Feasibility and Acceptability of Health Maintenance Organizations for Medical Care Service under the Social Security System: Policy Research

Abstract

Health maintenance organization (HMO) is one of interesting models for responding to Social Security Office’s (SSO) medical service developments. Therefore, feasibility and acceptability of stakeholders were needed to be studied for further planning decisions. Methodology: This policy research study was to assess the feasibility and acceptability of three proposed HMO models with the SSO transforming into supervisory and monitoring roles. Model one was the HMO through a large private hospital network; model two, HMO through the public health insurance or regional health system; and model three; HMO through a private insurance company. Four key informants groups were selected by using purposive sampling including 1) policy executives serving as HMOs, 2) service providers, 3) service users, and 4) executives or experts with relevant roles. Qualitative data were collected, and content analysis was performed. Results: HMO model two was the most feasible model regarding service area coverage, economies of scale, experiences of management and credibility, etc. However, there were other challenges such as regional health system capacity. Stakeholders concerned that insurer’s overhead cost would take away the desirable benefits of service users, especially in private HMOs that might have a for-profit culture. Some opinions suggested on more precise improvements of the current system instead of establishing HMOs. In addition, they disagreed on the sub-district health promoting hospital acting as gatekeeper at primary care level, as this would deprive user’s rights and create barrier of access to health services. Conclusion and discussion: Although the proposed HMO model two was considered the most possible, skeptics were on limited competitions within the HMOs. HMOs might not reduce the health expenditures because of overhead cost and long-term investment in primary care system. Further study should consider possible competitive HMO models or other HMOs in Thailand such as medical schools network.