An independent body is needed to audit the health insurance fund.

(Baonghean)Explaining the issue of health insurance coverage for medical examinations and treatment before the National Assembly's Committee on Social Affairs on March 1, 2017, the Director General of Vietnam Social Insurance, Ms. Nguyen Thi Minh, highlighted a regrettable reality of unhealthy competition among medical facilities, especially private ones, such as promotions, attracting patients with gifts, prescribing many technical services, etc., leading to an artificial increase in demand for medical services.

In addition, the Director General of Vietnam Social Security also pointed out the increasing abuse and exploitation of the health insurance fund by medical facilities, such as: increasing the number of prescribed paraclinical tests and X-rays; health insurance patients going for medical examinations multiple times a day, week, or month to get medicine (from July 2016 to February 2017, over 1.2 million health insurance participants went for medical examinations two or more times each month; 3 million visits were multiple times on the same day or multiple times in a month).

There were even cases where people went for checkups and medication up to 308 times at 23 different places in 8 months (in Ho Chi Minh City), 197 times at 5 different places (Ho Chi Minh City and Binh Duong), or someone who went for medical checkups 160 times at 20 different facilities in the fourth quarter of 2016…

The reason for this explanatory session is understandable, given the recent nationwide uproar over the overspending of the health insurance fund, amounting to thousands of billions of dong (Nghe An province has the second-largest overspending in the country, second only to Thanh Hoa).

The reasons for the large overspending in health insurance are not something that only the Director General of Vietnam Social Security had to point out; they had already been mentioned many times before by relevant agencies, sectors, and the media. But what are the effective solutions to prevent unfair competition, abuse, and profiteering from the health insurance fund?

Reviewing the issuance of health insurance cards at the Social Insurance Office of Vinh City. (Photo: Archival image)

Those in charge have proposed many solutions, most notably the opinion of Mr. Hoang Van Hao – Deputy Director in charge of the Department of Health – during a working visit with the National Assembly delegation at the end of February: “Besides the Social Insurance agency assigned to manage the health insurance fund and the health agency implementing it, there needs to be an additional agency for independent auditing to ensure objectivity and transparency in the implementation of the fund, and to prevent abuse of the health insurance fund…”.

Just think about it, the Social Insurance sector is not only entrusted with managing the health insurance fund but also directly disburses health insurance payments to contracted healthcare providers. Managing and disbursing funds simultaneously, the Social Insurance sector wields immense power.

And the reality is that whenever an agency or unit is granted significant power, while oversight mechanisms are lacking (or lax), abuse of power or misuse of authority is more likely to occur.

The social insurance sector has a fairly large team of inspectors and auditors. This team is responsible for inspecting and controlling the implementation of medical examinations and treatments by public and private hospitals contracted to provide health insurance services. However, in the field of medical examination and treatment, accurately and comprehensively assessing each individual case is truly challenging.

It requires assessors to have solid professional expertise in the medical field; and at the same time, they must have practical experience. The assessment team of the Social Insurance sector is, of course, trained, but they do not regularly have access to actual medical examination and treatment practices, and relying solely on records makes it very difficult to provide accurate assessments.

Therefore, without an independent auditing agency, allowing the Social Insurance agency to rigidly disburse health insurance funds will create difficulties for medical facilities; consequently, those receiving health insurance-covered medical treatment will also face numerous complications from these facilities.

Conversely, if the inspection process is lax, or worse, if there is collusion and illicit sharing of profits between inspectors (or social insurance agencies) and health insurance-covered medical facilities, it will lead to disastrous losses of health insurance funds.

The goal set by the Party and the State is to implement universal health insurance, thereby ensuring that people receive the best possible healthcare benefits. Therefore, the safe management of the health insurance fund is extremely important. To achieve this, it is necessary to prevent overspending and to avoid abuse or other irregularities in the use of the health insurance fund.

Therefore, Mr. Hoang Van Hao's proposal to establish an independent assessment agency is a good one and should be considered. If there were an independent agency to assess health insurance-covered medical examinations and treatments, it would undoubtedly enhance transparency and objectivity; minimize abuse and other irregularities in health insurance-covered medical examinations and treatments; and lead to better management of the health insurance fund!

Nhat Lan