Deputy Director of Social Insurance: Why do you have an abdominal ultrasound if you get scratched by a cat?

(Baonghean.vn) - At the conference to summarize the health insurance examination and treatment work in 2016 and deploy tasks in 2017 organized by Nghe An Department of Health on the morning of December 28, Dr. Pham Gia Van, Deputy Director of Nghe An Provincial Social Insurance asked hospital leaders: 'If the patient is at home, why is it recorded as inpatient treatment?' 'If a cat scratches you, why do you have an abdominal ultrasound?....'

>>> Health Insurance Fund Deficit

Attending the conference were representatives of the Nghe An Department of Health, Nghe An Social Insurance and leaders of public and non-public medical examination and treatment units in the area.

23 hospitals and medical centers denied payment

This is the first specialized conference on health insurance examination and treatment, the purpose of the conference is to draw lessons, listen - answer, and solve problems in the process of health insurance examination and treatment, limit the situation of exceeding the fund while still ensuring the rights of patients.

Information from the report shows: In 2016, the rate of health insurance participants in the whole province reached 81.3% with nearly 2.5 million people. In the first 10 months of the year, 39 hospitals, 6 medical centers with beds and 487 medical stations along with 4 hospitals of ministries and branches in the area provided medical examinations for over 4.6 million people, and inpatient treatment for 477 thousand people.

Pharmacist Hoang Van Hao - Deputy Director in charge of Nghe An Department of Health opened the conference.

In the first 9 months of the year, the total cost of health insurance examination and treatment was nearly 1,959 billion VND, the balance with the health insurance fund was negative nearly 373 billion VND. The reason for the fund overrun was due to the impact of adjusting the price of medical services; Health insurance examination and treatment policy; Many hospitals deploy high technology in medical examination and treatment.

There are also subjective causes from the Social Insurance agency as well as medical facilities abusing tests, techniques, drugs, bed days, not recognizing each other's results, and charging incorrect prices for services...

Also according to the report: In the first 6 months of 2016, through interdisciplinary inspections as well as appraisals at 23 hospitals and medical centers in the province, Nghe An Social Insurance "temporarily" refused to pay nearly 52.6 billion VND. Of which, 18.3 billion VND was refused to pay and 34.3 billion VND was waiting for the opinion of Vietnam Social Insurance.

The fact that many hospitals in the province focus on developing high technology is also the main reason for exceeding the health insurance fund.

The reason for the refusal to pay is due to the joint inspection by the Department of Health - Social Insurance, as well as the team of Social Insurance appraisers identifying many establishments that are violating the law and state regulations; The reason for waiting for opinions to pay is due to the shortcomings arising in the actual implementation as well as the conflicting regulations and instructions between the two sectors of health and social insurance.

Should we invite an independent appraisal agency?

At the meeting, representatives of medical examination and treatment facilities raised the shortcomings, difficulties and questions surrounding the health insurance examination and treatment in 2016 in Nghe An. According to the Department of Health, there were up to 80 different contents, recommending that the health sector and social insurance need to have solutions to thoroughly resolve the problem to ensure the legitimate and increasing health care needs of the people in general and health insurance participants in particular.

Doctor Pham Gia Van - Deputy Director of Nghe An Social Insurance answered questions and said that strengthening supervision is the optimal measure to reduce health insurance overspending.

At the meeting, Dr. Pham Gia Van - Deputy Director of Nghe An Social Insurance Department answered, clarified and acknowledged these opinions. Dr. Pham Gia Van said: "It is very painful to have to postpone and "temporarily" refuse to pay such a large amount of money that is not in accordance with regulations. Medical facilities say they are not profiteering, but when I ask this question, are you surprised: "Why is the patient recorded as inpatient when he is at home?" "Why is an abdominal ultrasound performed when he is scratched by a cat?"...".

Concluding the meeting, Pharmacist Hoang Van Hao - Deputy Director in charge of the Department of Health stated: "The viewpoint of the medical sector is to properly implement the State's policies and laws, ensure the legitimate rights of patients and ensure the legitimate rights of medical examination and treatment facilities.

The Department of Health will not ask for any medical facility that does wrong. If the Social Insurance Agency concludes that it is incorrect, the Department of Health is ready to give its opinion. If any violation is discovered, the Department will take disciplinary action and transfer it to the investigation agency.

Doctor Nguyen Hong Truong - Director of Vinh City General Hospital suggested: "There needs to be truly sustainable solutions to balance the fund as well as ensure patient rights, such as unifying the treatment process or promoting the application of information technology".

Mr. Hao also raised the issue: "If the Social Insurance's appraisal team is inexperienced and lacking in expertise, we should invite independent appraisal agencies with high expertise. Currently, many medical facilities are "suspended" waiting for payment opinions, the Social Insurance should pay attention to resolving the issue so that the units have operating funds, not affecting medical examination and treatment work."

Thanh Son