Focusing on the assessment of key performance indicators that need to be achieved

In a report on the implementation of Health Insurance policies, Mr. Le Van Phuc - Director of the Department of Health Insurance Implementation at Vietnam Social Security, stated that in the first 6 months of the year, there were 64.2 million medical examination and treatment cases nationwide, representing a 29.2% increase compared to the first 6 months of 2022. The total expenses for Health Insurance-covered medical services across the country amounted to 46,236 billion VND, marking a 23.4% increase, with the requested expenses for reimbursement from Vietnam Social Security increasing by 16.2%. As of October 30, 2022, the average inpatient treatment rate for the first 6 months of 2023 nationwide stood at 10%, reflecting a 1.7% increase compared to the same period the previous year. Many provinces and cities exceeded the national average in terms of budget utilization."

The projected total expenditure for Health Insurance-covered medical services for the entire year 2023 is 120,666 billion VND, achieving 107% of the Government's budget estimate. It is estimated that 40 provinces will exceed the Government's budget estimate, with some provinces having particularly high rates of expenditure, including Vinh Phuc at 116.7%, Phu Tho at 115.7%, Thanh Hoa at 113.3%, Thua Thien Hue at 111.8%, Bac Ninh at 111.5%, Kien Giang at 111.4%, Dong Thap at 110.7%, Nghe An at 110.6%, Hanoi at 110.4%, Dak Lak at 110.2%, Ca Mau at 110.0%, Dong Nai at 110.0%, Thai Binh at 109.7%, and Quang Ninh at 109.6%.

In the actual implementation of the policy during the first 6 months of 2023: Social Insurance offices directly signed Health Insurance contracts with 2,830 Health Insurance providers (among these, there were 1,784 public healthcare facilities and 1,046 non-public healthcare facilities), this corresponds to 46 central-level facilities, 563 provincial-level facilities, 2,088 district-level facilities, and 133 healthcare agencies (equivalent to commune-level facilities). Additionally, there were nearly 10,000 healthcare stations providing Health Insurance services through contracts with district hospitals or health centers or facilities assigned tasks by the Department of Health (in reality, there were 11,700 registered healthcare stations, but currently, only 9,750 are active). Compared to 2022, this represents an increase of 140 contracted healthcare facilities, with 64 of them being public healthcare facilities and 76 being non-public healthcare facilities.

Deputy Director General of Vietnam Social Security, Mr. Nguyen Duc Hoa, delivered directing remarks at the conference

Mr. Phuc highlighted several issues at the conference, particularly for localities with high healthcare expenses for Health Insurance patients, exceeding 85% of the budget. He advised these localities to collaborate with the Department of Health to provide recommendations to the Provincial People's Committee regarding monitoring and cost control measures; ensure the availability of pharmaceuticals and medical supplies. Regarding the resolution of issues and backlog in settling Health Insurance-covered medical expenses in some localities, Mr. Phuc stressed that this is not a debt owed to Vietnam Social Security but rather arises from incomplete documentation, procedures, or conditions for settling expenses. Provincial Social Insurance offices and relevant units within the region need to enhance coordination to find lasting solutions to these issues.

Referring to the outstanding healthcare expenses for Health Insurance patients from previous years, which were included in the 2021 settlement, Mr. Phuc stated that these are costs that exceeded the budget, economic-technical norms, and the approved total payment amount after appraisal, and sought the opinion of the relevant authorities.

According to regulations, Social Insurance office can only settle costs that healthcare facilities propose for payment along with complete and proper documentation as required. In cases where additional Health Insurance expenses arise due to objective or specific reasons within the year, the Social Insurance office collaborates with the healthcare facility to identify the causes. In this process, the healthcare facility is responsible for providing clarification and elucidating valid factors contributing to the increase or decrease in expenses. After examining these costs, the Social Insurance office can then include them in the settlement or seek opinions from relevant authorities (Vietnam Social Security Board of Commissioners, the Ministry of Health, the Government, etc.) to find solutions to address them.

Furthermore, there are still some Healthcare Insurance expenses that currently exceed the economic-technical norms and the budget… that are being proposed for payment by healthcare facilities, but they lack the necessary valid documentation for settlement purposes. Many healthcare facilities have surpassed the total payment limit from previous years but have yet to provide a reasonable explanation for this increase.

Director of the Department of Health Insurance Implementation at Vietnam Social Security, Mr. Le Van Phuc, reported on the implementation of the Health Insurance policy for the first six months

Assessing the results of implementing the Health Insurance appraisal process according to Decision No. 3618/QD-BHXH dated December 12, 2022, by the Director-General of Vietnam Social Security, Mr. Duong Tuan Duc - Director of the Center for Medical Claim Review, also highlighted several issues to be considered in the Health Insurance cost appraisal activities. Mr. Duc provided examples of inconsistencies that need to be addressed immediately during the specialized appraisal processes at local Social Insurance offices. This includes the developments in healthcare services during the first 7 months of the year, unusual increases in costs at healthcare facilities due to various factors, and the need for local Social Insurance offices to ensure that healthcare facilities comply with data sharing regulations in terms of timeliness and data quality. He also emphasized the importance of not advancing or settling data incorrectly and rejecting payment requests that do not match the electronic data with the patient records.

Some healthcare facilities have significantly higher average costs, such as Vinmec International General Hospital (Hanoi) with an average outpatient cost of 3.2 million VND per visit (mainly related to diagnostic tests and imaging), Vinmec Central Park International General Hospital (Ho Chi Minh City) with an average outpatient cost of 1.8 million VND per visit, and the Cancer Hospital (Hanoi) with an average outpatient cost of 1.78 million VND per visit.

Additionally, the abuse and misappropriation of the Health Insurance fund at private multi-specialty clinics in certain provinces, such as patients receiving medical certificates for Health Insurance benefits without actually visiting the clinics or doctors issuing these certificates without providing services at the clinics, etc… these are the limitations and existing challenges related to the lack of thorough oversight in the execution of Health Insurance contracts. For instance, there have been cases of fraudulent documentation for Health Insurance benefits in Dong Nai province, and recently, Nghe An’s Public Security initiated legal proceedings against a group of individuals who falsified medical records to receive life insurance and exploit Health Insurance funds. The Vinh City police are currently requesting Vietnam Social Security to assess the damage to prosecute those involved in Health Insurance fraud.

The Director of the Center for Medical Claim Review highlighted some existing issues, such as incorrectly pricing technical services, additional payments for technical services, healthcare facilities practicing without registering their medical practice, simultaneous registration of medical practices, failure to request healthcare facilities to adjust their operating licenses when expanding their scope, and healthcare facilities not being re-evaluated after 5 years as specified in Circular No. 23/2005/TT-BYT issued by the Ministry of Health.

At the conference, leaders of various units under Vietnam Social Security and local Social Insurance offices focused on evaluating and identifying the difficulties and challenges encountered in meeting their targets and tasks. For instance, some provinces experienced a high increase in Health Insurance expenditures, including Hau Giang, Tra Vinh, Dong Thap, Vinh Long, Kien Giang… The issue of exceeding the allocated budget, surpassing the budget estimate, and exceeding the total payment limit still persists in many healthcare facilities. Additionally, there are ongoing challenges in the process of provisional funding and settling the costs of Health Insurance-covered medical services in certain regions.

The Director of the Center for Medical Claim Review, Mr. Duong Tuan Duc, delivered a speech

Phu Tho and Nghe An Social Security offices reported on the status of implementing the Health Insurance cost estimate for the year 2023. They also collaborated with the Provincial Department of Health to forecast the expected expenditures across the province based on the total payment limit at healthcare facilities. Additionally, they coordinated with the police and the Provincial Department of Finance in managing healthcare facilities, forming inspection teams to visit healthcare facilities with unusual healthcare expenses; through that inform, raise