Nghe An seeks solutions to avoid exceeding the estimated cost of medical examination and treatment Health Insurance

Current situation and risks

According to Social SecurityNghe An: In the first quarter of 2023, the total number of health insurance examinations and treatments in the province was 1,309,588, an increase of 42.54% over the same period in 2022 (ranked 4th highest nationwide). The amount of money that health insurance facilities requested the Social Security agency to pay was 1,026 billion VND, an increase of 32.21% over the period in 2022 (ranked 3rd highest nationwide). The frequency of health insurance examinations and treatments in the province was 1.55 times/card, 55% higher than the same period in 2022 (1.0 medical examination and treatment time/card).

Comparing the indicators with the region and the whole country, in the first quarter of this year, the average medical examination and treatment cost of the province was 861,209 VND/visit, higher than the national average (765,186 VND/visit) and the regional average (715,707 VND/visit). The rate of inpatient treatment was 13.78%, an increase of 3.8% over the same period in 2022, 1.41 times higher than the whole country (9.71%), and also higher than the region (11.15%). The average treatment day was 6.97 days, a decrease of 1.7% over the same period in 2022, higher than the whole country (6.3 days), higher than the region (6.5 days).

After the Covid-19 epidemic, the number of patients seeking medical examination and treatment increased significantly. Photo: Document

During this period, the number of out-of-line inpatient medical examination and treatment at provincial facilities was 33,181, an increase of 55% over the same period in 2022. The out-of-line inpatient medical examination and treatment costs proposed for payment by provincial facilities was 158 billion VND, an increase of 22% over the same period in 2022. The health insurance medical examination and treatment facilities with a high rate of out-of-line patients compared to the total number of inpatients are Nghe An Traditional Medicine Hospital (98%); Nghe An Rehabilitation Hospital (93%); Nghe An Eye Hospital (81%).

Medical facilities have added more treatment beds than planned, 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 costs.

In addition, the number of patients going to the hospital multiple times has increased. According to statistics on the monitoring system, the number of people with health insurance cards going to the hospital multiple times a day/week/month at many medical facilities, there is a phenomenon of going to the hospital with health insurance in groups (in the same village, hamlet) outside the designated area... Some facilities have not seriously implemented the checking and comparison of health insurance cards and valid photo identification documents, checking the medical examination history at the reception gate to detect cases of abuse of health insurance cards, cases of going to the hospital multiple times in violation of regulations.

Through the work of checking patients at departments and rooms, the provincial Social Insurance found that there was a situation where relatives who went to take care of patients also became patients (Traditional Medicine Hospital, Rehabilitation Hospital); the situation where hospitals organized medical examinations at medical stations, then sent vehicles to take patients to the hospital for surgery. Through checking inpatients treated during and outside of office hours at 18 medical examination and treatment facilities in Vinh city, it was found that in some hospitals, the rate of absent patients was very high.

In addition, the implementation of daytime treatment for traditional medicine, rehabilitation, and radiotherapy has not been well implemented. In the first quarter of 2023, the number of patients receiving daytime treatment accounted for only 21.4% of the total number of patients receiving traditional medicine and rehabilitation treatment.

On the other hand, implementing the autonomy mechanism, to increase revenue, facilities are tending to increase the wide prescription of technical services, especially increasing the prescription of tests and paraclinical. Meanwhile, the number of medical examination and treatment visits with a drug cost structure of less than 20% of the total cost is 414,137 visits, accounting for 36.6% of the number of visits to medical examination and treatment. Data analysis also shows that the number of medical examination and treatment visits at the grassroots level is not increasing proportionally compared to the remaining levels, especially the rate of increasing inpatients at the provincial level.

Nghe An's medical sector's promotion of advanced technology development to bring benefits to patients is also an objective reason for the high cost of health insurance. Photo: Document

Mr. Thai Ba Thang - Deputy Director of Nghe An Social Insurance warned: With the increase in the first quarter of 2023, if there is no effective control, the assigned budget of up to 4,000 - 5,000 billion VND will be gone. The problem is that the two sectors of Social Insurance and Health must take drastic action, find ways to overcome and prevent the subjective causes of this sudden increase.

Fundamental solution: Reasonable, logical and legal

At the Conference to find solutions to effectively manage the Health Insurance Fund, Provincial Social Insurance andNghe An Department of Healthhas focused on analyzing objective and subjective causes and finding fundamental and effective solutions to strictly control, use the health insurance fund properly and effectively and ensure people's rights. Accordingly, the objective causes leading to the increase in health insurance costs are that Nghe An has a large area, a large population (4th in the country); people's living standards are still low (especially in 11 mountainous districts and towns), population quality is not high, the rate of people with diseases is high; disease patterns are complicated, especially after the Covid-19 epidemic; preventive health resources are weak...

Meanwhile, in the province, the group of health insurance card structure has a health insurance benefit rate of 95% to 100%, higher than the average of other provinces and cities in the country. The local health care system is relatively complete in scale and implements specialized techniques of the provincial and central levels. The private medical facility development ranks 4th nationwide... Since 2016, with the new health insurance policy (Law amending and supplementing a number of articles of the Health Insurance Law) allowing district-level communication and inpatient treatment at provincial levels outside the line to enjoy inpatient benefits in the right line (from January 1, 2021), creating conditions for inpatients at the above levels, which has increased the cost of health insurance.

Regarding subjective causes, according to Dr. Nguyen Thanh Ngoc - Deputy Head of the Medical Affairs Department (Nghe An Department of Health): "The sector has directed medical examination and treatment facilities: Receive patients for inpatient treatment appropriate to their medical condition; provincial medical examination and treatment facilities are responsible for advising and guiding patients on appropriate treatment at the district level. In cases where patients do not need to be inpatient, they must establish outpatient or day-patient medical records. However, some medical examination and treatment facilities have not been really determined in implementing these instructions."

Regarding the low cost structure of medicine in the total treatment cost, pharmacist Tran Minh Tue - Deputy Director of Nghe An Department of Health mentioned the current trend of treatment without using or using less medicine in the health sector. Regarding the implementation of daytime treatment, there is a problem that occurs: "Where will patients from the districts go to provincial hospitals after daytime treatment?"

The provincial Social Insurance and Nghe An Department of Health signed a Regulation on coordination in implementing health insurance policies and laws, including the content of good control of the Health Insurance Fund. Photo: Thanh Chung

Based on a reasonable and legal analysis, the Social Insurance and Health Insurance sectors of Nghe An have proposed fundamental measures to effectively control the use of the Health Insurance Fund, which are: Continuing to strengthen coordination and information exchange between the two sectors to promptly handle incidents, problems and sudden increases; strengthening inter-sectoral supervision, inspection and examination to assess the admission of patients for inpatient treatment and detect and handle cases of abuse of the Health Insurance Fund.

Promote the use of information technology to check and compare health insurance cards, check medical examination and treatment history, detect cases of health insurance card abuse, cases of multiple medical examinations not in accordance with regulations; promote communication work so that people with minor illnesses can receive medical examination and treatment at grassroots health facilities; raise awareness of health care facilities in the management and rational use of health insurance funds, associated with the responsibility of the head; direct health care facilities to properly implement professional regulations, admit patients for inpatient treatment appropriate to their illness, and advise and guide patients on appropriate treatment at district levels./.