Health insurance examination and treatment: 'Advertise goat head, sell dog meat'

(Baonghean) - Many non-public hospitals, many private clinicsdoes not guarantee the quality of medical staff, doctors or facilities but still has a huge number of patients.The question is whether the quality of medical examination and treatment is guaranteed and commensurate with the costs paid by the health insurance fund and directly paid by the people or not?

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

"Hang sheep's head but sell dog meat"

It is undeniable that through promoting the socialization of healthcare, Nghe An has many more hospitals and clinics with good facilities and equipment.

Thanh An Saigon Hospital is assessed by the Department of Health and Social Insurance (SI) of Nghe An province as having good facilities, equipment and machinery to ensure medical examination and treatment; and is contracted by the Social Insurance agency to examine and treat health insurance.

There was a time when this was a medical examination and treatment address that people considered and chose. But over time, the number of people coming for medical examination and treatment gradually decreased. However, from 2012 to 2015, the cost of health insurance examination and treatment here always exceeded a rather large number (in 2012 it exceeded 4 billion VND, in 2013 it exceeded 6 billion VND, in 2014 it exceeded 6 billion VND, in the first 2 quarters of 2015 it exceeded nearly 6 billion VND).

In November 2015, in Official Dispatch No. 3568/BHXH-GĐBHYT, the provincial Social Insurance Department clearly stated that Thanh An Saigon Hospital exceeded the fund for many consecutive years; paid for technical services not in accordance with regulations; the situation of medical staff examining and treating patients in medical records and nurses not having specialized expertise; incomplete legal procedures...

Minh Hong General Hospital and Nghe An Eye Hospital share the same medical examination and treatment facility.

Entering 2016, Thanh An Saigon Hospital fell into a situation of many months of delayed salaries for its employees. The peak was in early August 2016, when the team of doctors and nurses of this hospital stopped working collectively, causing disruption in medical examination and treatment. Because of this, the two sectors of Health and Social Insurance had to spend a lot of time to resolve; even re-evaluating the ability to respond in organizing medical examination and treatment to decide whether to continue the health insurance medical examination and treatment contract or not; issues of finance and professional human resources are concerns that have been raised.

Talking to reporters, Dr. Nguyen Van Tong - Executive Director of Thanh An Saigon Hospital said: At present, the hospital is basically stable in terms of both personnel and finance. People have returned to see a doctor, although the number is still limited. However, when mentioning the team of doctors and nurses arranged in the departments, detailed data on health insurance examination and treatment, Dr. Tong and the Deputy Director in charge of hospital administration refused to provide it.

Also while Dr. Tong was talking to reporters, there was an incident where people went to the director's office to protest the hospital's deliberate detention of patients, not allowing them to be transferred to other hospitals even though they did not have the conditions for treatment (according to the patient's family); the doctor on duty was not attentive, even neglected to be present at the clinic, causing patients to have to go back and forth to request many times, waiting and wasting time...

Waiting area at Thanh An General Hospital

According to Dr. Tong, the respondent (living in Le Loi Ward, Vinh City - PV) has cancer and had to go to Bach Mai Hospital for treatment. Now he wants to go to a provincial hospital for further treatment, but has not been approved by the examining doctor. "The doctor on duty is not in the clinic because he might be having surgery. Please wait a moment in the clinic..." - Dr. Tong explained to the respondent. Through this incident, the shortage of human resources at Thanh An Saigon Hospital has been somewhat exposed.

A few hundred meters from Thanh An Saigon Hospital, Nguyen Minh Hong General Hospital has had very few patients coming for medical examination and treatment in recent years. There have been cases where organizations and individuals who disagreed with the medical examination and treatment have transferred their health insurance cards to other hospitals.

However, from 2012 to present, Nguyen Minh Hong General Hospital has always used more than the Health Insurance Fund (in 2012, it exceeded 1.1 billion VND, in 2013, it exceeded 2.9 billion VND, in 2014, it exceeded nearly 1.9 billion VND, and in the first 9 months of 2015, it exceeded nearly 3.5 billion VND). In December 2015, in Official Dispatch 3759/BHXH-GĐBHYT, the provincial Social Insurance pointed out a series of shortcomings here such as the widespread ordering of tests and paraclinical tests; many types of tests were ordered multiple times, monthly, in a mass manner, not according to the specific condition of the patient...

According to Dr. Nguyen Xuan Loan - Director of Nguyen Minh Hong General Hospital, since the time of the opening of the route according to Circular 40, the number of medical examinations and treatments has increased, especially for multi-level patients in the province (in the first 8 months of 2015, there were 6,300 initial medical examinations and treatments; but in the first 8 months of 2016, it increased to over 18,500 medical examinations and treatments). Observation shows that Nguyen Minh Hong General Hospital has currently "reserved" half of its rooms for Nghe An Eye Hospital.

When asked whether the concession of space will affect the quality of examination and treatment for patients? According to Dr. Nguyen Xuan Loan, Nghe An Eye Hospital was allowed to temporarily set up here (about 5-6 years) because the Provincial People's Committee had an opinion (?); and in fact, it does not affect the examination and treatment work (?). However, according to Dr. Loan, Nguyen Minh Hong General Hospital no longer has a Surgery department and the hospital is gradually moving towards becoming a place to care for cancer patients...

In the province, in addition to non-public hospitals, there are two more general clinics in Hoang Mai town (Hong Tung General Clinic and Quang Khoi General Clinic) that are contracted by the Social Insurance Agency to provide health insurance examination and treatment. Regarding the conditions of facilities and equipment, Quang Khoi General Clinic has been invested quite well, while Hong Tung General Clinic does not ensure quality. Regarding medical staff and doctors at these clinics, according to the responsible person, the registration list is complete but the quality is not guaranteed to be consistent.

People wait to do medical examination procedures at Quang Khoi General Clinic.

Despite such infrastructure and human resources, Quang Khoi General Clinic had 18,596 medical examinations and treatments in the first 6 months of the year; Hong Tung General Clinic had 5,916. And also because of the nature of being just a clinic, these facilities do not provide inpatient treatment; when patients need treatment, they must be transferred to Hoang Mai Town Medical Center or transferred to a higher level, causing the patient and the health insurance to pay again for the same clinical symptoms!

Loosening the inspection and testing work?

For many years, through the assessment of health insurance examination and treatment, the Social Insurance Agency has pointed out that one of the biggest problems of hospitals and clinics is the overuse of technical services, prescribing many unnecessary tests for patients, not according to the actual condition of the disease to receive health insurance funds. And of course, the Social Insurance Agency has stepped in and proposed preventive solutions; many hospitals have had part of their health insurance examination and treatment costs deducted.

As Dr. Pham Gia Van - Deputy Director of the Provincial Social Insurance discussed, the provisions of the law do not allow Social Insurance agencies to carry out inspection, examination and handling of violations. Therefore, with signs of law violations, we have to "rely on" the health sector; as for Social Insurance agencies, in addition to establishing monitoring systems, we try to maximize inspection and appraisal work.

Hong Tung General Clinic (Hoang Mai Town).

In fact, Article 41 of the Law on Health Insurance passed by the National Assembly on November 14, 2008, specifically stipulates the responsibilities of health insurance organizations, such as: Managing and using health insurance funds; Signing health insurance medical examination and treatment contracts with medical examination and treatment facilities; paying health insurance medical examination and treatment costs; Checking the quality of medical examination and treatment; health insurance appraisal; protecting the rights of health insurance participants; resolving recommendations, complaints and denunciations about health insurance regimes according to authority; applying information technology in health insurance management, building a national database system on health insurance...

In Article 29, the Law on Health Insurance also clearly stipulates health insurance appraisal: Checking medical examination and treatment procedures 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 the costs of medical examination and treatment under health insurance; Health insurance appraisal must ensure accuracy, publicity, and transparency; Health insurance organizations carry out health insurance appraisal and are legally responsible for appraisal results.

Is it true that Nghe An Social Insurance has not fulfilled its role properly, or has been lax in assessing health insurance, leading to the above situation?

What did the specialized inspection force of the Department of Health do? According to the investigation, for many years, only once (in May 2015) did the Department of Health direct the establishment of an inspection team on prices of medical examination and treatment services and human resources at non-public hospitals. In fact, the team only inspected 4 hospitals: Thai An General Hospital, Cua Dong General Hospital, Phu Dien General Hospital and Thanh An Saigon General Hospital. At these 4 hospitals, there were only a few violations of human resources conditions at Thai An General Hospital, Phu Dien General Hospital and Thanh An Saigon General Hospital (total fine was 26 million VND)...

Recalling the story of forged signatures on test papers that happened at Thanh An General Hospital in Saigon in 2015 (the provincial Social Insurance has recovered over 64 million VND) with a representative of the Department of Health Inspectorate. According to this inspector, he heard about the incident, but did not see the Social Insurance agency transfer the file. In fact, the cost of a test sample is 200,000 VND; the amount of over 64 million VND, will correspond to hundreds of test samples and records. When the test sample has a forgery problem, are those hundreds of records guaranteed? Why did the Department of Health Inspectorate know about the matter but not recommend the leaders to inspect and check? According to this person, the Department of Health Inspectorate has a lot of work to do, moreover, regarding this incident, the department leaders did not see the department leaders direct the inspection and clarification!

The situation of abuse and profiteering from the health insurance fund has also been clearly pointed out by Vietnam Social Security in Official Dispatch No. 3358/BHXH-CSYT (on rectifying the health insurance appraisal work in the last 6 months of 2016 sent to affiliated agencies). And among many preventive measures, Vietnam Social Security has directed affiliated agencies to coordinate with the Department of Health to establish an interdisciplinary inspection team to inspect all medical examination and treatment facilities showing signs of abusing the health insurance fund, abnormally increasing health insurance examination and treatment costs, increasing frequency of patients undergoing medical examination and treatment; after inspection, resolutely recover medical examination and treatment costs used in violation of regulations; in cases of major and systematic violations, the case file will be transferred to the police for investigation...

PV Group