Nghe An: Risk of exceeding health insurance fund by 1,700 billion VND

(Baonghean) - In the first quarter of 2017, medical examination and treatment facilities in Nghe An requested the Social Insurance to pay more than 700 billion VND under the Health Insurance regime, an increase of 75% compared to the same period last year.

In 2016, Nghe An ranked second in the country in terms of exceeding the Health Insurance Fund (HIF). Although all levels and sectors have taken action and implemented many corrective measures, the situation of exceeding the fund continues to be alarming. Nghe An Social Insurance (SI) forecasts that if the fund usage trend continues as above, in 2017, the total expenditure proposed by medical examination and treatment facilities will reach over 3,500 billion VND, exceeding the fund by about 1,700 billion VND.

In the first quarter of 2017, medical examination and treatment facilities in Nghe An requested the Social Insurance to pay more than 700 billion VND under the health insurance regime, an increase of 75% compared to the same period last year. Nghe An Social Insurance forecasts that if the fund usage rate continues as above, in 2017, the total expenditure requested by medical examination and treatment facilities will reach over 3,500 billion VND, exceeding the fund by about 1,700 billion VND. Meanwhile, the estimated excess fund of Nghe An is only 800 billion VND. Why does the situation of exceeding the health insurance fund in Nghe An show no signs of stopping?

'Patients' go to the doctor more than 20 times/month

Nghe An Social Insurance determined that one of the reasons for the excess of the health insurance fund is still due to abuse, even signs of profiteering from both patients and medical examination and treatment facilities. This situation has been identified since 2016.

Staff at Vinh City General Hospital guide people in measuring blood pressure. Photo: PV

According to the statistics of Nghe An Social Insurance, 65% of the total number of patients who went for medical examination and treatment in the first quarter of 2017 went for examination 2 times or more. A large part of them were not in the group of chronic diseases, and had to return for examination according to appointment. There were cases that went for examination so many times that Nghe An Social Insurance "zoned" such as: Tran Huu Hoang, health insurance card code CC1404017975862, went for examination 62 times, Nguyen Huu Nhuan, health insurance card code CC1404017944904, went for examination 57 times, Trinh Hong Thang, health insurance card code CC1404017958857, went for examination 29 times... It is estimated that on average, each month, there are people who go for examination more than 20 times?!

Another phenomenon of fund abuse is cases of health insurance cards for the poor because they are recognized as “poor households” despite having average or even good incomes. Some families have children who work and have stable incomes but still separate their household registration so that their parents can be “recognized” as “poor households” or “near-poor households”.

Regarding medical examination and treatment facilities, Nghe An Social Insurance listed the "tricks" of abusing the health insurance fund such as: indiscriminately assigning patients for inpatient treatment but when the social insurance inspectors came to check, many patients were absent; performing technical services beyond their capacity; assigning unnecessary technical services; charging incorrect prices for technical services;... Nghe An Social Insurance refused to pay for health insurance examination and treatment costs that were not in accordance with regulations.

There are units that have been refused payment of tens of billions of dong. In the first 6 months of 2016, Nghe An Social Insurance has refused to pay nearly 52.6 billion dong. Of which, 34.3 billion dong is waiting for the opinion of Vietnam Social Insurance.

A summary report of inpatient examination of health insurance provided by Nghe An Social Insurance.

Exceeded funds due to mechanism change

In 2017, a number of articles of the Law on Health Insurance were added, and a number of provisions of the Amended Law came into effect, affecting the implementation of health insurance policies in the area. Accordingly, health insurance participants received increased benefits, for example, the poor were increased from 95% to 100%, which also contributed to increased fund expenditure.

The structure of the health insurance card in Nghe An is also characterized by a large proportion of policy beneficiaries. Specifically, Nghe An currently has more than 2.4 million people participating in health insurance, but only about 300,000 people pay the highest premium (4.5% of monthly salary), accounting for 12.5% ​​of the total number of health insurance participants. The groups of people paying low premiums and receiving high payments such as the poor, meritorious people, children, etc. are the groups with the greatest need for medical examination and treatment.

Structure of groups participating in health insurance in Nghe An divided by benefit level as of April 2017 (data provided by Nghe An Social Insurance).

Another change is that the new medical service price according to Circular No. 37 of the Ministry of Health - Ministry of Finance has been structured with additional salary costs and is unified for hospitals of the same level nationwide. In 2016, only private facilities will be able to apply the new price. Analyzing the proposed payment data under the health insurance regime of hospitals in the province in the first 3 months of the year, the increased cost due to price changes is nearly 178 billion VND. However, this increase in expenditure was predicted in advance and is completely justified.

In addition, in 2017, Nghe An had 8 autonomous public service units that ensured regular operating expenses, including: Nghe An Provincial General Hospital, Nghe An Obstetrics and Pediatrics Hospital, Oncology Hospital, Endocrinology Hospital, Rehabilitation Hospital, Northwest Regional General Hospital, Southwest Regional General Hospital, Vinh City General Hospital. The state budget will stop providing these units with an expense of about 165 billion VND/year for service activities, including salaries. So where do hospitals get their salaries from? It is the service revenue and health insurance payment costs. The ratio between these two revenue sources in hospitals is clearly different, mostly from health insurance costs. Nghe An Provincial General Hospital: over 80% of revenue comes from health insurance examination and treatment, Vinh City General Hospital: over 95% of revenue comes from health insurance examination and treatment...

Thus, part of the increased cost in using the health insurance fund comes from the fact that public hospitals implement the autonomous mechanism, the state budget stops "pouring money". This cost falls on the health insurance fund, but the user's contribution does not increase, so increased spending and exceeding the fund are inevitable results./.