Attending the conference were experts from the World Bank (WB), the Ministry of Health (MoH), Vietnam Social Security (VSS) and related units. In the opening speech, Mrs. Sarah Bales - WB consultant shared an overview of the status of using inpatient services in Vietnam. Accordingly, the hospitalization rate in Vietnam is relatively high (over 120 visits per 1000 people in 2018). At the same time, the trend of choosing inpatient medical facilities is increasingly concentrated at the upper level. The average number of inpatient days of Vietnam is also quite high compared to other countries in the region. Health expenditures for inpatient services accounted for 50.6% of total recurrent health expenditures for inpatient services (2017), and 63.3% of health insurance spending in 2018 was spent on inpatients.

Sharing at the conference, Director of the Center for Medical Claim Review (VSS) Duong Tuan Duc said: The reason for the increase in the rate of inpatient treatment and the average day of treatment in Vietnam is due to the fact that medical facilities are self-financed and wages are included in the bed price, accounting for 54-56%. That is, the more patients are admitted to inpatient treatment and the longer they stay, the higher the salary for medical staff. This is also a policy question that we would like to ask the Health Strategy and Policy Institute and the experts present at the conference.

Illustrative image (source: internet)

“A specific example is the rate of patients being discharged and admitted to the hospital on weekdays according to statistics across the country: Monday and Tuesday are the days patients are discharged the most; Saturday and Sunday are the lowest. Most of the patients discharged on Saturdays and Sundays are patients who show up at the maternity hospitals after giving birth. We hope that the Institute can study and evaluate the impact of indications for inpatient treatment on capacity, responsiveness, and ability to provide medical services with indications for inpatient treatment in Vietnam”, suggested Duc.

Sharing international experience, Mrs. Sarah Bales said: “Inpatient visits are determined by the doctor's appointment to the hospital. In countries, it is usually acute hospitalization only when the doctor sees the need for a patient to stay in the hospital for one night or more. For each inpatient session, the appointing doctor must clearly state enough information in the medical record to demonstrate the clinical need for the patient to be hospitalized.

Giving in-depth analysis of the clinical criteria that determine the need for hospitalization, the WB's representative said: There are many different sets of criteria to support clinical decisions, in which the tool assesses the clinical relevance of the indication for hospitalization.

Comparing the clinical criteria that determine the need for hospitalization being applied in Vietnam with AEP, Sarah said: “Most of the criteria applied in Vietnam are only related to the pathology, and no criteria related to intensity of care or treatment. At the same time, the criteria in Vietnam do not have a quantitative threshold, and many of them do not distinguish the need for hospitalization. In addition, the expert said that in Vietnam, there are no specific regulations that doctors must specify the clinical reasons for the indications for hospitalization. In Decision No. 4210/QD-BYT, there are 4 reasons for hospitalization including correct route, emergency, improper levels and inter-provincial levels. However, this is still not a clinical reason for hospitalization.

Agreeing on the necessity of developing a set of criteria for the appointment of hospital admission, Dang Sy Huy, an expert from the World Health Organization (WHO), said: “In Vietnam, the decision to the patient's hospitalization or non-hospitalization is mostly based on the doctor's feelings. We don't have a single criterion to say whether a patient needs hospitalization or only outpatient treatment. Not only that one, but also other decisions such as hospital discharge or infusion are also made emotionally without any criteria. We should change all of these in the direction of developing specific standards and criteria similar to AEP for each doctor's admission decision.”

Illustrative image (source: internet)

“These criteria are not only related to the expertise and fields of the health insurance fund; but also a matter of expertise that benefits all parties. Patients will not need to be hospitalized for unnecessary reasons, avoiding unnecessary complications during treatment. At the same time, it is also good for the doctor's profession.”, Mr. Huy emphasized.

Regarding research on the potential to reduce hospital admission rates by enhancing primary care for some diseases that are sensitive to outpatient services, Sarah Bales said: Potentially avoidable inpatient treatment is the treatment of diseases that have the potential to prevent diseases or provide effective and timely care at the community-based primary care level. These diseases are also referred to as Ambulatory Care Sensitive Conditions (ACSCs).

Possible primary care options to avoid hospitalization for ACSC include: Reducing and managing disease risk factors, Vaccination, Dental Health Checkup, Sexual Health Checkup, Prenatal care, Timely diagnosis and prescription of medications to manage infections, Lifestyle interventions to reduce the development of chronic disease, Chronic disease management to slow disease progression and risk of complications symptoms, including support for self-management of the disease.

She also noted: Classifying an inpatient session as a "potentially avoidable inpatient" is different from the concept of "inappropriate inpatient treatment". Potentially avoidable inpatients means that these episodes, if prevented and managed optimally earlier in the community (outpatient, primary care), have the potential to avoid aggravation to the point of requiring inpatient services. Diseases susceptible to inpatient services (or avoidable inpatient episodes) are classified into 3 groups, including: Vaccine-preventable diseases, Acute diseases, and Chronic diseases.

Regarding the method of identifying potentially avoidable inpatient episodes (or patients with diseases susceptible to outpatient services), Sarah said: Identifying ICD-10 codes of disease groups that can be prevented and treated to avoid hospitalization based on previous studies of susceptibility to outpatient services. Consult with clinical staff on the suitability of the list of diseases based on the following criteria: Patients with that disease account for a significant proportion of the total number of inpatient visits; diseases that can be avoided or treated at the primary care level or by outpatient services; relatively simple specific disease, diagnosis and assignment of ICD-10 codes; rely on data used in health insurance payments to determine the number of potentially avoidable inpatient visits; calculate indicators such as the rate of potentially avoidable inpatients per 1000 population; proportion to the total number of inpatients.

Mrs. Nguyen Thi Thanh Ha - Head of Division of Health Insurance Implementation (VSS) believes that the use of the potential boarding rate index in monitoring the payment formula according to the DRG and to the output is appropriate, and can be assessed by the regulator with the current database. However, the top basic task that needs to be done in the near future is to develop a set of criteria for appointing hospital admission, on the time to do day treatment or inpatient treatment, etc. "I really want to build a common standard because now hospitals also have their own standards for each disease. The nature is not the standard of the Ministry of Health, but the standard of each disease in the guidelines for diagnosis and treatment, as the Ministry of Health has not yet prescribed any hospital admission criteria. Currently, with the system and the database code on the inspection system, I think we can completely do it", Ha emphasized.

On whether there are any regulations in Vietnam for doctors to comment on the causes and reasons for admission before being admitted to the hospital, Ha said: Regulation 4210 are just codes of contents related to the payment of costs of medical care and health insurance, but it is not related to the clinical content. But regarding the content as presented by the representative of the World Bank wants to be shown in the electronic medical record, currently the MoH is still developing that encrypted content. According to the regulations on medical records, before deciding whether a patient should be admitted to the hospital for inpatient or outpatient treatment, the doctor must base on a combination of factors: the reason for the patient's likelihood of being admitted to the hospital, physical factors, and test results. Only then can the doctor decide whether the patient should be treated as an inpatient or only as an outpatient. Those regulations are contained in many documents, so it is wrong to say that Vietnam has no documents or regulations.

Giving the conclusion speech of the conference, Mrs. Sarah Bales expressed her gratitude towards experts for their opinions, contributions and sharing. These are the problems that Vietnam is facing in practice, which will need experts and policy makers to continue discussing to come up with appropriate solutions. The WB commits to accompany and support Vietnam in this activity./.