Review of piloting capitation payment method for Health Insurance -based healthcare in some...

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


• 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


• 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


• 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



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)


• 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


• 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


• 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


• 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


• 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


• 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


• 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


• 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


• 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


• 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


• 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


• 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.


• 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

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