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Review of piloting capitation payment method for Health Insurance -based healthcare in some provinces of Vietnam CBEH Vietnamese group. Review of piloting capitation payment method for Health Insurance -based healthcare in some provinces of Vietnam. Team Group: Nghiêm Trần Dũng - PowerPoint PPT Presentation
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Review of piloting capitation payment method for Health Insurance -based
healthcare in some provinces of Vietnam
CBEH Vietnamese group
Review of piloting capitation payment Review of piloting capitation payment method for Health Insurance -based method for Health Insurance -based
healthcare in some provinces of Vietnamhealthcare in some provinces of Vietnam
Team Group: 1. Nghiêm Trần Dũng2. Hoàng Thị Phượng3. Tran Quang Thong4. Dương Đức Thiện5. Nguyễn Bích Lưu6. Nguyễn Thị Vân Anh
National Coordinator Nguyễn Thị Kim Phương
Hanoi 4/2010
BackgroundBackground• Current fee for service payment system
has led to over-supply and over consumption
• HI funds faces serious deficits in recent years: 2005: - 138 bill.; 2008: 1500 bill.
• There have been several pilots in introducing capitation payment methods in the last several years but there is no critical evaluation of these pilots so that lessons can be learnt and forwarded steps can be recommended.
• The government is interested and commited to reform provider payment mechanism in health insurance
Objectives Objectives • To describe the piloted capitation mode in
selected provinces in Vietnam.• To analyze advantages and disadvantages
challenging healthcare providers and HI agencies upon implementation of the capitation mode in the current context in Vietnam.
• To make policy recommendations on continued improvements towards an appropriate reimbursement mode in Vietnam.
MethodologyMethodology• Study design: A cross – sectional study• Data collection:
– Collecting available information and data– In-depth interviews– Focus group discusions
• Study site: Hai Duong, Thanh Hoa, Ha Nam, Hoa Binh
• Target group: i) Health policy maker; ii) Health manager; iii) Health Insurance Agency; iv) Health Care Provider
Main findingMain finding Situation of piloting capitation payment method for
health insurance in selected provinces. Premium design, identification Changes after implementation of capitation
payment method Constraints and difficulties in the pilot design and
implementation
Situation of piloting capitation for HI in Situation of piloting capitation for HI in selected provinces (1)selected provinces (1)
• HI coverage and enrollment composition in selected provinces
50.7 52.8
22.429.029.7
19.0
66.560.9
0.84.0 3.4 2.4
18.824.2
7.7 7.7
35.231
53.4 51.6
0
10
20
30
40
50
60
70
Hải Dương Hà Nam Hòa Bình Thanh Hóa
Compulsory
Poor
People’s voluntary
Student
Coverage
Situation of piloting capitation for HI in Situation of piloting capitation for HI in selected provinces (1)selected provinces (1)
• Scope and point of time starting capitation-based mode pilotNo Piloted
provinces Scope of implementing Point of time
starting
1 Hai Duong 12/13 district hospitals and their communes
Since 2007
2 Ha Nam 6/6 district hospitals and their communes
01/01/2009
3 Thanh Hoa 2/21 district hospitals (Hà Trung is a lowland district and Mường Lát is a mountainous district)
01/01/2009
4 Hoa Binh 04/10 district hospitals: - 02 district hospitals applying two models capitation and user fees (Mai Châu and Tân Lạc): 50% capitation premium + 50 user fees and 3 communes for each one - 02 district hospitals applying 100% capitation payment model (Lạc Sơn and Yên Thuỷ)
01/01/2009
Situation of piloting capitation for HI in Situation of piloting capitation for HI in selected provinces (2)selected provinces (2)
• Some characteristics of piloting district hospitals– Located in poor districts, among them there is one
mountainous district (Mường Lát, Thanh Hoa)– Lact of material facility, equipment and manpower – Scale of planed hospital beds from 50 – 120 and actualy
beds from 50 – 262 – Most hospital overloaded, capacity of bed over 150% (Hà
Trung, Mường Lát, Nam Sách, Tân Lạc) – Responsibility for examination and treatment for 70% HI’s
patientsThe big difference between scope and capacity of perfoment of hospital related to cost and premium design, idetification in each hospital
Situation of piloting capitation for HI in Situation of piloting capitation for HI in selected provinces (3)selected provinces (3)
• Implementation process– Implementing follow the regulation of MoH, MoF and VSS– Developing pilot project had involved stakeholders (Both PSS and
Health Bureau)– Training for leaders, health staffs and all head of commune health
stations
However: - Less participating of Provincial Health Dept. and health
facilities - Most of medical doctor was lack of knowledge on
capitation payment method because of limited dissemination and training insufficiency
Premium design and identification (1)Premium design and identification (1)Content Hải Dương, Thanh
HóaHà Nam Hòa Bình
Payment method applied
Capitation Capitation Capitation + user fees
Capitation implementer
District hospital + CHS
District hospital + CHS
District hospital + CHS
Beneficiaries All PHC registers at district or commune level
All PHC registers at district or commune level
All PHC registers at district or commune level
Benefit package covered in the capitation fund
(Excluding some costly services)
Commune services
District services
Provincial + central services
Bypassing patients
Commune services
District services
Commune services
District services
Bypassing patients
Premium design and identification (2)Premium design and identification (2)Content Hải Dương,
Thanh HóaHà Nam Hòa Bình
DHS fund Local spending, direct and multiple-level reimbursement
Q = M x N x k
- Thanh Miện: 156,070
- Nam Sách: 154,829 - Mường Lát: 120.162
- Hà Trung: 159.067
Local spending and direct
Q = M x N x k
Bình Lục: 217.456 đ (40.1% local spending)
Phủ Lý: 217.456 đ (17.7% local spending)
Half premium – only aply for local spending (district and communue)
Q = M x N x k
Mai Châu: 65.000 đ
Tân Lạc: 50.000 đ
CHS fund Medicines, medical material, technical services
CHSF = (MxNi)x90%x20%
Medicines, medical material, technical services
CHSF = (MxNi)x90%x20%
Qi = ni x 12.000d package excluding bird attendence
Premium design and identification (3)Premium design and identification (3)Content Hải Dương, Thanh
HóaHà Nam Hòa Bình
Fund surplus Incompliance with Decree 43
Incompliance with Decree 43
Incompliance with Decree 43
Fund overuse Commune social security fund settled 50%,
50% submitted to competent authorities
Commune social security fund settled 50%,
50% submitted to competent authorities
Support by KICH project: VND10,000/card (reservation fund)
Premium design and identification (3)Premium design and identification (3)
• List of items not covered in the premium – Continuous blood dialysis – Thẩm phân phúc mạc
– Cancer
– Transplants
– Hemophilia disease
– Thanh toán hộ
– Co - payment
– People’s vuluntary HI
• k : annual cost index (currently 1.1)
Changes after piloting capitation Changes after piloting capitation payment method (1)payment method (1)
• Card composition prior to and after pilotingType of HI Nam
Sách Thanh Miện
Bình Lục Phủ Lý
Mường Lát
Hà Trung
Tân Lạc
Mai Châu
Prior to pilot
45,606
40,079
46,130 41,920 26,957 60,745 36,959 28,968
Compulsory 35,918
30,681
26,100 25,433
1,694 18,930 5,362 3,818
For the poor - -
9,217 9,476
25,255 32,529 27,561 20,206
Student voluntary
9,678
9,378
1,960 2,096
0 8,584 3,086 3,974
People voluntary
10
20
8,853 4,915
8 702 950 970
Since pilot 47,686
41,427
51,257 54,338
29,163 50,870 38,704 27,030
Compulsory 36,918
31,681
29,000 23,063
2,221
18,199 5,535 3,627
For the poor - -
10,242 6,838
26,936
24,401 29,424 18,986
Student voluntary
10,758
9,726
2,178 4,714
0 6,805 2,262 3,114
People voluntary
10
20
9,837 19,723
6
1,465 1,484 1,304
Difference 2,080
1,348
5,127
12,418
2,206
(9,875)
1,746
(1,939)
Changes after piloting capitation Changes after piloting capitation payment method (2)payment method (2)
• Assignment of capitation fund in the year of piloting (including commune fund) in selected district hospitals
No. District hospital Number of PHC
registration cards
Premium (Average capitated
premium level /card x 1.1) Unit: VND
Global capitation fund
Unit: VND
1 Thanh Miện 41,427 156,070 6,465,501,208 2 Nam Sách 47,686 154,829 7,383,183,653 3 Phủ Lý 17,188 217,456 661,561,170 4 Bình Lục 34,356 217,456 2,995,838,253 5 Mường Lát 29,163 120,162 3,504,285,000 6 Hà Trung 50,870 159,067 8,091,724,000 7 Mai Châu 27,030 65,000 3,561,037,000 8 Tân Lạc 38,704 55,000 4,290,031,000
Changes after piloting capitation Changes after piloting capitation payment method (3)payment method (3)
• Average cost of outpatient consultation prior to and after the year of piloting
Prior to capitation
Capitation year
Premium/user fee difference
No. District hospital
(1) (2) ± % 1 Nam Sách 20,665 25,046 + 4,381 +21.2 2 Thanh Miện 15,943 18,841 + 2,898 +18.2 3 Bình Lục 22,619 29,545 + 6,926 +30.6 4 Phủ Lý 85,771 107,359 + 21,588 +25.2 5 Mường Lát 76,152 74,605 - 1,547 -2.0 6 Hà Trung 70,293 85,892 + 15,599 +22.2 7 Tân Lạc 75,778 94,101 + 18,323 +24.2 8 Mai Châu 83,472 108,115 + 24,643 +29.5
Changes after piloting capitation Changes after piloting capitation payment method (4)payment method (4)
• Average cost of inpatient contact prior to and after the year of pilotingNo. Health
facility Prior to
capitation application
Capitation application
year
Premium/user fee difference
(1) (2) ± % 1 Nam Sách 159,306 286,911 + 127,605 + 80.1 2 Thanh Miện 181,425 190,155 + 8,730 + 4.8 3 Bình Lục 366,996 501,229 + 134,233 + 36 4 Phủ Lý 169,716 186,305 + 16,580 + 9 5 Mường Lát 559,575 592,053 + 32,478 +5.8 6 Hà Trung 1,055,785 1,124,464 + 68,679 +6.5 7 Tân Lạc 594,000 644,000 + 50,000 +8.4 8 Mai Châu 884,000 1,012,000 + 128,000 +14.4
Changes after piloting capitation Changes after piloting capitation payment method payment method (5)(5)
• Fund balancing capacity prior to an after applying capitation
No. Hospital
Capitation fund assigned for 1
year
Expenditures at health facilities between 01 and
09/2009 Balance
1 Nam Sách
7,383,183,653 7,933,463,809
- 550,280,156
2 Thanh Miện
6,463,726,879 6,942,427,244
- 478,700,365
3 Bình Lục
2,287,000,000 2,546,000,000 - 259,000,000
4 Phủ Lý
523,000,000 643,000,000 -120,000,000
5 Mường Lát
3,504,285,000 4,104,634,492 - 600,349,420
6 Hà Trung
10,621,724,000 10,075,574,086 + 546,149,914
7 Tân Lạc
4,290,031,000 3,671,871,000 + 618,160,000
8 Mai Châu 3,561,037,000 4,797,360,000 - 1,236,323,000
Changes after piloting capitation Changes after piloting capitation payment method payment method (6)(6)
• Fund overspending in the last 6 months in 2008 and first 6 months in 2009 in Hải Dương province
-
200,000
400,000
600,000
800,000
1,000,000
1,200,000
Tứ kỳ GiaLộc
BìnhGiang
NinhGiang
ThanhMiện
NamSách
NhịChiểu
ChíLinh
KimThành
Unit: VND 1000 Exceeded fundin the last 6months, 2008Exceeded fundin the last 6months, 2009
Changes after piloting capitation Changes after piloting capitation payment method payment method (7)(7)
• Overspent amount in 6 months in 5 district hospitals in Ha Nam
-
200,000
400,000
600,000
800,000
1,000,000
Unit: VND 1.000
ThanhLiêm
Duy Tiên Bình Lục Lý Nhân Phủ Lý
Changes after piloting capitation Changes after piloting capitation payment method payment method (8)(8)
• Expenditure composition by hospital (%)
Item Thanh Miện
Nam Sách
Phủ lý Bình Lục
Mường Lát
Hà Trung
Mai Châu
Tân Lạc
Local payment
45.4 41.9 17.7 40.1 44.5 62.1 82.6 81.7
Local and bypassing multile-level payment
54.1 57.4 81.7 59.5 55.3 37.8 17.1
18.1
Direct payments
0.5 0.7 0.6 0.4 0.2 0.1 0.3 0.2
Changes after piloting capitation Changes after piloting capitation payment method payment method (9)(9)
• Increase rate of hospital service provision in the year piloting
compared to previous year (%) Hospital Outpatient
consultation Lab test
X-ray CT-Scan Ultrasound Inpatient referral
Outpatient referral
Nam Sách -2.6 55.8 6.3 0 13.9 43.5 -12.7 Thanh Miện -2.6 15.6 57.3 0 13.4 5.9 3.6 Bình Lục 7.4 19.5 8.3 0 -1.8 -10 40 Phủ Lý 19.2 28.9 2.2 0 83.2 26.5 25.2 Mường Lát 3.1 0.5 -21.6 0 28.2 0 0 Hà Trung 33.7 31.8 0 0 35.2 16 14.2 Tân Lạc 0 0 0 0 0 0 0 Mai Châu -13.4 8.7 18 14.4 6.2 -53 29.3
Constraints and difficulties in the pilot Constraints and difficulties in the pilot design and implementation (1)design and implementation (1)
• From policy perspective:– Legal framework and document were not adequate,
systematic and overlapping
– User fees policy has reflected a lot of disadvantages
– Change of health financing policy with the hospital autonomy (Decree 43) and social mobilization (Circular 15)
– Technical delineation of area is not adequate
– Regulation on referral
– Slippage in prices (k) was not appropriate
Constraints and difficulties (2)Constraints and difficulties (2)
• From social security – FFS was applied very long
– Awareness on capitation payment method was still limited
– Social insurance examiners were short in quantity and poor in quality
– Lack of tool for controlling quality of health care service
– Hospital do not have IT management and unified report system
– The pilot capitation was not adequate
Constraints and difficulties (3)Constraints and difficulties (3)
• From health facility perspective – Most hospital did not balance fund, due to
• Premium of capitation was inappropriate
• Quality of health service of hospitals was not uniform:– Health staff was short in quantity and poor in quality in both
district and commune
– Material facilities and equipments are backward
– District hospitals did not have specialized departments
The rate of patient referral was very high (the average 50%, Phủ Lý 80%)
Did not control multiple – level payment
Constraints and difficulties (4)Constraints and difficulties (4)
• From health facility perspective– The reimbursement mechanism of HI
generated difficulties challenging hospital– Assign HI card was not pay attention to age,
sex, patent of disease and region…– Health worker’s awareness and behavior are
challenging Most of medical doctor do not want to apply capitation because they did not have incentive motivation
Conclusion (1)Conclusion (1)
• Process of piloting capitation– The stakeholders were aware of right policy and
importance of renovating the payment methods.– There was higher consensus in central level and
provincial than in health facilities– The role of health bureau and health facilities was
limited in developing and designing of project
Conclusion (2)Conclusion (2)
• Premium design and identification – Calculating premium based on the expenditures in
the previous year seemed not to be rational. Tend to spend more to be a basis for a larger capitation fund assigned in the subsequent year.
– k = 1.1 seemed not truly reflect the factors driving health cost increase.
– Premium including local and by-passing multiple-level payments when hospitals could not control expenditures
Conclusion (3)Conclusion (3)
• Changes after piloting capitation– Improving self – motivate and responsibly of
health facilities in providing health care services– Patient’s spending did not decrease but it tended
to increase in some professional activities– Deficit fund in most hospital
• Material facilities, equipment and capacity can be impacted on quality services and balance fund
• No evidence was available of impacts of the capitation method on service quality and patients’ satisfaction.
Recommendation (1)Recommendation (1)
• Premium design, identification– The capitation payment mode should be applied to
local payments at the grassroots level – The premium should base on the available fund
taking into consideration of the harmonized healthcare need at the district and upper levels
Recommendation (2)Recommendation (2)
• Premium design, identification – Need to calculate premium for the whole province
or nation based on the financing capacity and adjustment with some factors (mountainous, remote areas, gender, age, disease pattern of card holders…).
– Formulate solutions in terms of payment methods in provincial and central hospitals as well as specialized ones.
Recommendation (3)Recommendation (3)
• Implementation– Need to guide specify management, use or
solutions in case of capitation fund surplus or deficit
– Link the reimbursement mechanism to assurance of services quality in health facilities
– Improve social insurance examiner and adjust of roles and tasks of the HI staff
– Establish to converge the highest qualified experts in the HI to carry out HI-related technical
Thanks for your attention