medical care as such service is essential and not excludable, while also raise the standard and quality of emergency medical care provided at hospitals. More importantly, UCEP marks a reformation of emergency medical service system, and is an innovation that has never been utilized anywhere before.

UCEP is linked with Category 1 “Delivering inclusive and equitable services for all” in the way that this initiative represents an innovation, a new method which entitles the rights to access safe, efficient and free-of-charge compulsory life-saving emergency medical care at any hospitals up to 72 hours of first admission, either public or private, to all emergency patients in Thailand regardless of their entitled healthcare schemes, age, gender, ethnicity, race, financial ability, occupation or other social or economic status that may discriminate them from receiving necessary emergency medical care.

UCEP policy supports two (2) Sustainable Development Goals; Firstly, UCEP supports SDG3 in ensuring healthy lives and promoting well-being for all, supporting the global action towards target 3.4 in reducing premature mortality from non-communicable diseases through prevention and treatment, and target 3.6 in halving the number of global deaths and injuries from road traffic accidents since UCEP attempts to ensure and increase the accessibility to necessary emergency medical care at any hospitals for every emergency patients in the country. With increased accessibility to emergency healthcare, the policy aims at reducing mortality and disability rates born from emergencies. Secondly, UCEP supports SDG10 in reducing inequality in healthcare within the country. It supports global action towards target 10.2 in empowering and promoting the social, economic and political inclusion of all, irrespective of age, sex, disability, race, ethnicity, race, ethnicity, origin, religion or economic or other status, since UCEP is a social protection that is being approved by Thai government to ensure greater equity to receive emergency medical care of the population regardless of any social or economic status and irrespective to age, gender, race or other discriminatory factors.

UCEP is working based on a strategy that balances its social, economic and environmental sustainability. Socially, the concept of UCEP itself keeps the policy sustainable as it is a social protection policy that responds to actual need/explicit demands of the population in accessing safe and necessary emergency medical care that has an impact on their survival. Economically and environmentally, UCEP reduces a burden of the population towards paying for emergency medical care that cause significant expenses, protects their personal savings and reduces social insecurity and risk of population of being bankrupt from the high cost of medical care.

UCEP policy has addressed a shortfall of Thailand’s unequal healthcare schemes that initial pilot program called EMCO (Emergency Claim Online) tried to solve. UCEP has been improving EMCO which was trailed with voluntary will of private hospitals since 2012. From initial phase of EMCO, citizens and hospitals didn’t have mutual understanding on medical emergencies and the policy. Private hospitals didn’t comply with EMCO due to the lack of legal enforcement so the hospitals requested services fee from patients. The policy had not been well-organized in various aspects such as legal enforcement, financial stability and referral system. UCEP responds to this shortfall by revising the Health Facility Act and issued subordinate laws to increase enforcement involving all private hospitals into the process and utilized fee schedule price for reimbursement. The Cabinet assigned the three healthcare schemes to reimburse service fee back to hospitals with agreed fee schedule. Payment will be reimbursed under conditions the National Institute for Emergency Medicine (NIEM) decided through Pre-authorization (PA) program. Public hospitals joined UCEP to refer patients back to their registered hospitals when life-saving conditions have been solved. NIEM promotes public literacy about UCEP and guarantees the rights of the patients.

UCEP is an inclusive initiative whose principles cover all Thai population who are emergency patients regardless of their sex, gender or sexual preferences.

The target group of UCEP initiative was all Thai population (66 millions) who are emergency patient whose conditions meet the criterion including trauma and non-trauma i.e. unconscious/not breathing; gasping/ difficulties of breathing; drowsy/sweating/seizure; acute/critical chest pain; hemiparesis; continuous seizure and other additional symptoms that could lead to deaths or failure of important organs. In 2018, 1.7 million emergency patients in Thailand access to free conventional public emergency medical services from scene to public hospitals. A statistical data shows that UCEP has granted these patients a greater access to emergency medical care at private hospitals. By October 2019, 446,702 emergency patients had accessed to private emergency medical care and within this number, 58,484 critical patients from the three healthcare schemes have met the criterion. 84 percent of the critical patients survived from their acute illnesses. All of them don’t need to pay for the services, and the private hospitals can reimburse from the healthcare schemes. The average number of the critical patients that met the criterion increases 115 percent within two years. Less than one percent (0.11%) of all patients filed complaints which is a small number compared with the total number of patients who joined UCEP.

Since 2012 that EMCO had been established, several policy dialogues had been conducted and evaluating, founding legal enforcement, financial stability, referral system and other aspects of EMCO had not been well-organized. Resulting from the dialogues, the Health Facility Act B.E.2541 (A.D.1998) was revised and announced on December 2016. Subordinated laws were issued on March 28, 2017 by the Cabinet. And finally resulted in the execution of UCEP on April 1, 2017. The Cabinet assigned National Health Security Office, Social Security Office (Ministry of Labour), Comptroller General’s Department (Ministry of Finance) and other healthcare schemes to support UCEP. The Cabinet also assigned Department of Health Service Support (Ministry of Public Health) and NIEM to supervise and facilitate UCEP policy. By this assignment, NIEM developed an emergency medical criterion through pre-authorization (PA) program and drew up regulated fee for service (fee schedule) upon the agreement from stakeholders. During the operation, NIEM as a facilitator of the policy not only makes publications about UCEP to raise public awareness, but it organizes several meetings with multi government and private agencies to encourage close collaboration to strengthen efficiency of the policy; including monitoring and keeping up with the feedback. NIEM also plays a dedicated role as UCEP Coordination Center and customer service to provide technical and medical consultation and receive complaints. National Health Security Office (NHSO) becomes a clearing house for reimbursement between private hospitals and the three healthcare schemes. Monitoring and evaluation on UCEP performances have been conducted regularly. The policy has been monitored and reported monthly to the Emergency Medical Service Board of NIEM, and evaluated by external parties. UCEP performances has also been reported to the Minister of Public Health, National Reformation Committee and the Cabinet. The public has also been informed of the performances of UCEP.

There are three main obstacles that pushed UCEP to be improved. First, the public knowledge towards definitions of medical emergency are not compatible with healthcare personnel, leading to conflicts between patients and hospitals. Second, reimbursement fee from healthcare schemes is lower than hospital service prices causing them a lower reimbursement fee. Responding to these obstacles, NIEM and all stakeholders try to promote public education to increase mutual understanding about UCEP by many methods such as written and online publications. NIEM and all stakeholders try to revise and improve fee schedule.

Since Thailand decides to establish the three main healthcare schemes for Thai citizens, the action led to successful results for all. However, equity gap between the three healthcare schemes persisted. To minimize the gap, UCEP initiative is an innovative for Thailand healthcare system in the way that has never happened before. It utilizes the integration between the powerful network of healthcare system in Thailand, working together for emergency patients, through mechanisms of coalition, collaboration, legal enforcement, finances, information technology and medical consultancy system.

UCEP is inspired from the Universal Declaration on Human rights. UCEP is a new initiative in Thailand that is being developed from EMCO that was initiated from article 28 of the Emergency Medical Act B.E.2551 (A.D.2008) stating that emergency patients have rights to get the priority of care in any hospitals and the hospitals could not bring their inability to pay for services to prevent the patients from receiving essential emergency medical care.

To the organization’s knowledge, UCEP initiative has never been adopted or transferred to other countries or other regions. Within Thailand, UCEP has been applied to whole country and not specific to any cities or provinces. By this concept, Thailand would like to introduce UCEP to any country or region in the world through the United Nations (UN).

UCEP underpins a fundamental concept of human rights that any country or any region should take interests. UCEP initiative has been executed for two years in Thailand and still opens for continuous monitoring and evaluation for further improvement. UCEP will become a model of equity for anyone who needs life-saving interventions in healthcare system of the world regardless of the financial ability to pay for saving one’s life. NIEM and its alliances can become a learning center for other countries that are interested to use UCEP to initiate their country’s people-centered policy by transferring knowledge, best practices, obstacles and case studies.

The Cabinet allocates all resources for UCEP with their policies through legal enforcement mechanism. The management function has been assigned to NIEM, the Ministry of Public Health (MOPH) and other government agencies. The budget for reimbursing service fee comes from healthcare schemes (Universal Healthcare Coverage scheme, Civil Servant Medical Benefit Scheme, Social Security Scheme and other schemes) through pre-authorization program that is supervised by NIEM. For the operational level, services and manpower come from private and public hospitals. Emergency patients can utilize this service from anywhere in Thailand.

Institutionally and financially, UCEP works based on universal human rights concept and policy that promotes integration of legal mechanisms, technical protocols, information sharing and national budget. UCEP is not only a populism policy but it is a national enforcement with legal binding. Technically, UCEP enhances usual medical care to become more accessible, reliable and accountable to the equality of the public.

Yes

Internally, UCEP was formally and regularly evaluated by using statistical data to analyze and evaluate the progress of the policy annually, while also receive opinions of emergency patients to evaluate the outcomes of the policy, then reports to the Emergency Medical Service Board of NIEM. Externally, UCEP policy was evaluated by Faculty of Medicine, Mahidol University with the general objective to study the extent in which UCEP has resulted in the desirable outcomes and study the potential of development. The evaluation was conducted with mixed methodology following “Policy Process” which includes analysis and evaluation over agenda-setting, formulation, implementation and evaluation.

Internally, NIEM uses the number of complaints and the actions taken to complaints as indicators. The external evaluation from Mahidol University rests on four indicators including; 1) accessibility to emergency medical services of private hospitals; 2) transparency and compliance to fee schedule and the ability to prevent abusive behavior; 3) quality of care and 4) capacity of reimbursement. The study utilizes both qualitative and quantitative tools to collect and analyze the data using content analysis and individual informal interviews, while adopts a statistical analysis to find a quantitative conclusion.

External and internal evaluation lead to main findings as follows; There was a gradual increase in the access to emergency medical care during the ten-month period since execution of the policy (April 2017 - January 2018) especially with less urgent patients. This finding suggests that citizens are aware of the policy and were trying to use their rights. Still, some patients do not have a clear understanding how the policy works and have conflict with hospitals. When compared to EMCO, emergency patients had more access to free emergency medical care in hospitals and suggests that UCEP helps minimize equity gap among healthcare schemes. There are several more high-risk medical emergencies that are unclear whether to be included in Pre-authorization (PA). There are some healthcare schemes whose regulations are incompatible to UCEP, resulting in hospitals not being able to do reimbursement. 0.11 percent of all patients filed complaints. All of them had gone through process of customer protection. All above mentioned were reported to the Cabinet to be informed of the progress and obstacles of the policy. At the present, UCEP is on-going process of development.

The government UCEP policy has been implemented with collaboration from several relevant agencies, both public and private sectors. The Cabinet pushed and issued a policy; the Ministry of Public Health enforced regulations on private hospitals and manages hospital referral system to their registered hospitals of their schemes after 72 hours of first admission. NIEM and MOPH supervise, regulate, monitor and evaluate the policy and NIEM also functions as a customer protection entity. The policy was delivered to all private hospitals to perform emergency patient care, and funded by the healthcare schemes including Civil Service Healthcare Benefits controlled by the Comptrollers’ General Department, Universal Healthcare Coverage fund controlled by National Health Security Office who also acts as the Clearing House, Social Security Fund controlled by the Social Security Office and others. The emergency patients that need life-saving intervention could access to any nearest hospitals for utilizing the services free-of-charge.

Stakeholders of this initiative engage in several levels; including policy and decision-making level, operational level and community level going through every steps of the policy process with several of meetings, seminars, workshop, conferences, etc. To construct and execute this policy, there are many stakeholders involved. In the policy and decision-making process, the Cabinet pushed and issued a policy. Ministry of Public Health (MOPH) enforced regulations on private hospitals. NIEM and MOPH supervise, regulate, monitor and evaluate the policy and NIEM also functions as a customer protection entity. In the operational level, MOPH manages hospital referral system to their registered hospitals of their schemes after 72 hours of first admission. All private hospitals perform emergency patient care. Healthcare schemes including Civil Service Healthcare Benefits controlled by the Comptrollers’ General Department, Universal Healthcare Coverage fund controlled by National Health Security Office who also acts as the Clearing House, Social Security Fund controlled by the Social Security Office and others reimburse to the hospitals. In the community level, the emergency patients that need life-saving intervention could access to any nearest hospitals for utilizing the services free-of-charge. All levels need to work well together to execute an efficient policy.

The key lessons learned from UCEP are firstly, equity in healthcare system can be possible with the collaboration among policy-makers, healthcare providers and the community; secondly, emergency medical care is the essential public service that should be put in the first priority of public welfare. Thirdly, UCEP is the first policy that could integrate all healthcare schemes together. From this integration, the concept of equity can be extended to other areas of health issue i.e. chronic diseases treatment. Fourthly, well collaboration among policy-makers and healthcare providers is the key success for the ultimate goal to serve the community. Currently, the UCEP alliances plan to improve the policy by encouraging the revision of some incompatible regulations and the fee schedule (price and list of medical interventions and drugs). The alliances also plan to increase more public awareness campaign to promote greater understanding of medical emergencies in the community.