MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH NATIONAL ISTITUTE OF HYGIENE AND EPIDEMIOLGY --------------- -------------- LE TRI KHAI HEALTH INSURANCE CAPITATION PAYMENT METHOD AT SOME COMMUNE HEALTH STATIONS IN DAK TO DISTRICT OF KON TUM PROVINCE Major: Public Health Code: 62.72.03.01 THESIS SUMMARY HANOI - 2014
The thesis was completed at NATIONAL ISTITUTE OF HYGIENE AND EPIDEMIOLGY Supervisors: 1. Professor Nguyen Cong Khan, PhD 2. Tran Van Tien, PhD Objecter 1: Objecter 2: Objecter 3: Professor Truong Viet Dung, PhD Ha Noi Medical University Professor Dao Van Dung, PhD The Party Central Committee s Commission for Popularisation and Education Nguyen Hoang Long, PhD Ministry of Health The thesis will be presented at the Thesis Council of State meeting at the Institute of National Hygiene and Epidemiology, at: hour date month year... The thesis is available at: 1. The national Library 2. The Library of the National Institute of Hygiene and Epidemiology
1 INTRODUCTION Payment method (PM) is one of the five important components to improve the efficiency and equity of the health system. PM has an important role in the connection between health finance and the provision of health services (HS), this is a key task to control the health expenditure and quality of health-care services by creating the appropriate promoted mechanisms. In Vietnam, PM is an important issue for financial mechanisms at the supply health service facilities. Nowadays, fee-for-service payment is still mainly PM applying for HS in general as well as health insurance services in particular. With this PM, it is extremely difficult to control the health expenditures due to the nature of fee-for- service PM which is to encourage health facilities to supply as many services as beneficial. The law on health insurance has stipulated three pricipal methods of health expenditures using health insurance are capitation, fee-for-service, and case-based reimbursement. The Ministry of Health and Ministry of Finance have defined a roadmap of capitation PM. According to the roadmap, all of the registered primary health care facilities has follow the capitation PM, starting in 2015. Commune Health Station (CHS) is one of the registered primary health care services at the commune level. Worldwide, the most advanced and optimal PM for primary health care service is the capitation PM, because it works towards health care activities for the people to the preventive medicine activities, and promotes people s health, and manages chronic diseases at the community level.
2 Capitation PM is now applying in Vietnam which has many shortcomings both in the design, the practical implementation, and the impact. To provide the updated scientific evidence for the development, and perfection of the health expenditures followed the health insurance capitation in the CHSs, and can be applied at scales larger, we have conducted the research project "Health insurance based capitation payment model for health-care expenditures at some commune health stations in Dak To district of Kon Tum province" with the following objectives: (1) Describe the situation of fee-forservice payment method using health insurance at some CHSs of Kon Tum province in the period of 2011-2012; (2) Evaluate the effectiveness on some health care indicators, appropriate prescription, and health care expenditure control of health insurance capitation PM at some CHSs in Dak To district, Kon Tum province. * The novelty of the thesis: 1. Described the situations of health insurance payment method by fee-for-service at some CHSs of Kon Tum province in the period of 2011 2012 2. Contributed to the development of the health insurance expenditure under capitation PM model in some pilot CHSs followed the general principles of the world and in accordance with the practice in Vietnam, as well as the effective pilot model evaluated. 3. Provided the updated scientific and practical evidence in the PM innovation of health service expenditure, especially the development, modification and finalization of the instructions
3 of health insurance capitation PM. It contributes to the Health Insurance Law implementation successfully in the Universal Health Coverage Strategy by 2020 in Vietnam. Thesis structure: The main part of the thesis consists of 150 pages (not including covers, acknowledgment, annex, references, index), including Introduction: 2 pages, Objectives: 1 page; Chapter 1: Background: 48 pages, Chapter 2: Method: 26 pages, Chapter 3: Results: 40 pages, Chapter 4: Discussion: 30 pages, Conclusions: 2 pages, and Recommendations: 1 page. The thesis has 41 tables, 3 pictures, and 3 charts. There are 106 references, of which 55 Vietnamese references, and 51 English references. Chapter 1 BACKGROUND 1.1. Health service payment method in the world 1.1.1. Primary health care payment methods There are three main payment methods for primary health care, including Line-item budget, fee-for-service and capitation. 1.1.2. Hospital payment methods There are five major hospital payments. The two methods have been mentioned above (line-item budget, and fee-forservice) that can be applied to inpatient services. Three different methods are daily treatment, case-based, and the total budget. 1.2. Payment methods in Vietnam PM for health care expenditure in our country has experienced a long period of budget allocations followed line-item budget (patient s beds and areas of payroll for preventive medicine).
4 Since the policy of partial charges was changed in 1989, feefor-service PM, an added method has been applying in parallel with the budget allocation method. It gradually becomes the main PM in the health care system. Capitation PM has piloted in 2005, with the growing scale of the number of establishments and service facilities. Case-based PM has only tested for some group diseases, and it is now preparing the required database for the development and applying at a larger scale. Operational results based PM has only pilot in several communes in Nghe An province. Under general direction, the effort to develop and perfect the various PM to supplement and replace the fee-for-service PM are being implemented. 1.3. The research on and experiences of capitation payment method Thailand is one of the countries that has successfully applied the capitation PM for health expenditures. Historically, health service expenditure PM in Thailand, the capitation PM is applied for the first time in 1991 in health and social insurance system applied to the private sector. Meanwhile, capitation payment is applicable to both outpatient and inpatient health care services. Ten years later, when the Universal Health Coverage program was being implemented, capitation PM was used as a limitation for outpatient health services. According to the experts of Thailand, the application of capitation payment for inpatient treatment area may affect the rights of patients by the risk of service reduction to patients during hospitalization. Capitation PM is considered a fairly successful program in the Universal Health Coverage Program in Thailand. The application of capitation PM in Thailand has
5 been effective when the service providers develop health care network at the community to limit treatment services at the hospital. The scale for capitation payment only includes outpatient services but do not include the diseases with big expenditures. Capitation payment rate is determined based on the frequency of use of outpatient services in the year, and the average expenditure for one outpatient health examination. Due to the limited data one expenditures, Thailand uses the fee-forservice expenditure to calculate the average expenditure. The average expenditure was adjusted for age and gender. Capitation fund allocated to the district health centers (DHC) includes expenditure for outpatient health care in the higher level of referral. A recent study in Thailand has demonstrated financial resources shifted from provincial to district level, and has brought many benefits to the poor living in Thailand. During the implementation process under capitation payment, monitoring, especially the indicators of utilize, and quality of health care service, are particularly focused. Thanks to the good information system, the monitoring of utilize indicator, expenditure, and quality of service are updated completely and regularly. Results of monitoring and evaluation showed that the capitation payment increased the original name of drugs, more appropriate diagnosis and treatment. It is, therefore, reducing the treatment expenditure and increasing the efficiency of health service provision. 2.1. Study locations Chapter 2 METHODS
6 2.1.1. Districts, communes for the intervention: Dak To district was purposely selected for the pilot. Selection criteria the pilot intervention communes are: (i) Health insurance participation rate and primary health care registration at the CHSs account for 70% or more of the population; (ii) The communes have medical doctor and health workers in CHSs commit to implement the model; (iii) The CHSs have computers and staff have good skills on computer in order to manage the health insurance expenditure software; and (iv) the distance from the commune to the district hospital is not too close ( 10 km) to limit the pass line in health examination. With the above criteria, we selected 3 communes (Ngoc Tu, Dak Nga, and Dak Tram) as intervention communes. 2.1.2. District, communes for control: Selection criteria the district, communes for control include: (i) The district has similar socio-economic conditions social and ethnic groups with the intervention district; (ii) DHC has district hospital to provide directly health care support for CHSs in health insurance; (iii) Health insurance participation rate and primary health care registration at the CHSs account for 70% or more of the population, the CHSs have medical doctors; and (iv) the distance from the commune to the district hospital is not too close ( 10 km) to limit the pass line in health examination. The Kon Ray district was selected as control district, in which 3 communes namely Dak Tre, Dak Pne, and Dak Khoi were selected as control communes. 2.2. Study time: From October 2011 to May 2014, in which intervention in 2012 and data collection in the field from April to July, 2013.
7 2.3. Study design: Control trial design was employed. 2.4. The research methods, intervention activities, and capitation formula 2.4.1. The research methods Table 2.1: Research methods Objectives, research methods, and key indicators Objective 1: Descriptive study: Health examination and health insurance expenditure indicators Objective 2: - Descriptive study: Effectiveness is measured by improved health care indicator, the increasing rate of less health examination, and health insurance expenditure controlled after the intervention among the intervention and control groups. - Research on appropriate prescription: Effectiveness is measured by the number of less average drugs/prescription; proportion of prescription having domestic antibiotic; proportion of prescription have original name, proportion of prescription having more than 5 day antibiotic use, and proportion of prescription with more appropriate medicine before and after intervention between the control and the intervention groups. - Research on the satisfaction of the patients: The effectiveness is measured by the higher proportion of the patients satisfied with the health services in the CHSs after the intervention compared with the control group. - Qualitative study on the effectiveness of the the pilot model: The effectiveness is measured by the comments of the interviewees about the increasing quality of health services, decreasing Description Quantitative Quantitative Effectiveness evaluation Quantitative Quantitative Quantitative
8 referral rate, over-estimated frequency of health examination, the people are more reliable, and satisfied on health services provided by the CHSs after the intervention, capitation fund are secured and remaining. - Research on the completed health service expenditure at the CHSs: This is the supplement study for the above studies to identify the current investment to guide the prioritized financial investment for CHSs operation, health service cost adjusting and capitation fund calculation for CHSs. Quantitative 2.4.2. Intervention activities and capitation formula 2.4.2.1. Intervention activities: Intervention activities were implemented from 01/01 to 31/12/2012 with the following key activities: Iinterdisciplinary between Department of Health and Provincial Social Insurance issued the plan for the pilot project; training for related staff in different levels on capitation PM application and improving quality of health services; adding human resources for health care by health insurance between district social insurance and DHC, of which clearly stated articles on capitation PM in the CHSs; monitoring; evaluate and report the pilot model 2.4.2.2. Capitation formula * Formula for fixed expenditure identification: C = fx(m1+m2+s+v1) = fxu Of which: C is the fixed expenditure for one health insurance people; f is the frequency quota for health examination/card/year in the CHSs (an estimation of 1.0); U = (M1+M2+S+V1), is the average medicine expenditure for one health examination in CHSs; M1 is the medicine expenditure
9 for one health examination; M2 is the average technical service expenditure/health examination (the value is now 0, it will be identified later); S is fee for health examination; V1 is consumable equipment. * Fixexd fund for each CHSs: Fixed fund = (NxC)+(NxA- Pfund) Of which: Fixed fund is capitation fund; N is the number of health insurance cards registered for primary health care in the CHSs; C is fixed fund per card; A-P fund is the adjustingpromoting fund, equal to 10.0% of C. 2.5. Study subjectives: Health insurance services in the 6 study CHSs; Outpatient prescriptions have antibiotics in 2011 and 2012 of the 6 CHSs; people aged 18 years old using health insurance were health examination and treatment of the 6 CHSs in 2012; representatives of staff involved in the pilot model and the provincial, district, and commune level; financial expenditures for goods and bought services in the 6 study CHSs in 2012. 2.6. Sample size 2.6.1. Descriptive study: Health insurance health care and health care expenditure indicators in 2011 and 2012 of the registered health insurance people of the 6 CHSs and the 2 districts. 2.6.2. Research on the appropriated prescriptions - Using the sample size formula to compare two prevelances: - Of which: n is the minimum sample size; Z (1-α/2) : with 95% confident interval (CI), two way test, Z (1-α/2) = 1,96; p =
10 (p 1 +p 2 )/2; 1-β is the sample power, in this study 1-β = 85%; p 1 : The increase of appropriated prescription prevalence after intervention compared to before the intervention in the intervention communes, estimating p 1 =10%; p 2 : The increase of appropriated prescription prevalence after intervention compared to before the intervention in the control communes, estimating p 2 =3%. - Replacing the numbers to the formula, we have n = 222, this number will be multiplied with 2, the coefficient sample design, the sample size will be 444. It is rounded 450 prescriptions will be investigated before and after the intervention in each group. Thus, 150 prescriptions will be assessed before the intervention, and 150 prescriptions will be assessed after the intervention in each CHS. 2.6.3. Research on the satisfaction of the patients - Using the sample size formula to compare two prevelances: - Of which: n is the minimum sample size; Z (1-α/2) : with 95% confident interval (CI), two way test, Z (1-α/2) = 1,96; p = (p 1 +p 2 )/2; 1-β is the sample power, in this study 1-β = 85%; p 1 : The prevalence of the patient satisfied with the heath services of the intervention CHSs after the intervention, estimating p 1 = 85%; p 2 : The prevalence of the patient satisfied with the heath services of the control CHSs in post-test, estimating p 2 =70%. - Replacing the numbers to the formula, we have n = 138, this number will be multiplied with 2, the coefficient sample design, the sample size will be 276 people. Thus, 92 patients in 2012 will be interviewed in each commune. In fact, totally 636
11 people (Ngoc Tu: 107, Dak Ro Nga: 106, Dak Tram: 104, Dak Tre: 108, Đak Pne: 106 và Đak Koi: 105) were interviewed. 2.6.4. Qualitative research: In-depth interview: 7 interviews; Group discussions: 5. 2.6.5. Research on the full expenditure of health care services of the CHSs: Full expenditure of health care services in 2012 of the 6 CHSs. 2.7. Sampling method: Purposively cluster sampling followed 3 steps: the 1 st step: select intervention and control district, the 2 nd step: select 3 communes for intervention, 3 communes for control, the 3 rd step: select sample units. 2.8. Variables, indicators and the research contents: Based on the objectives of the study, and the sub-studies, key variables, indicators, and contents will be identified. 2.9. Data management and analysis - For the descriptive study and the full expenditure of health care services of the CHSs, the collected data will be clean, and entered to the MS Excel 2007 for calculation later on. For the research on the appropriated prescriptions and the satisfaction of the patients, the information will be coded, clean before entering using Epidata 3.1. The STATA software will be used for analysis. - All of the health insurance health services in 2011 will be adjusted to the cost of 2012 based on the consumer index published by the General Statistics - Some formula used in the study + Formula for average expenditure/health examination
12 x i X = Of which: X is average expenditure/health examination; x i is the money paid for the health examination followed i (i= the number of health examination: 1, 2...); n 1 is the total number of health examination in the CHSs yearly + Formula for average expenditure/card/year: n 1 Y = y i Of which: Y is the average expenditure/card/year; y i is the money paid for health examination followed i (i= the number of health examination: 1, 2...); n 2 is the number of registered card for primary health examination in the CHSs in the year. + Formula for increased proportion between 2012 and 2011: Increased proportion (%) = n 2 (Indicator 2012 - Indicator 2011) x 100 Indicator 2011 - Stata software will be used to test the different between variables in 2011 and 2012 by the following tests: Wilcoxon signed-rank test for abnormal distribution data; Z test for two prevalence; ( 2) or fisher s exact test for category variables more than 1 group; Mann-Whitney test for quantitative variables in the two independent groups; the statistically significance at 5.0% (p<0.05). - Logistic regression model between the satisfaction of the patients and some related factors will be built.
13 - Qualitative data will be categorized by topics for further analysis. 2.10. Ethics: The study s proposal has been approved by the Scientific and Ethic in Human Research Committee at the National Institute of Hygiene and Epidemiology. Chapter 3 RESULTS 3.1. Situation of health insurance expenditures for health care by fee-for-service payment method in some CHSs in 2011-2012. Table 3.1: Health examination using health insurance at 3 CHSs of Kon Ray district Content 2011 2012 Increasing (%) p Tests Total health examination in the 8408 10761 28.0 - CHSs Average health 0.9 1.1 22.0 0.3173 Wilcoxon examination signed-rank Health examination 1.0 1.2 25.9 0.3173 test frequency/card/year Proportion of referral (%) 5.6 4.9-13.3 0.0152 Z test Number of people were health checked 891 909 2.0 - in the DHC + Having referall letter: Yes 475 527 10.9 - Proportion % 53.3 58.0 8.8 0.0224 Z test + Having referall letter: No 416 382-8.2 - Proportion % 46.7 42.0-10.0 0.0224 Z test The table 3.1 showed that, in comparison to 2011, in 2012 the referral proportion decreased 13.3%, the proportion of
14 people was heath checked in the DHC with referral letter increased 8.8%. The differences are statistically significant, p<0.05. Talbe 3.2: Health insurance expenditures at the 3 CHSs of Kon Ray district Unit: 1000 VNĐ Content 2011 2012 Total health insurance expenditures - Fee for health examination Proportion (%) of fee for health examination - Medicine cost Proportion (%) of medicine cost - Consumable equipment cost Proportion (%) of consumable equipment cost - Technical service cost Proportion (%) technical service cost Average expenditure/health examination Average expenditure/card/ye ar 68071 4 87151 1 Increasin g (%) p 28.0-7178 8609 19.9 - Tests 1.1 1.0-6.3 0.2495 Z test 66706 6 84206 2 98.0 96.6-1.4 26.2 - <0.000 1 500 13386 2575.7-0.1 1.5 1989.9 <0.000 1 5970 7454 24.9 - Z test Z test 0.9 0.9-2.5 1.0000 Z test 81.0 81.0 0-78.1 98.3 25.9 0.3173 Wilcoxo n signedrank test
15 Table 3.2 demonstrated that the total health insurance expenditures at the three CHSs in 2012 increased by 28.0% compared with in 2011, of which fee for health examination grew up by 19.9%, medicine cost increased by 26.2%, technical-service cost increased by 24.9%, the most increase is the consumable equipment, by 2575.7%. The proportions of costs for fee for health examination, medicine, technicalservices in 2012 decreased compared with in 2011 (p<0.05). The proportion of consumable equipment in 2012 much increased in comparison to 2011. The difference is statistically significant, p <0.05. 3.2. The effectiveness of capitation health insurance payment method in some CHSs of Dak To district 3.2.1. Appropriate prescriptions Table 3.9: Increased proportions in some prescription indicators between 2012 and 2011 among CHSs of the two districts Content Dak To district (%) Kon Ray district (%) p (Z test) Origin of antibiotics - Domestic 0 7.3 <0.0001 Names of antibiotics - Original 120.5 4.0 <0.0001 - Original + branch name -33.3 200.0 <0.0001 Number of days using antibiotics - 4 days -66.7 50.0 <0.0001 Table 3.9 showed that the rate of prescriptions having domestic antibiotics in 2012 and the increased rate of prescription with the original names of Dak To district were
16 higher than that in the Kon Ray district; by constrast, the increased rate of prescriptions having both original and branch names, and prescriptions having antibiotics for 4 days in Kon Ray were higher than that in Dak To district. The differences are statistically significant (p<0.05) Table 3.12: The increased rates of some prescription indicators in CHSs of the two districts in 2012 compared to 2011 Content Dak To district (%) Kon Ray district (%) p (Z test) Average number of medicines/prescription 2.6 5.1 0.0256 Prescriptions with appropriate antibiotic with diagnose 11.6-1.4 <0.0001 Table 3.12 presented that the rate of increasing average number of medicine/prescription of Dak To district was less than that of Kon Ray district. The rate of increasing prescriptions with appropriate antibiotic with diagnose of the Dak To district was higher than that in Kon Ray district. The differences are statistically significant, with p<0.05. 3.2.2. The satisfactions of the patients Table 3.17: Multivariable logistic regression model Dependent variable: The patients satisfaction OR 95%CI Characteristics District - Control (for comparison) 1 - - Intervention 2.3* 1.1 4.7 Waiting time
17 - Less than 15 minutes 75.5* 13.8 412.5-15 - <30 minutes 51.1* 7.0 371.8-30 minutes(for comparison) 1 - Health examiner - Medical doctor/medical doctor assistants 6.7* 2.8 15.6 - Nursing, Midwife 2.5* 1.2 5.5 - Don t know (for comparison) 1 - Medicine provision followed prescription - Exactly as in the prescription 44.9* 20.1 100.0 - Don t know (for comparison) 1 - Note *: Statistically significant difference Table 3.17 showed that, after controlling for confounding factors (independent variables in the model are similar), satisfaction on health care services of the patient in the intervention communes is 2.3 times higher than that in the control communes (OR = 2.3; 95%CI: 1.1 4.7). The shorter waiting time, the higher satisfaction of the patients. The patients had the highest satisfaction since the health examiners are medical doctor/medical doctor assistants. The satisfaction of patients distributed medicines exactly as in the prescription is 44.9 times higher than the people who do not know. The difference is statistically significant (OR = 44.9; 95%CI: 20.1 100.0). 3.2.3. Some health insurance health care indicators Bảng 3.20: Comparison of the increased proportions of some health insurance health care indicators between 2012 and 2011 at CHSs of the two districts Content Dak To Kon Ray p district (%) district (%) (Z test) Total health examinations at CHSs 23.4 28.0 <0.0001 Average health examinations 15.6 22.0 <0.0001 Health examination 16.6 25.9 <0.0001
18 frequency/card/year Times of referral -18.1 10,9 <0.0001 Total health examinations at DHC -22.7 2.0 <0.0001 Of which: having referral letter -18.1 10.9 <0.0001 Proportion % 5.9 8.8 0.0082 The talbe 3.20 showed that the increased proportions of some health insurance health examination indicators between Dak To and Kon Ray districts are statistically significant differences, of which all of the proportions of the indicators in Dak To district are less increased than the Kon Ray district. 3.2.4. Expenditures of health insurance health examinations Table 3.23: Comparison of the increased proportions of health insurance health examination expenditures at the CHSs of the two districts between 2012 and 2011 Content Dak To district (%) Kon Ray district (%) p (Z test) Total expenditures of health insurance health examinations -1.6 28.0 <0.0001 Fee for examinations 15.6 19.9 <0.0001 Proportion (%) of the fee for examination 17.5-6.3 <0.0001 Medicine cost -2.3 26.2 <0.0001 Proportion (%) of the medicine cost -0.7-1.4 - Consumable equipment cost 53.8 2575.7 <0.0001 Proportion (%) of the consumable equipment cost 56.3 1989.9 <0.0001 Technical service cost 20.0 24.9 <0,0001 Proportion (%) of the technical service cost 22.0-2.5 <0.0001 Average expenditure/card/year -7.0 25.9 <0.0001 The table 3.23 demonstrated the increased proportions of indicators reflexted the health insurance health examination expenditures between CHSs of the two districts. The
19 differences are all statistically significant (p<0.05), of which all of the proportions of the Dak To district were less increased compared with Kon Ray district, except for the fee for examination, medicine cost, and technical service proportions. Table 3.30: Capitation fund balancing of the three CHSs of Dak To district in 2012 Unit: 1000 VND Content 1. Capitation Fund - Initially (according to the plan) Ngoc Tu Dak To Nga Dak Tram Total 101,154 112,232 154,481 367,866 - After adjusting 151,730 134,854 200,987 487,571 - Added money 50,577 22,623 46,506 119,705 - Expenditures of health examination 135,455 116,620 195,751 447,826 Accounting for (%) 89,3 86,5 97.4 91.8 - Remaining after adjusting 16.275 18.234 5.236 39,745 Accounting for (%) 10.7 13.5 2.6 8.2 2. Adjusting-Promoting Fund - Initially (according to the plan) 36,787 - After adjusting 48,757 - Added money from other sources 70,948 - Total fund 119,705 The table 3.30 showed that total health examination expenditure (not included technical service expenditures) accounted for 91.8% capitation fund of the three communes, the overall remaining proportion of the three communes is 8.2% capitation fund, total Adjusting-Promoting fund reachs 119,705,000 VND and 100% of this fund has been adjusted for the lack of capitation funds
20 3.2.5. Qualitative research: Almost all of the ideas and comments obtained from indepth-interviews and group discussions agreed that the capitation health insurance pilot model at the CHSs is effective, especially the improved health examination services, reducing the referall, total times of health examinations were out of the expectation, the people are more satisfy with the heath services at the CHSs compared to before the intervention. Capitation fund at the CHSs are secured and remaining. 3.2.6. Full expenditures of health care services at the CHSs Table 3.35: Comparison of unit expenditure and maximum fees Content 1. Regular expenditure (not include medicine and consumable equpiment) 2. Invested expenditure and regular expenditure (not include medicine and consumable equpiment) Actual expenditure (1000 VND) Maximum fees followed the Circular no. 4 (not include medicine and consumable equipment) Expenditure (1000 VND) Maximum fund proportion/ actual expenditure (%) 80.5 5 6.2 92.8 5 5.4 The talbe 3.35 compared the unit expenditure (not include medicine and consumable equpiment) and the corresponding maximum service fees (not include medicine and consumable equpiment) followed the Circular no.4 of the Ministry of
21 Heatlh and Ministry of Finance. The hospital fees are very low in comparison with the unit expenditure of the provided services. For the unit expenditure only regular expenditure was calculated, the proportion of average taken back expenditure of the 6 CHSs is 6.2%. For the unit expenditure, including both invested expenditure, and regular expenditure, the proportion of average taken back expenditure of the 6 CHSs is 5.4%. Chapter 4 DISCUSSION 4.1. Situation of fee-for-service health insurance health care payment method in some CHSs 2011-2012 The table 3.1 showed that the total health examinations, average health examinations, and the frequency/card/year of the three CHSs of Kon Ray district in 2012 all increased in comparison with in 2011. This is the evidence that the health insurance implementation at the CHSs has initially certain effective. Almost all of the people participating at health insurance registered for primary health care at the CHSs. They are more trusted to the health care services provided by the CHSs than before. Compared to 2011, the proportion of referall in 2012 decreased 13.3% (p<0.05). This is added evidence that almost all of the common diseases can be treated at the CHSs. The CHSs only sent severe disease patients, and cannot be treated at the CHSs to DHC for health examinations. The talbe 3.2 showed that medicine cost, accounting for 97-98%, is the main expenditure of the structure of health insurance health examination expenditure, consumable
22 equipment and technical-service costs take small proportions. The study s results showed that the total health insurance health care at the 3 CHSs of Kon Ray district in 2012 increased 28.0% compared with in 2011, of which all of the sub-totals increased. The increase can be explained by the increase of health examinations at the CHSs because the average cost/health examination in 2011 and 2012 is similar (81,000VND). However, average expenditure/card in 2012 was 25.9% higher than that in 2011. This is completely exact with the argument of fee-for-service PM that health examination expenditure is increasing regularly. 4.2. The effectiveness of capitation health insurance health care PM at some CHSs of Dak To district 4.2.1. Prescription appropriately: Comparing the increased proportions of some prescription indicators at CHSs of the two districts between 2012 and 2011 (Table 3.9) found that the proportions of the prescriptions having domestic antibiotics, and the increased proportions of prescriptions having original medicines of Dak To district were higher than that of Kon Ray district. On the other hand, the increased proportions of the prescriptions having both original and branch names, and using antibiotics 4 days of Kon Ray district were higher in Dak To (all of the differences are statistically significant). They are good evidence of the effective interventions in the intervention group compared with the control group. Comparing the increased proportions of total prescriptive indicators at CHSs of the two districts between 2012 and 2011
23 (table 3.12) found that the increased proportions of average number of medicines/prescription, and antibiotics appropriated with diagnoses between the two districts are statistically significant differences (p<0.05). The increased proportion of average number of medicines/prescriptions of Dak To district was less than in Kon Ray district, and higher increased proportion of prescriptions having antibiotics appropriated with diagnose in Dak To district than in Kon Ray district was reported. It is, therefore, applying capitation health insurance can control the increasing of medicines. By doing this, the health insurance health examination expenditure is less increased and more appropriate antibiotic prescription is made. 4.2.2. The satisfactions of the patients: In the multiple logistic regression model (table 3.17), in order to control the confounding factors (all of the factors are considered similarly), the service users in the intervention district are 2.3 times higher satisfaction than that in the control district (OR = 2.3; 95%CI: 1.1 4.7). The result showed that the pilot model has clear and good effectiveness. 4.2.3. Some health insurance health examination indicators: Since comparing the increased proportions of some health insurance health examination indicators at the CHSs of the two districts between 2012 and 2011 (Table 3.20) we found statistically sifnificant differences with p<0.05, of which all of the proportions of Dak To district were less increased in comparison to the Kon Ray district. This suggests that comparing with the CHSs applying fee-for-service health insurnace, the CHSs applying capitation health insurance were
24 better controlled the increased health care indicators, then contributed to the reduction of the increased expenditures of health insurance health care. 4.2.4. Health insurance health care expenditure: Comparing the increased proportions of health insurance health care expenditures at the CHSs of the two districts between 2012 and 2011 (Table 3.23) showed that the differences are statiscally significant (p<0.05), and all of the increased proportions of Dak To district are less than that of the Kon Ray district (except the health examination fees, medicine cost proportion, and technical-service cost proportion). This is, again, good evidence that the CHSs applying capitation health insurance could better controll the increase of health insurance health care in comparison with the CHSs applying the fee-for-service health insurance payment. The higher increased proportions of health examination fees and the proporiton of technical-service cost at the capitation health insurance CHSs than that at the fee-for-service health insurance is a good sign. It suggests that the CHSs applying the capitation health insurance PM provided more and more health care services. This is totally different with the theory of capitation payment that the health facilities receving capitation fund tend to limit health care provison for the patients. 4.2.5. The full expenditure of health care service at the CHSs: Compare to the maximum cost of the Circular number 4 of Ministry of Health Ministry of Finance, the average taken back expenditure was only 6.2% (only regular expenditure), much lower that the study conducted by Hoang Van Minh
25 (18.9%). If both the investment expenditure and regular expenditure were calculated, the average taken back expenditure is 5.4% (Table 3.35). This is showed that the studied CHSs are experiencing with the lack of fund for health care services. Fees for health care services should be increased in the near future. CONCLUSIONS 1. Situation of fee-for-service payment for health care based on health insurance at some CHSs, 2011-2012 - The fee-for-service PM for total health examinations at the three CHSs increased by 28.0% in 2012 compared to in 2011. The average health examinations and health examination frequency/card were all increased in 2012 compared to 2011. - Total health insurance-based health examination expenditures increased by 28.0% in 2012 compared to in 2011 at the CHSs using three fee-for-service PM, of which all of the sub-totals increased average expenditure/card in 2012 increased 25.9% compared to in 2011. - Compare to 2011, the average health examination expenditure per one health examination at the three fee-forservice PM CHSs in 2012 increased at all of the groups, except for the group 4. This conclusion suggests that there were an increase of service provison, utilization, and health insurance health examination expendtures at the CHSs applying fee-for-service PM in 2012 compared to in 2011. 2. The effectiveness of health insurance based capitation payment method at some CHSs of the Dak To district
26 - The increased proportion of domestic antibiotic, prescriptions having original names of medicines, qne appropriate antibiotics with diagnose at the thee pilot CHSs were 100%, 120.5%, and 11.6%, respectively, higher than that at the three fee-for-service payment CHSs, 98.9%, 4%, and - 1.4%, respectively. The increased proporiton of avearge number of medicines/prescription at the three capitation PM CHSs was 2.6%, less than that at the three fee-for-service PM CHSs (5.1%). - Considering that all of other factors are similar, the service users satisfactions at the three pilot CHSs were 2.3 times higher than that at the fee-for service PM CHSs. - Total health examinations at the three capitation health insurance CHSs in 2012 increased by 23.4% compared to in 2011; the average health examination and health examination frequency/card in 2012 all increased compared to in 2011. The increase proportions of health care indicators of the three pilot CHSs were lesser than that at the three control CHSs. - Health insurance-based total health examination expenditures at the three pilot CHSs of capitation health insurance PM in 2012 reduced by 1.6% in comparison with those in 2011, of them the medicine cost decreased but all of others increased; average expenditure/health examination, and average expenditure/card in 2012 all decreased compared to in 2011. The increased proportions of all indicators refected health insurance health care expenditure of the three pilot CHSs were lesser compared to the three control CHSs, except the fee for examinations, the proportion of medicine cost, and
27 proportion of technical-service cost. This is a good sign for the CHSs applying the capitation helath insurance in terms of providing more health care services for the patients. - In comparison with in 2011, the average health care expenditure per health examinations and per health insurance card at the pilot CHSs in 2012 all decreased of all groups. The increased proportions of average health care expenditure per health examination followed each group, and per health insurance card followed sex and age group at the three CHSs applying capitation health insurance PM were lesser than that at the three CHSs appying fee-for-service PM. - Fixed funds after adjusting of Ngoc Tu, Dak Ro Nga, and Dak Tram communes were 57,300, 45,900, and 49,700 VND, respectively. Total health care expenditure accounted for 91.8%, the overall remaining proportion was 8.2% of the capitation funds of the three communes. There were no communes spending over funds. - Results from the qualitative research showed that almost all of the ideas and comments obtained from indepth interviews and group discussion agreed an effective pilot model of capitation health insurance for CHS. They also suggested that the model should be expanded to other districts in the near future. - Average expenditure unit of the six CHSs with three, five, and seven expenditure components were 55.9, 134.8, and 147.2 thousand Vietnam dong, respectively. The proportion of average taken back expenditure is 6.2% (only the regular expenditure), 5.4% (both investment expenditure, and regular expenditure) compared to the full cost.
28 This conclusion evidenced that the CHSs applying capitation health insurance PM have a clear effectiveness on some health care indicators, service quality, and better control health care expenditure in comparison with the feefor-service payment CHSs, that meet the expectations of stakeholders (social insurance agencies, health care service providers, and health-insured people). However, some results from the professional study such as quality of prescription, improved health examination quality... could be confounded by professional training but not merely the impacts of capitation PM. RECOMMENDATIONS 1. Develop a roadmap and change the health insurance - based fee-for-service PM into health insurance capitation PM as soon as possible at the CHSs. 2. The pilot model of capitation health insurance PM for health care expenditure has been conducted at the 3 CHSs of Dak To district, Kon Tum province which shows as an effective model. Therefore, the model needs to be tested in different socio-economic areas in order to thoroughly assess and apply nationwide as soon as possible. 3. The fees should be adjusted for health care services at the commune level, so appropriate for the situations in different stages. 4. The budget allocation method should be innovated appropriately for CHSs to ensure that the budget will be paid for preventive medicine and public health services.
PUBLICATIONS 1. Le Tri Khai, Nguyen Cong Khan, Tran Van Tien, Hoang Van Minh (2014), Reality some activity indicators and costs of health insurance by fee-for-service payment method at some commune health stations of Kon Ray district of Kon Tum provice in 2011-2012, Vietnam Journal of Preventive Medicine, Volume XXIV, 6(155) 2014, p. 121-127. 2. Le Tri Khai, Nguyen Cong Khan, Tran Van Tien, Hoang Van Minh (2014), Impacts of pilot model of capitation payment method on prescribe medicine at some commune health stations of Kon Tum province, Vietnam Journal of Preventive Medicine, Volume XXIV, 6(155) 2014, p. 128-134. 3. Le Tri Khai, Nguyen Cong Khan, Tran Van Tien, Hoang Van Minh (2014), Impacts of pilot model of capitation payment method on health care utilization of health insurance at some commune health stations of Kon Tum province, Vietnam Journal of Preventive Medicine, Volume XXIV, 8(157) 2014, p. 93-100. 4. Le Tri Khai, Nguyen Cong Khan, Tran Van Tien, Hoang Van Minh (2014), Differences in some activity indicators and costs of health care services of commune health stations by provider payment methods in Kon Tum province, Vietnam Journal of Preventive Medicine, Volume XXIV, 8(157) 2014, p. 101-108. 5. Le Tri Khai, Nguyen Cong Khan, Tran Van Tien, Hoang Van Minh (2014), Impact of the pilot model of capitation health insurance payment method on the satisfaction of the patients at some commune health stations of Kon Tum province, Journal of Medical Research, 91(6) - 2014, p. 118-128.