Team Group: Nghiêm Trần Dũng 2. Hoàng Thị Phượng 3. Tran Quang Thong 4. Dương Đức Thiện

1. Review of piloting capitation payment method for Health Insurance -based healthcare in some provinces of Vietnam CBEH Vietnamese group

2. Review of piloting capitation payment method for Health Insurance -based healthcare in some provinces of Vietnam • Team Group: • Nghiêm Trần Dũng • 2. Hoàng Thị Phượng • 3. Tran Quang Thong • 4. Dương Đức Thiện • 5. Nguyễn Bích Lưu • 6. Nguyễn Thị Vân Anh National Coordinator Nguyễn Thị Kim Phương Hanoi 4/2010

3. Background • 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

4. 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.

5. Methodology • 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

6. Main 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

7. Situation of piloting capitation for HI in selected provinces (1) • HI coverage and enrollment composition in selected provinces

8. Situation of piloting capitation for HI in selected provinces (1) • Scope and point of time starting capitation-based mode pilot

9. Situation of piloting capitation for HI in 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 patients The big difference between scope and capacity of perfoment of hospital related to cost and premium design, idetification in each hospital

10. Situation of piloting capitation for HI in 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

11. Premium design and identification (1)

12. Premium design and identification (2)

13. Premium design and identification (3)

14. 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)

15. Changes after piloting capitation payment method (1) • Card composition prior to and after piloting

16. Changes after piloting capitation payment method (2) • Assignment of capitation fund in the year of piloting (including commune fund) in selected district hospitals

17. Changes after piloting capitation payment method (3) • Average cost of outpatient consultation prior to and after the year of piloting

18. Changes after piloting capitation payment method (4) • Average cost of inpatient contact prior to and after the year of piloting

19. Changes after piloting capitation payment method (5) • Fund balancing capacity prior to an after applying capitation

20. Changes after piloting capitation payment method (6) • Fund overspending in the last 6 months in 2008 and first 6 months in 2009 in Hải Dương province

21. Changes after piloting capitation payment method (7) • Overspent amount in 6 months in 5 district hospitals in Ha Nam

22. Changes after piloting capitation payment method (8) • Expenditure composition by hospital (%)

23. Changes after piloting capitation payment method (9) • Increase rate of hospital service provision in the year piloting compared to previous year (%)

24. Constraints and difficulties in the pilot 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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.

31. 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

32. 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.

33. 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

34. Thanks for your attention