Payment Reforms for Prehospital Care Services in a Middle Income Country: Assessing Implementation and Patient Outcomes Using a Mixed-Methods Approach

Introduction. Financing health systems constitutes a key element of well-functioning healthcare system. Prior to 2015, two new fnancial arrangements (direct-pay and E-claim systems) were introduced on a voluntary basis which aimed to pool more fnancial resources and improve cash fow of prehospital care systems. Te aims of this study were to (1) assess the efects of direct-pay system in terms of (a) timeliness of reimbursement to EMS agencies, (b) changes in clinical care processes, and (c) the outcomes of patient care as compared to previous system; (2) identify the reasons for or against EMS agencies to participate in direct-pay system mechanisms; (3) identify the emerging issues with potential to signifcantly further the advancement of EMS systems. Using a mixed-methods approach, retrospective datasets of 3,769,399 individual records of call responses from 2015 to 2017 were analyzed which compared EMS units with the direct-pay system against those without in terms of time fow of claim data and patient outcomes. For qualitative data, in-depth interviews were conducted. Results. EMS units participating in both systems had the highest percentages of fnancial claim being made in time as compared to those not participating in any (p=0.012). However, there were not any practically meaningful diferences between EMS units participating and not participating in either of the payment systems in terms of patient care such as appropriateness of response time, airway management, and outcome of treatment. Analysis of data from focus-group and individual interviews ended up with a causal loop diagram demonstrating potential explanatory mechanisms for those fndings. Conclusion. It is evident that progress has been made in terms of mobilising more fnancial inputs and improving fnancial information fow. However, there is no evidence of any changes in patient outcomes and quality of care. Furthermore, whether the progress is meaningful in flling the gaps of fnancial demands of the prehospital care systems is still questionable. Room for future improvement of prehospital care systems was discussed with implications for other countries.