Proposal to amend the concept and content of health insurance appraisal in the draft Law on Health Insurance

The proposals ofVietnam Social SecurityAll of these are aimed at ensuring the rights and interests of health insurance participants and overcoming the shortcomings and difficulties of current regulations; in which, amending and supplementing the concept and content of health insurance appraisal is an urgent issue, arising from practical requirements.

Clause 2, Article 29 of Law No. 46/2014/QH13 dated June 13, 2014 on amending and supplementing a number of articles of the Law on Health Insurance (current Health Insurance Law) stipulates the content of health insurance appraisal performed by the Social Insurance agency (SI), including: Checking procedures for medical examination and treatment under health insurance; Checking and evaluating the prescription of treatment, use of drugs, chemicals, medical supplies, equipment, and medical technical services for patients; Checking and determining costs of medical examination and treatment under health insurance. However, through the process of organization and implementation over the past many years, it has been shown that this regulation is no longer suitable to reality, causing many difficulties and inadequacies for both the SI agency and the SI agency.medical facilities and difficult to implement.

In fact, medical facilities are specialized agencies with a team of well-trained, qualified, and most specialized doctors and nurses, who are also the ones who directly examine, treat, and understand the patient's condition. Therefore, the regulation that the Social Insurance agency is responsible for checking and evaluating the prescriptions for the use of drugs, medical supplies, technical services, etc. by doctors and nurses is not consistent with the functions and expertise of the Health Insurance assessor.

Not to mention, in many cases, to evaluate treatment indications, it is necessary to have a medical professional council undertake the task; human resources to do the workHealth Insurance Assessment trained in many different fields such as medicine, pharmacy, economics and finance... and are currently in great shortage.

The shortcomings of this regulation have led to difficulties for the Social Insurance Agency and medical facilities to reach an agreement on the appraisal results, leading to delays in payment of health insurance medical examination and treatment costs, affecting the medical examination and treatment activities of medical facilities.

Based on practical difficulties, to ensure the benefits of health insurance examination and treatment and effectiveness, feasibility, and compliance with current regulations, Vietnam Social Security proposes to amend and supplement the concept and content of health insurance appraisal in the draft revised Law on Health Insurance in the direction that health insurance appraisal has the task of checking, reviewing, and comparing requests for payment of health insurance examination and treatment costs of health insurance examination and treatment facilities and health insurance participants with the provisions of the law on health insurance and other relevant legal provisions as a basis for determining the costs of health insurance examination and treatment within the scope of payment of the health insurance fund. At the same time, promptly make recommendations and warnings to health insurance examination and treatment facilities about unreasonable costs so that the medical examination and treatment facilities can consider and adjust accordingly.

This proposal is completely consistent with the tasks of the Social Insurance agency assigned by the Government in Decree No. 75/2023/ND-CP amending Decree No. 146/2018/ND-CP detailing and guiding measures to implement a number of articles of the Law on Health Insurance.

From the above situation, amending and supplementing the concept and content of health insurance appraisal is an urgent and necessary issue to overcome the limitations, difficulties and inadequacies of the current Health Insurance Law. At the same time, the responsibilities between the parties must be clearly and transparently defined, the tasks assigned must be in accordance with the functions and tasks of the parties and ensure feasibility in implementation. This amendment brings positive impacts not only to the Social Insurance agency, health insurance medical examination and treatment facilities, and State health management agencies, but also ensures the rights and interests of health insurance patients.

Specifically as follows:

First, for health insurance patients:

The amendment to the concept of health insurance appraisal does not reduce the rights of health insurance participants nor does it affect the health insurance examination and treatment process of health insurance participants because the examination, review and comparison are carried out after the patient has completed the medical examination and treatment process. In terms of expertise, health insurance patients are still assessed and prescribed according to their medical condition.

Second, for the Social Security agency:

- The task of the health insurance appraiser of the Social Insurance agency is still to check, review, and compare the payment requests of health insurance examination and treatment facilities with the provisions of the law on health insurance and other relevant legal provisions as a basis for determining the costs of medical examination and treatment within the scope of payment of the health insurance fund and ensuring the rights of health insurance participants when going for health insurance examination and treatment.

- In the coming time, the Social Insurance agency will continue to strengthen the implementation of health insurance appraisal to effectively manage and use the health insurance fund, in accordance with the provisions of law, contributing significantly to the basis for unifying appraisal results between the Social Insurance agency and health insurance examination and treatment facilities, overcoming the current situation of slow payment and settlement of health insurance examination and treatment costs. At the same time, well protecting the rights of health insurance participants.

- Is the basis for implementing electronic health insurance appraisal in accordance with the Party's viewpoint on digital transformation in the new period.

Third, for health insurance examination and treatment facilities:

After the concept of health insurance appraisal is revised, it will:

- Maximally overcome the lack of consensus on medical expertise between health insurance examination and treatment facilities and social insurance agencies and limit the arising of problems in the implementation of health insurance policies and laws.

- Contribute significantly to the payment and settlement of health insurance examination and treatment costs with health insurance examination and treatment facilities within the time limit prescribed by the Law on Health Insurance.

- Ensure the rights and responsibilities of medical practitioners and medical facilities in examining and treating patients as prescribed in the Law on Medical Examination and Treatment.

Fourth, for the State health management agency:

No additional work is created for other agencies because the inspection, examination, and evaluation of treatment prescriptions, drugs, technical services, and quality control of medical examination and treatment... as stipulated in the Law on Medical Examination and Treatment are the responsibility of the State health management agency.

- The responsibilities between the parties are clearly and transparently defined, and the assigned tasks are in accordance with the functions and duties of the parties as stipulated in the Law on Medical Examination and Treatment.

In addition to the proposal to amend the concept and content of health insurance appraisal, Vietnam Social Security also proposed many solutions to ensure health insurance benefits for participants and they have been basically incorporated into the draft revised Law on Health Insurance, such as: cases of some serious and dangerous diseases that are treated in the wrong area, without needing a referral letter (instead of having to have a referral letter as at present); health insurance payment for cases of treatment of strabismus, myopia and refractive errors of the eyes for people under 18 years old (instead of only for people under 6 years old as at present)...

Currently, the draft amended and supplemented Law on Health Insurance is continuing to collect opinions from ministries, branches and experts; it is expected to be submitted to the National Assembly in October 2024./.