Nghe An: 'Blaming' each other in the management and use of health insurance fund

(Baonghean) - Exceeding the health insurance fund has long been considered a problem of the two sectors of health and social insurance. However, if we fully recognize the nature of a social welfare policy, this is the responsibility of many sectors and agencies.

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

» 'Clearing the name' of patients and medical facilities

Medical examination with high-tech imaging machine at Tay Nam General Hospital.

The debate is never over.

One issue that the two sectors are still debating has not reached a consensus and is causing difficulties for facilities implementing the health insurance examination and treatment policy: the number of examinations. In Decision 1313/QD-BYT dated April 22, 2013 of the Ministry of Health on promulgating guidelines for medical examination procedures at the hospital's Examination Department, the target is set: "By 2015, on average, each examination room strives to examine a maximum of 50 patients/8 hours and by 2020, only 35 patients/hour.

In case the number of patients suddenly increases due to various reasons, we strive to ensure that each examination room does not increase by more than 30% of the above target.

Nghe An Social Insurance based on this Decision issued Official Dispatch 1737 dated September 16, 2016 "On rectifying the work of appraisal and control of health insurance examination and treatment costs", with the following content: Review and check the frequency of medical examination at the examination department of medical examination and treatment facilities, only accept payment of health insurance examination and treatment costs for each examination room for a maximum of 50 patients/8 hours.

On one side is the standard to strive for, on the other side is the "floor" standard while from reality to the goal to strive for is a whole problem.

Some manifestations of fund abuse such as using other people's health insurance cards, patients going to the hospital multiple times, hospitals abusing technical services and drugs, etc. are only on the unilateral analysis of the social insurance sector. The payment plan is also proposed by the social insurance sector itself, but the two sectors have not yet agreed on a common set of rules on treatment regimens, identification of technical service and drug abuse, or solutions to handle cases of fund abuse.

Emergency patient at Thanh Chuong General Hospital.

Loose coordination, the two sectors also show signs of "blaming" each other in the management and use of the health insurance fund. Ms. Nguyen Thi Kim Tien, in her explanation session with the National Assembly delegates on March 1, 2017, stated her opinion: The desire of the people and patients to go to good hospitals for examination is legitimate. The fault here lies in poor management, organization, and investment.

According to Ms. Kim Tien, there are still no measures to manage and control patients who come to the clinic multiple times. However, since June 2016, all hospitals have had to connect to the electronic health insurance assessment information system and join the national common data storage system for the social insurance agency to assess.

Just enter the insurance card number to access the medical examination and treatment history of the cardholder. However, through observation, when receiving patients, some hospitals, even though they know that the patient has been examined many times before, still "turn a blind eye".

Urgent need for a common voice

Many localities have had effective solutions in controlling the health insurance fund, that is, the health sector issues and agrees with the social insurance to standardize treatment regimens for each disease with indications for technical services, drugs, and specific number of visits as a basis for doctors to prescribe, social insurance officers to appraise, and pay.

For example, Hanoi Social Insurance has agreed with local medical examination and treatment facilities on how to manage and treat chronic diseases such as hypertension and diabetes with specific instructions on the types of drugs to use and the number of visits per year at all levels, saving costs for the health insurance fund.

This treatment regimen is consulted and developed by leading medical experts so patients can rest assured to follow it, not to go beyond the recommended level or number of times.

The two sectors also need to work together to develop sanctions to handle violations and abuse of the health insurance fund to have a basis to handle violations that are on the rise, especially when connecting provinces for medical examination and treatment in the coming time.

In case the health insurance fund has an imbalance in revenue and expenditure, there needs to be more involvement from the Government, the Ministry of Finance, People's Committees at all levels, and auditing agencies to come up with a plan to arrange financial resources to ensure the maintenance of health insurance examination and treatment.

And in particular, it is necessary to review the role of a sector that has never been mentioned before in the management and use of the health insurance fund: the Department of Labor - Invalids and Social Affairs. The reason is that this agency plays the role of "weighing and measuring", managing beneficiaries of policies, including policies to support participation in health insurance. In the face of the situation of "wrong" policy enjoyment as many cases have been discovered in the past, it is time for the Department of Labor - Invalids and Social Affairs to be more proactive and active in controlling and using the health insurance fund to maintain the stability of a humane policy, ensuring the rights of the people.

Reporter team