Health Insurance Fund Deficit: 'Broken' then 'Firefighting'

(Baonghean) - The phenomenon of profiteering from the health insurance fund has appeared for a long time, but it was only when the Vietnam Social Security released information that Nghe An ranked second in the country in health insurance fund deficit that the relevant parties 'frantically' searched for the cause and clarified responsibilities.

Lesson 1:» Going to the hospital with a health insurance card is as easy as... going to the market

Lesson 2:» Health Insurance Deficit: Hospitals with huge investments, request to be 'demoted'

No surprise when funds are exceeded

In 2016, two new circulars related to health insurance examination and treatment services came into effect, namely Circular 40/2015/TT-BYT regulating initial health insurance examination and treatment registration and referral for health insurance examination and treatment and Circular 37 (joint) unifying prices for health insurance examination and treatment services among hospitals of the same rank nationwide.

In the first 6 months of 2016, Nghe An Health Insurance Fund spent 1,200 billion VND, an increase of 60% compared to the same period in 2015. Illustrative photo.

While Circular 40 is also known as the “open-line” Circular (effective from January 1, 2016), Circular 37 sets new prices for medical services, including costs such as salaries and special allowances (implementation roadmap from March 1, 2016). With these changes, Vietnam Social Security forecasts the increase in medical examination and treatment costs (not including the impact of new prices) at about 15% compared to 2015. However, by the end of the first 6 months of 2016, the average cost increase nationwide has reached 25% if calculated according to the old price, 40% if calculated according to the new price, far exceeding the forecast. It is estimated that the whole country has 37 provinces that have spent more than the allocated fund with a total amount exceeding about 3,400 billion VND. Nghe An ranks second in the country in terms of fund surplus (351 billion VND), only after Thanh Hoa (the 2 most populous provinces in the country).

According to the report of Nghe An Social Insurance, in the first 6 months of 2016, the expenditure from the province's Health Insurance Fund reached nearly 1,200 billion VND, an increase of nearly 60% compared to the same period last year. Regarding the fund overspending, Nghe An Social Insurance said that there were 3 objective reasons:Increase medical service prices according to Circular 37,Open medical examination and treatment lines according to Circular 40 and increase the number of health insurance cards.

In addition to the two reasons predicted by Vietnam Social Security, the increase in the number of health insurance cards causing increased expenditures was explained by Mr. Pham Gia Van - Deputy Director of the Provincial Social Security: In Nghe An, there are currently about 2.4 million people participating in health insurance, but only 300,000 people pay at the highest level (4.5% of monthly salary), the rest are subjects with low premiums, policy subjects (poor people, meritorious people, children). However, this group has a large demand for medical examination and treatment, enjoys high benefits, so participating in health insurance will contribute to increasing the fund's expenditures.

However, can the above objective reasons explain the "huge" overfund figure, bringing Nghe An to second place in a worrying ranking? Nghe An Social Insurance said that the 351 billion VND overfund figure is only the total number of payment requests from medical facilities, and the agency is still evaluating how much will be paid and disbursed, and has not yet reached a specific conclusion.

Not ready to implement the new Circular

With Circular 40, patients with health insurance cards have the right to receive initial medical examination and treatment at district-level hospitals in the same province. Due to the wide choice, patients tend to go to district-level hospitals instead of going through health stations as before. According to statistics, the number of patients visiting health stations in Nghe An province in the first 6 months of the year decreased by 195,403 visits (30.34%). The result is an estimated increase in health insurance fund expenditure of over 27 billion VND, because the average cost of medical examination and treatment at the district level is about 215,550 VND/visit higher than at the commune level.

Patients wait for their turn for examination and treatment at Vinh City General Hospital - one of the medical facilities with reported figures for the first 6 months of the year exceeding the fund by over 36 billion VND.

The interconnected system also makes the management problem more complicated when patients can choose any medical facility in the same line instead of being tied to the facility where they initially registered for medical examination and treatment. In fact, the phenomenon of patients holding health insurance cards going to see a doctor and get medicine at many facilities in a short period of time, even returning to the same medical facility, has been recorded.

To monitor and limit this situation, in June 2016, Vietnam Social Security launched the Health Insurance Assessment Information System. The system is connected to medical facilities nationwide and is continuously updated. When patients complete procedures and enter their Health Insurance card number, the system will provide information on their medical examination and treatment history, thereby detecting any abnormalities.

However, through the fact that patients holding health insurance cards "successfully" passed through a series of medical facilities in a short time as reflected in previous articles, Nghe An Social Insurance explained that the provided system is only a data storage system, while the software for managing and entering data depends on each medical facility. Up to now (nearly 1 year after Circular 40 took effect), the installation and use of the software for managing and entering data has not been completed, even the list of services and techniques is not yet synchronized, causing difficulties in monitoring medical examination and treatment work.

According to the Nghe An Newspaper reporter at a medical facility in the province, the display screen of this software, which is said to be incomplete, still provides the patient's medical history after entering the card number. So is it really due to objective reasons that patients "slip through" the doors of medical facilities with the same symptoms in a short time?

Screenshot of software at a hospital in the province. Medical examination and treatment history is displayed in detail after entering the patient's health insurance card number.

Another problem that arose during the implementation of Circular 40 was the ranking of non-public medical facilities. According to the leaders of the Department of Health and Social Insurance of Nghe An province, there are no criteria to classify private medical facilities, but the payment of health insurance is related to the ranking (level). In order to be able to pay health insurance at private facilities, there is no other way but to let these facilities "temporarily" enjoy the same payment level as the ranked public facilities. That is why private hospitals in Nghe An before 2014 enjoyed the same level as class IV facilities (commune health stations), in 2014 they were "upgraded" to class II (provincial level) and then at the end of 2015 they "dropped" to class III (district level). The level of health insurance payment for medical examination and treatment services in the non-public sector also fluctuates accordingly, although the level of investment in equipment and facilities in many private facilities is considered "greater" than that in the public sector.

From here, the question arises: Is there any discrimination or inequality between the public and non-public systems? Why can't the criteria for evaluating and ranking public hospitals be applied to private hospitals? Not to mention the rights and responsibilities when participating in social welfare mechanisms and policies, the lack of uniformity in standards and assessments will create gaps in the management of health service quality, affecting social security.

"Broken" management

Faced with the situation of overspending the health insurance fund with signs of profiteering, Vietnam Social Security has issued Official Letter No. 3358/BHXH-CSYT on rectifying the health insurance appraisal work in the last 6 months of 2016 to its affiliated agencies. It emphasizes: The situation of abuse and profiteering of the health insurance fund tends to increase at medical facilities, leading to overspending of the health insurance fund used in the first 6 months of 2016 in many localities.

Vietnam Social Security requires its affiliated agencies to fully analyze and evaluate the rate of cost increase and the imbalance of the health insurance fund in the first 6 months of 2016, and forecast for the whole year of 2016; re-evaluate all health insurance costs in the first 6 months of 2016; strengthen cost control, prevent abuse of the health insurance fund...

At the same time, direct the affiliated agencies to coordinate with the Department of Health to inspect all medical facilities that show signs of fund abuse; after inspection, resolutely recover medical expenses used in violation of regulations; in case of major and systematic violations, transfer the case to the police for investigation...

Under the direction of Vietnam Social Security, the provincial Social Security has worked with the Department of Health to establish 3 inspection teams for medical examination and treatment facilities; coordinated with PC46 of the provincial Police to investigate, verify, and handle units with signs of abusing and profiting from the health insurance fund... The provincial Social Security also reviewed the balance data of the health insurance fund in the first 6 months of the year at medical facilities that "surpassed the fund" dramatically.

This agency even "strongly" changed payment contracts with facilities "showing signs of fund abuse"; set up technical barriers to limit the phenomenon of widely prescribing high-tech tests and services; changed the average cost per capita to control medical examination and treatment work. However, these solutions can only bring about immediate reductions in fund expenditures and are not sustainable. Moreover, when district-level hospitals in the province are connected, is the management and application of payment fund levels for each hospital based on the number of registration cards still appropriate?

It is necessary to recognize a reality: Open healthcare system means improving the quality of healthcare services that people receive, so increased spending is an obvious consequence. The important thing here is how the Social Security agency faces this change, and what solutions it chooses to regulate and maintain an important social welfare mechanism.

Cutting down on “spending” on health care services or increasing revenue by expanding the scope of coverage and increasing health insurance premiums – these contradictory solutions need to be applied in a harmonious manner, with a clear roadmap and a complete monitoring mechanism to ensure people’s rights and maintain stability in welfare policies and the health system. Don’t wait until the situation “breaks down” and then “put out the fire” with sudden, sometimes extreme measures.

Reporter group