The Role of Utilization Review Nurses to Support the Financial Stability of Public Hospitals: Case Study of Golden Jubilee Medical Center, Faculty of Medicine Siriraj Hospital, Mahidol University

Abstract

Thailand provides fundamental healthcare rights to citizens through three major healthcare schemes: the Civil Servant Medical Benefit Scheme (CSMBS), the Universal Coverage Scheme (UC Scheme), and the Social Security Scheme (SSS). Since public hospitals are the main contributors to healthcare service in Thailand, most of their income comes from these three healthcare schemes. However, existing studies indicate that public hospitals frequently face financial difficulties and budget deficits due to partial reimbursement by the government in practice. Additionally, patients generally do not contribute to covering the excess costs. These issues have become a financial stability problem for public hospitals.

This article shows a case study integrating two principles: Public Private Partnerships (PPPs) and Enterprise Risk Management (ERM), to enhance financial sustainability via the roles of utilization review nurses under four key terms: 1) medical care review for claiming healthcare rights; 2) pro-spective review and pre-authorization; 3) concurrent review; and 4) fax claim processing. By implementing this strategy, public hospitals can strengthen their financial stability and ensure long-term sustainability. The case study of the Golden Jubilee Medical Center is presented to demonstrate the practical implications of this approach and highlight the significant contributions of utilization review nurses in addressing financial challenges within public hospitals. The information is summarized in the form of a model (the P4T Model) illustrating the application of support for the financial stability of public hospitals through the role of utilization review nurses.