Nghe An warns of risk of exceeding health insurance medical examination and treatment expenditure estimates

There are both objective and subjective reasons.

Causes leading to the risk of exceeding the estimated cost of medical examination and treatmenthealth insuranceclearly recognized: Nghe An is a large province with a large population and low population quality, especially in mountainous districts. The disease model in Nghe An is complicated, especially after the Covid-19 epidemic, the rate of people getting sick, the need for health care increases in both quantity and quality... Meanwhile, the group of health insurance card structures with health insurance benefits from 95% to 100% of the province is higher than the average of other provinces and cities in the country.

After the Covid-19 pandemic, the number of people in need of health care increased. Photo: Thanh Chung

Ms. Nguyen Thi Hong Hoa - Director of Nghe An Department of Health said: Nghe An has a relatively complete medical examination and treatment system in terms of scale and implementation of specialized techniques at provincial and central levels, the private medical examination and treatment facilities are the 4th most developed in the country. In addition, recent health insurance policies (especially the policy of connecting to districts and inpatient treatment at provincial levels with inpatient treatment in the right line from January 1, 2021) have created favorable conditions for people to access high-tech services. Meanwhile, the Health Insurance Medical Examination and Treatment Fund plays the role of the main source of payment for people's medical examination and treatment costs.

In addition to the above objective reasons, Mr. Hoang Van Minh - Director of Nghe An Social Insurance pointed out the subjective reasons: Some medical examination and treatment facilities are not highly aware of the responsibility for managing and rationally using the Health Insurance Fund according to Directive No. 29/2012/CT-UBND dated November 10, 2012 of the Provincial People's Committee on strengthening responsibility in managing and using the Health Insurance Fund and Directive No. 10/CT-BYT dated September 9, 2019 of the Ministry of Health on strengthening the prevention and combat of abuse and profiteering of the Health Insurance Fund; the responsibility for managing the health insurance examination and treatment fund has not been assigned to the heads of medical examination and treatment facilities.

The development of high technology also affects the increase in medical examination and treatment costs under health insurance. Photo: Thanh Chung

Some medical examination and treatment facilities have not been really drastic in admitting patients for inpatient treatment appropriate to their medical condition. Provincial medical examination and treatment facilities have not advised and guided patients on appropriate treatment at the district level (meeting all conditions and professional technical qualifications) but have increased the number of patients being admitted for inpatient treatment outside the district level. In the first quarter of 2023, the number of out-of-line inpatient examinations and treatments at provincial medical examination and treatment facilities was 33,181, an increase of 55% over the same period in 2022. The out-of-line inpatient treatment costs that provincial medical examination and treatment facilities proposed to pay was VND 158 billion, an increase of 22% over the same period in 2022.

Medical examination and treatment facilities add more treatment beds than the assigned bed plan while medical staff, facilities and equipment have not been supplemented, affecting the quality of examination and treatment. Adding more hospital beds and widely assigning patients to inpatient treatment, prolonging inpatient treatment time is one of the causes leading to hospital overload and increasing medical examination and treatment costs.

Many issues of concern

The policy of connecting district hospitals and inpatient treatment at provincial hospitals outside the provincial hospital with inpatient treatment at the right hospital has created favorable conditions for people to access high-tech services but also increased costs. Photo: Thanh Chung

Recent,Social Insurance Management Council Supervisory DelegationVietnam had a working session with the Provincial People's Committee. One of the working contents was to evaluate the management and use of the estimated budget for medical examination and treatment under health insurance... At the meeting, regarding the risk of exceeding the estimated budget for medical examination and treatment under health insurance, the Supervisory Delegation said that it was mainly due to objective reasons, but at the same time, it also pointed out the notable existing problems that are contradictory to the development of technical services.

Firstly, the average cost of a treatment in Nghe An is 861,209 VND/treatment, higher than the national average of 765,186 VND/treatment. Specifically:

The average cost of medical records at hospitals in Nghe An province is higher than the national average. Graphics: Huu Quan

Second, the medical examination and treatment indexes of Nghe An province are always higher than the national average. Specifically:

The rate of inpatient treatment and average treatment days in Nghe An is higher than the national average. Graphics: Huu Quan

Third, there is an inadequacy in the procurement of medicines through bidding when comparing the winning bid prices between the Department of Health and medical examination and treatment facilities. With the same type of medicine, a pharmaceutical company, but the medicine purchased by the medical examination and treatment facility has a higher content than the Department of Health purchased a little but the price is many times higher... Through the procurement of medicines, it shows that the rate of people with diabetes is much higher than the whole country.

Reviewing medical records shows some noteworthy figures. That is, there are over 73,900 outpatients with 10 or more diseases; up to 732,579 inpatients with 5 or more diseases. We need to review the reality of medical records to make corrections. In addition, it is also necessary to establish an interdisciplinary team to check the issue of ordering tests and diagnostic imaging; the issue of the number of patients transferred to the Central level is very large (in 2022, about 400,000 patients, the cost of examination and treatment of health insurance at the Central level is 694 billion VND). Do these numbers reflect the quality of healthcare and health of Nghe An people?

Mr. Nguyen Duc Hoa - Deputy General Director of Vietnam Social Security

One of the effective solutions to prevent and combat abuse and exploitation of the Health Insurance Fund is to promote digital transformation in healthcare to detect patients who visit the clinic multiple times. Photo: Thanh Chung

The monitoring team also stated: Facilities are tending to increase the prescription of medical services to increase revenue and ensure salary payment for staff, leading to the widespread prescription of technical services, especially increased prescription of testing, paraclinical and technical services.

There must be fundamental solutions.

To prevent the risk of exceeding the estimated expenditure for medical examination and treatment under health insurance, Mr. Nguyen Van Cuong - Vice Chairman of the Vietnam Social Security Management Council suggested: Nghe An province should continue to direct the effective exploitation and management of the Health Insurance Medical Examination and Treatment Fund, and implement the assignment of financial autonomy to medical examination and treatment facilities according to a reasonable roadmap; direct the bidding of materials and medicines at medical facilities in accordance with regulations; direct departments and branches to strengthen inspection, examination, and inspection of inpatients at provincial hospitals outside of working hours to assess the admission of inpatients; strengthen the dissemination of policies and laws on health insurance.

Comrade Nguyen Van Cuong - Vice Chairman of the Vietnam Social Security Management Council suggested: Nghe An province continues to direct the exploitation and effective management of the Health Insurance Medical Examination and Treatment Fund. Photo: Thanh Chung

Receiving opinions from the Supervisory Delegation, Vice Chairman of the Provincial People's Committee Bui Dinh Long also requested the Supervisory Delegation to recommend to the Government to issue a synchronous policy system, suitable to reality. For example, it is necessary to assess the reality between health insurance collection and benefits, the policy of connecting the lines; study the allocation of the Health Insurance Examination and Treatment Fund and payment methods to ensure the rights of patients; there needs to be policy adjustments so that the staff can focus on performing professional tasks, and abuse and exploitation cannot be done.

To prevent the risk of exceeding the budget estimate, Nghe An province and the Social Insurance - Health sector have been and will direct medical examination and treatment facilities to strictly implement professional regulations in examination and treatment to save medical examination and treatment costs; work with medical examination and treatment facilities to increase medical examination and treatment costs in the first quarter of 2023 to have solutions to control medical examination and treatment costs in 2023 to adjust medical examination and treatment indicators to approach the average index of hospitals of the same rank, same level, same specialty nationwide; assign responsibility to heads of medical examination and treatment facilities in organizing the implementation of health insurance policies in the area.

Comrade Bui Dinh Long - Vice Chairman of Nghe An Provincial People's Committee commented: There needs to be policy adjustments so that the staff can focus on performing their professional tasks, and abuse and exploitation cannot be done. Photo: Thanh Chung

Nghe An Social Insurance needs to strengthen the appraisal of health insurance examination and treatment costs in accordance with the procedures of Vietnam Social Insurance, especially focusing on controlling health insurance examination and treatment costs for medical examination and treatment facilities with warnings from the Appraisal Information System; resolutely refuse to pay unreasonable and illegal costs; strengthen information and communication work on the rights and responsibilities of organizations and individuals in implementing health insurance policies and laws./.