Health insurance coverage: A big challenge for medical facilities in Nghe An

From January 1, 2020, people with health insurance cards can go to medical examination and treatment at provincial-level medical examination and treatment facilities nationwide without needing a referral from the district level and will be paid by the health insurance fund for inpatient treatment costs according to the scope of benefits and levels as in the correct line. Photo: Internet

More benefits, more pressure...“Some laugh, some cry”

According to the provisions of Clause 6, Article 22, Law on Health Insurance (HI): From January 1, 2021, the policy will be implemented.through lineprovince in inpatient treatment for health insurance examination and treatment. Accordingly, people with health insurance cards can go to medical examination and treatment facilities at provincial level nationwide without needing a referral from the district level and will be paid by the health insurance fund for inpatient treatment costs according to the scope of benefits and levels as in the right line (80%, 95% and 100%). Previously, when the provincial line was not connected, patients who went to medical examination and treatment in the wrong line were only paid 60% of inpatient treatment costs by health insurance.

Cases of medical examination, treatment, and inpatient treatment at the Central level without a referral letter will still be covered at 40%, except in emergency cases, patients who are ethnic minorities and poor households or people living in island communes and island districts.

Perform route clearanceHealth insuranceProvincial inpatient treatment for people with health insurance cards has created more convenience for patients. Patients have the right to choose according to their needs. However, this new regulation will also be a challenge for provincial hospitals. Hospitals will have to face the situation of "overload" when the number of inpatients increases. This requires hospitals to improve the quality of medical examination and treatment, innovate management methods, enhance service quality to attract patients; at the same time, find solutions to solve the overload situation.

Emergency patient at Nghe An Provincial General Friendship Hospital. Photo: Thanh Cuong

In Nghe An, implementing the new policy, “some laugh, some cry”. Provincial hospitals are implementing the autonomous mechanism and are “excited” at the prospect of a larger number of patients. The director of a provincial hospital confidently said: In the past, the hospital has been actively purchasing equipment, building facilities, and constantly investing in people, processes, and techniques. This has helped the hospital attract local patients. There is a risk of overload, but we are confident that we can meet it.

According to the hospital director: Controlling the flow of patients from lower-level hospitals to higher-level hospitals is similar to the principle of a light switch. If you want a patient to return to a lower-level hospital for treatment, you must conduct a triage examination. If you want to keep a patient, you must assign the patient to inpatient treatment... Although there are regulations, whether or not to admit or keep the patient for treatment depends on the conditions of the provincial-level patients.

Parents take their children to wait for medical examination at Nghe An Obstetrics and Pediatrics Hospital. Photo: Thanh Cuong

Doctor Vi Van Chien - Director of Tuong Duong District Medical Center said: Although there have been many developments, the provincial inpatient health insurance connection is really a concern of lower-level medical facilities. They are worried that provincial hospitals will receive a large number of patients. Patients with headaches, dizziness, and vestibular disorders can be treated at lower-level hospitals, but the provincial hospitals also receive treatment. Meanwhile, payment is the source of health insurance funds from lower-level hospitals. To avoid exploitation and unfairness, the authorities need to closely monitor and manage the conditions of facilities and human resources at the hospital, avoid the situation of 3-4 people sharing a bed; clearly distinguish between different levels of disease; strictly implement the form of transferring patients to lower-level hospitals when their condition is stable.

Upper-level hospitals continue to be overloaded, lower-level hospitals are likely to "collapse"

Many Nghe An health experts commented: With the policy of connecting inpatient health insurance, there will certainly be a trend of Vinh city residents flocking to Hanoi; Ha Tinh district and province residents flocking to provincial hospitals. This trend will continue at least throughout 2021. Provincial hospitals are already overloaded but do not miss the "opportunity to exploit". And even provincial hospitals themselves cannot refuse patients, because this is a legitimate right and request of patients. This policy will inadvertently hinder other policies, which are to prevent overload at higher levels and strengthen grassroots health care. Higher-level hospitals will continue to be overloaded, lower-level hospitals will find it difficult to develop, and will easily "collapse". This is a difficult problem.

Instructions for patients coming for medical examination and treatment. Photo: Tu Thanh

Direct provincial medical examination and treatment facilities to strengthen the management of medical examination and treatment service quality in accordance with the guidance in Circular No. 19/2013/TT-BYT dated July 12, 2013; develop diagnostic and treatment guidelines, including regulations on inpatient admission standards in accordance with professional requirements, equipment conditions and human resources of the hospital for at least 80% of common disease codes that the hospital is examining and treating, not prescribing inpatient treatment for cases that are not really necessary; direct the arrangement and allocation of hospital beds in accordance with the scale, equipment and human resources available at the medical examination and treatment facility.

Direct provincial general and specialized hospitals to support the transfer of techniques and technical expertise to lower levels; direct district and commune-level medical examination and treatment facilities to implement solutions to improve the quality of grassroots medical facilities, meet the medical examination and treatment needs of health insurance participants and reduce the situation of patients going to the provincial and central levels for medical examination and treatment; review and specify the levels of medical examination and treatment facilities in the area under their management authority, and at the same time coordinate with provincial-level Social Insurance to direct and organize inspections of health insurance examination and treatment at provincial, district and commune-level medical examination and treatment facilities, focusing on inspecting the appointment of inpatient treatment.

Examination and treatment for patients at Vinh City General Hospital. Photo: Duc Anh

Directive No. 25/CT-BYT is relatively clear in terms of policy, but medical facilities are still waiting for specific instructions to implement it fundamentally, ensuring the rights of patients./.