(QBĐT) - Some readers in Nam Ly Ward (Dong Hoi City) sent a letter to Quang Binh Newspaper reflecting on the change in regulations on medical examination and treatment (KCB) covered by health insurance (HI) on Saturdays and Sundays at non-public polyclinics (PKĐK) in Dong Hoi City. The opinion requested the authorities to clarify in order to have an answer for readers and ensure the rights of people in medical examination and treatment covered by health insurance.
According to the reflection of Mr. Nguyen Cong Hung, representative of the Nam Ly ward readers group, in 2024, some people participating in health insurance when coming to Tri Tam General Clinic, Nam Ly ward on Saturdays and Sundays will enjoy health insurance benefits. However, on January 5, 2025 (Sunday), when coming to see a doctor here, people will not enjoy health insurance benefits and must pay hospital fees. Through discussion with the representative of Tri Tam General Clinic, it is known that in 2025, the policy of the provincial Social Insurance agency is not to implement health insurance benefits on Saturdays and Sundays, so the clinic has no basis to resolve health insurance benefits for patients.
The content of the reader's letter also clearly states the needs and rights of health insurance participants and related regulations in Decree No. 146/2018/ND-CP, dated October 17, 2018 of the Government detailing and guiding measures to implement a number of articles of the Law on Health Insurance.
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To clarify readers' opinions, Quang Binh Newspaper has researched, grasped information and discussed with relevant agencies. Mr. Tran Quoc Xuan, CEO of Tri Tam Clinic Joint Stock Company, said that based on the contract between the provincial Social Insurance and the unit, from April 1, 2024, Tri Tam Clinic is allowed to serve people with health insurance cards for outpatient medical examination and treatment (except for Tet and public holidays). This has created great convenience for many people because they can take advantage of the time off on Saturdays and Sundays.
However, the 2025 health insurance contract between the provincial Social Insurance and Tri Tam Clinic Joint Stock Company stipulates that health insurance participants come for outpatient medical examination and treatment on working days of the week (except Saturdays, Sundays, Tet holidays, and public holidays). Therefore, the clinic does not organize health insurance medical examination and treatment on Saturdays, Sundays, Tet holidays, and public holidays according to regulations.
Discussing this issue, Director of the Provincial Social Insurance Tran Anh Tuan said that through the assessment of the implementation of health insurance medical examination and treatment, and the control of health insurance medical examination and treatment expenditures in 2023 and 2024, it was found that a number of medical examination and treatment facilities (PKĐK) were approved by the Department of Health for specialized technical services of traditional medicine (TM) and rehabilitation (PHCN). For patients with diseases that are indicated for treatment by TM-PHCN methods, it is necessary to have enough treatment time (usually lasting more than 7 consecutive days). For the above reasons, the Provincial Social Insurance has implemented a contract for health insurance medical examination and treatment with 4 medical examination and treatment facilities (including the PKKs: Bac Ly, Thuy Minh Tam, Tri Tam, Minh Anh) to organize health insurance medical examination and treatment on Saturdays and Sundays with the aim of ensuring the rights of patients with health insurance cards when they come to health insurance medical examination and treatment for diseases that are indicated for treatment by TM-PHCN methods (to have enough treatment time according to the treatment regimen).
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However, through controlling health insurance expenditures in 2023 and 2024, the total health insurance expenditures in the province exceeded the estimate, in which in 2023 it exceeded by nearly 13%, in 2024 it exceeded by 7.68%. There are many reasons for this situation, including the fact that the average cost per health insurance visit at general clinics (approving and performing specialized technical services of traditional medicine and rehabilitation) is higher than the average cost of health insurance facilities in the region and nationwide of the same rank, same level, and same form of organization.
| Director of the Provincial Social Insurance Tran Anh Tuan: To meet the needs of health care and ensure the rights of health insurance participants, the Provincial Social Insurance continues to monitor and evaluate the situation of health insurance health care in the province, especially when stopping receiving health insurance health care on Saturdays and Sundays (for patients coming for regular, non-emergency, non-acute health care... at the 4 health insurance health care facilities that have been deployed in the past). If there are any impacts on the needs and health care benefits of health insurance cardholders; there is an overload of health insurance health care; health insurance health care facilities commit to properly managing the use of health insurance funds, effectively controlling health insurance health care expenses..., the Provincial Social Insurance will agree with relevant units and health care facilities to have appropriate solutions to ensure the highest rights of health insurance participants, while using the health insurance fund effectively, economically, and controlling health insurance health care expenses well. |
Faced with this situation, the provincial Social Insurance has proactively reviewed and analyzed data to identify health insurance facilities in the province with health insurance costs that are higher than the average costs of health insurance facilities of the same class, same level, same specialty in the province/region/nationwide. The unit has notified the Department of Health to monitor, direct, inspect, and adjust; worked with a number of health insurance facilities with high health insurance costs to unify solutions to control health insurance costs, reduce high average cost indicators, but the efficiency is not high. Through analysis, it shows that the costs are unusually high for health insurance and the implementation of health insurance services related to traditional medicine and rehabilitation (at 4 non-public medical facilities performing health insurance on Saturdays and Sundays).
With the aim of implementing the health insurance policy well, ensuring the highest benefits of health insurance participants, using the health insurance fund effectively, economically, and controlling health insurance expenditures, the Social Insurance Agency has been and is continuing to coordinate with the health sector to implement many synchronous solutions. One of the important solutions is not to implement outpatient health insurance contracts for health insurance participants who go for health insurance treatment on Saturdays, Sundays, Tet holidays, and public holidays for all health insurance treatment facilities in the province, including 4 clinics: Bac Ly, Thuy Minh Tam, Tri Tam, and Minh Anh. For cases where health insurance patients come for medical examination and treatment in an emergency situation and health insurance patients with medical records for outpatient and inpatient treatment must continue treatment on Saturdays, Sundays, Tet holidays, and public holidays according to doctor's orders, they are still entitled to health insurance benefits according to regulations.
In addition, at point b, clause 10, article 27, Decree No. 146 stipulates that medical examination and treatment facilities are responsible for ensuring human resources and professional conditions. However, currently, the above facilities do not have enough specialties, so they do not guarantee the rights of people with health insurance cards when coming to receive health insurance treatment on Saturdays, Sundays, and holidays.
Ngoc Mai
Source: https://www.baoquangbinh.vn/toa-soan-ban-doc/202502/bao-dam-quyen-loi-cho-nguoi-dan-kham-chua-benh-bao-hiem-y-te-2224260/
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