Legal Development of the Referral System for Medical Insured in the Social Security System

Abstract

This research aimed to investigate the background and significance of referral system problems for the medical insured in the social security system, through the examination of concepts, theories, and principles relating to social security, legal measures towards the referral system for the medical insured, and analysis of managerial administration of the referral system in order that citizens of any social status could equally access public medical services, leading to the effective legal development, model, and mechanics of the referral system according to Constitution of the Kingdom of Thailand B.E. 2560 and similar public international laws of 4 countries: Germany, Sweden, the Philippines, and Korea. This qualitative research consists of documentary and field research through in-depth interviews. The research findings revealed that 1) in general, when the insuring hospital has less medical potential, experts, and devices to give the medical services, it is necessary to refer the patients to a hospital with higher potential, even though the insured had an accident or were sick, and 2) in terms of medical cost management, it was found that the referring-out hospital was still liable for some medical costs, which significantly affects the hospital administrators and doctors’ decisions when referring outpatients. When comparing the referral system of social insurance, national health insurance, and government welfare, there are differences between all three concerning the social insurance system. It indicated that medical cost management of the social insurance system, is inconsistent with the 20-year National Strategic Plan, under the Constitution of the Kingdom of Thailand B.E. 2560, as well as principles of public and international law. It is recommended that the draft of the “Announcement of Medical Committee based on the Social Insurance Act entitled: Principles and Medical Service Rates in Referral Cases for Benefits due to Accident or Sickness” should be arranged.