Can a disease management approach facilitate the inclusion of high-cost conditions in a benefit package? The case of renal therapy in Thailand.

People access health services to preserve or improve their health status. In some situations, accessing health services can lead individuals to pay relatively high proportions of their available income, which can push many households into poverty. Universal health coverage is a means to provide health coverage to everyone in terms of effective access to required health services with financial protection against catastrophic spending. In Thailand, the Universal Coverage Scheme (UCS) is the largest public insurance scheme. Launched in 2001, it covers 76% (48 million) of Thais. Its members are households mainly in the informal sector, lower socioeconomic groups, the elderly, the disabled, and all children under 12. In 2008, 7 years after its launch, the UCS introduced the renal replacement therapy (RRT) benefit intended to increase access to health services and reduce bottlenecks of treatment for end‐stage renal disease (ESRD). Although the UCS exists, there is inadequate health care infrastructure resulting in accumulated patients waiting for many kinds of treatments including RRT. To manage this problem, the UCS has introduced various socalled disease management programmes intended to increase access to highcost health services. The purpose of this study is to explore the introduction and functioning of a high‐cost health benefit programme of the UCS using the RRT programme as a tracer and assess how a disease management approach facilitated the inclusion of RRT in the benefit package. Its methods involve both qualitative and quantitative techniques to explore different aspects of high‐cost conditions and a disease management approach. They are 1) qualitative approaches of document review, semi‐structured interview, focus group discussion, and structured observation to explore the rationale of the RRT programme, also how the disease management approach works in administering and arranging the RRT programme; 2) age‐period‐cohort analysis based on administrative patient data of the National Health Security Office (NHSO) to assess the changing patterns of access to RRT and all‐cause mortality of ESED patients; and 3) cost modelling and time‐series projection of RRT patient numbers to estimate the long term financial consequences of the RRT programme. 4 This study found that the RRT programme was the outcome of lobbying by various stakeholders responding to concerns of the burden of ESRD on households and inequitable access to high‐cost treatment. Components of disease management, such as evidence‐based guidelines and collaborative practice, were crucial to organise the RRT programme and rapidly scale up access to care. The family played an important role in patients’ decision making to enroll in the RRT programme. Without family support, patients were likely to not take up the RRT benefit. Introduction of the RRT programme has resulted in a significant increase in access to care and decrease in the rising all‐cause mortality rate of ESRD patients. The RRT programme’s long term implications involve an increasing number of ESRD patients and growing budget needs for providing care. This study suggests strengthening involvement of various stakeholders, particularly community participation in health care in order to create efficient services that are responsive to the local needs. Locally made medications and budget optimisation and allocation should be put in place to manage the programme’s costs.