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During discussions on issues related to the Law on Medical Examination and Treatment (MET) and the Law on Health Insurance (HI), many delegates focused on analyzing shortcomings in the transparency of MET costs, the payment mechanism for medicines and healthcare services, and the rights of patients at healthcare facilities.

Transparency regarding the portion covered by health insurance funds and the portion paid out-of-pocket by the patient

Delegate Nguyen Khanh Vu (from the National Assembly delegation of Quang Tri Province) noted that while current law stipulates that patients with HI must pay for expenses outside the scope of their coverage, it does not clearly define the right to be informed in advance of these costs. Patients are only provided with information about service prices, while the right to have the payment details explained, as stipulated in Clause 2, Article 12 of the Law on Medical Examination and Treatment, only arises upon request.

Meanwhile, the level of HI coverage for participants varies from 80% to 100%, depending on the individual’s category, the healthcare facility, and the reimbursement rate for certain medications and services. Therefore, it is difficult for patients to accurately determine the amount they have to pay.

In fact, voters have reported cases where patients have to buy medicines and supplies that should have been covered by HI. In some cases, patients who followed the correct procedures for examination and treatment still had to pay additional costs beyond their co-payment, prompting the Ministry of Health to take corrective action.

According to Delegate Nguyen Khanh Vu, without prior notification, patients find it difficult to determine which charges are legitimate and which are not. This legal loophole could become an opportunity for overcharging at some medical facilities.

The delegate argued that while strengthening inspections and audits is necessary, it is not insufficient. If patients are unaware of their financial rights and obligations, they are unlikely  to detect and report violations. Prioritizing inspections of facilities with numerous complaints also fails to address the root of the problem, as patients cannot report violations if they are unaware, while inspections and audits primarily focus on addressing issues after violations have occurred.

Based on the above situation, delegate Nguyen Khanh Vu proposed adding to Article 12 of the Law on MET a provision that patients must be informed in advance of any out-of-pocket costs - those not covered by HI -  when medications, medical equipment, or technical services are prescribed (except in emergency cases). Furthermore,  the Government should be tasked with specifying the detailed content and form of such notification.

Clarifying payment responsibilities and expanding access to health insurance-covered medications

Focusing on ensuring the financial rights of patients, delegate Ha Anh Thu (Quang Ngai Province) proposed clarifying the mechanism for HI payments when patients choose on-demand services.

According to the delegate, before patients choose a service, healthcare facilities should clearly inform them of the estimated cost covered by the HI fund and the portion the patient must pay out-of-pocket. When making payments, these two amounts should be shown separately on the statement so that patients can easily track and compare them.

The delegate also suggested paying attention to the accessibility of medications as prescribed by doctors. The choice of medication must be based on the patient's condition and the effectiveness and safety of the treatment. When reviewing the list of medications covered by HI, priority should be given to considering new generation drugs with evidence of clear benefits for patients, such as extending survival time, reducing complications, or minimizing serious side effects.

The review process needs to identify the patient groups that would benefit most, while also assessing the cost of the entire treatment process and the affordability of the HI fund.

In cases where a medication prescribed by a doctor is covered by HI but the hospital is out of stock, it must explain the situation and proactively find alternative solutions to ensure treatment. If a suitable alternative is available, the doctor must clearly explain the clinical rationale for its use to the patient.

In cases where patients have to purchase medication themselves and are eligible for direct reimbursement, the hospital must issue a confirmation slip stating the medication shortage and instruct the patient to complete the necessary paperwork, including the invoice, to be submitted to the Social Security office. The Social Security office will then process the direct reimbursement based on the quantity and price on the invoice, subject to established reimbursement caps and the patient’s specific coverage level.

For medications not covered by HI, hospitals must clearly explain the reason for prescribing them and the costs that patients must bear themselves. According to delegate Ha Anh Thu, patients need to be fully informed of this information before purchasing the medication./.