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:
1. 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
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
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.
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
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
Situation of piloting capitation for HI in
selected provinces (1)
• HI coverage and enrollment composition in selected
provinces
66.5
70
60
60.9
53.4
52.8
50.7
51.6
Compulsory
50
Poor
35.2
40
31
24.2
29.7
30
20
10
18.8
19.0
People’s voluntary
29.0
22.4
Student
Coverage
0.8
4.0
7.7
3.4
7.7
2.4
0
Hải Dương
Hà Nam
Hòa Bình
Thanh Hóa
Situation of piloting capitation for HI in
selected provinces (1)
• Scope and point of time starting capitation-based mode pilot
No
Piloted
provinces
1
Hai Duong
2
Ha Nam
3
Thanh Hoa
4
Hoa Binh
Scope of implementing
12/13 district hospitals and
communes
6/6 district hospitals and
communes
Point of time
starting
their
Since 2007
their
01/01/2009
2/21 district hospitals (Hà Trung is a
lowland district and Mường Lát is a
mountainous district)
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
01/01/2009
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
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
Premium design and identification (1)
Content
Hải Dương, Thanh
Hóa
Hà Nam
Hòa Bình
Payment method
applied
Capitation
Capitation
Capitation + user
fees
Capitation
implementer
District hospital +
CHS
District hospital + District hospital +
CHS
CHS
Beneficiaries
All PHC registers at
district or commune
level
All PHC registers All PHC registers at
at district or
district or commune
commune level
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)
Content
Hải Dương,
Thanh Hóa
Hà Nam
Hòa Bình
DHS fund
Local spending, direct
and multiple-level
reimbursement
Q=MxNxk
- Thanh Miện:
156,070
- Nam Sách: 154,829
- Mường Lát: 120.162
- Hà Trung: 159.067
Local spending and
direct
Q = MxNxk
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 = MxNxk
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)
Content
Hải Dương, Thanh
Hóa
Hà 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)
• 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
payment method (1)
• Card composition prior to and after piloting
Type of HI
Prior to pilot
Compulsory
For the poor
Student
voluntary
People
voluntary
Since pilot
Compulsory
Nam
Sách
Thanh
Miện
Bình
Lục
Phủ Lý
45,606
40,079
46,130
41,920
35,918
30,681
26,100
25,433
9,678
9,378
9,217
1,960
Hà
Trung
26,957
1,694
60,745
18,930
25,255
32,529
0
8,584
8
702
9,476
2,096
10
20
47,686
41,427
51,257
54,338
36,918
31,681
29,000
23,063
8,853
Mường
Lát
4,915
29,163
50,870
18,199
2,221
Tân
Lạc
Mai
Châu
36,959
28,968
5,362
3,818
27,561
20,206
3,086
3,974
950
970
38,704
27,030
5,535
3,627
29,424
18,986
2,262
3,114
1,484
1,304
24,401
For the poor
Student
voluntary
People
voluntary
10,758
10
20
Difference
2,080
1,348
-
9,726
10,242
2,178
6,838
26,936
0
6,805
4,714
1,465
9,837
5,127
19,723
12,418
6
2,206
(9,875)
1,746
(1,939)
Changes after piloting capitation
payment method (2)
• Assignment of capitation fund in the year of piloting
(including commune fund) in selected district hospitals
No.
1
2
3
4
5
6
7
8
District hospital
Thanh Miện
Nam Sách
Phủ Lý
Bình Lục
Mường Lát
Hà Trung
Mai Châu
Tân Lạc
Number of
PHC
registration
cards
Premium
Global capitation
(Average capitated
fund
premium level
/card x 1.1)
Unit: VND
Unit: VND
41,427
156,070
6,465,501,208
47,686
154,829
7,383,183,653
17,188
217,456
661,561,170
34,356
217,456
2,995,838,253
29,163
120,162
3,504,285,000
50,870
159,067
8,091,724,000
3,561,037,000
27,030
65,000
38,704
4,290,031,000
55,000
Changes after piloting capitation
payment method (3)
• Average cost of outpatient consultation prior to and after the year of
piloting
No.
1
2
3
4
5
6
7
8
District
hospital
Nam Sách
Thanh Miện
Bình Lục
Phủ Lý
Mường Lát
Hà Trung
Tân Lạc
Mai Châu
Prior to
capitation
Capitation
year
(1)
20,665
15,943
22,619
85,771
76,152
70,293
75,778
83,472
(2)
25,046
18,841
29,545
107,359
74,605
85,892
94,101
108,115
Premium/user fee
difference
±
+ 4,381
+ 2,898
+ 6,926
+ 21,588
- 1,547
+ 15,599
+ 18,323
+ 24,643
%
+21.2
+18.2
+30.6
+25.2
-2.0
+22.2
+24.2
+29.5
Changes after piloting capitation
payment method (4)
• Average cost of inpatient contact prior to and after the year
of piloting
No.
1
2
3
4
5
6
7
8
Health
facility
Prior to
capitation
application
(1)
Nam Sách
159,306
Thanh Miện
181,425
Bình Lục
366,996
Phủ Lý
169,716
Mường Lát
559,575
Hà Trung
1,055,785
Tân Lạc
594,000
Mai Châu
884,000
Capitation
Premium/user fee
application
difference
year
(2)
±
%
286,911
+ 127,605
+ 80.1
190,155
+ 8,730
+ 4.8
501,229
+ 134,233
+ 36
186,305
+ 16,580
+9
592,053
+ 32,478
+5.8
1,124,464
+ 68,679
+6.5
644,000
+ 50,000
+8.4
1,012,000
+14.4
+ 128,000
Changes after piloting capitation
payment method (5)
• Fund balancing capacity prior to an after applying capitation
No.
Hospital
Nam Sách
1
Capitation fund
assigned for 1
year
Expenditures at
health facilities
between 01 and
09/2009
7,933,463,809
7,383,183,653
Thanh Miện
- 550,280,156
6,942,427,244
6,463,726,879
2
Balance
- 478,700,365
Bình Lục
3
2,287,000,000
2,546,000,000
- 259,000,000
523,000,000
643,000,000
-120,000,000
3,504,285,000
4,104,634,492
- 600,349,420
10,621,724,000
10,075,574,086
+ 546,149,914
4,290,031,000
3,671,871,000
+ 618,160,000
3,561,037,000
4,797,360,000
- 1,236,323,000
Phủ Lý
4
Mường Lát
5
Hà Trung
6
Tân Lạc
7
8
Mai Châu
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
Unit: VND 1000
Exceeded fund
in the last 6
months, 2008
Exceeded fund
in the last 6
months, 2009
1,200,000
1,000,000
800,000
600,000
400,000
200,000
Tứ kỳ
Gia
Lộc
Bình
Ninh Thanh
Giang Giang Miện
Nam
Sách
Nhị
Chiểu
Chí
Linh
Kim
Thành
Changes after piloting capitation
payment method (7)
• Overspent amount in 6 months in 5 district hospitals in Ha
Nam
Unit: VND 1.000
1,000,000
800,000
600,000
400,000
200,000
Thanh
Liêm
Duy Tiên
Bình Lục
Lý Nhân
Phủ Lý
Changes after piloting capitation
payment method (8)
• Expenditure composition by hospital (%)
Item
Local
payment
Local and
bypassing
multilelevel
payment
Direct
payments
Thanh
Miện
45.4
Nam
Sách
41.9
Phủ lý
17.7
Bình Mường Hà
Lục
Lát Trung
40.1
44.5
62.1
Mai
Châu
82.6
Tân
Lạc
81.7
54.1
57.4
81.7
59.5
55.3
37.8
17.1
18.1
0.5
0.7
0.6
0.4
0.2
0.1
0.3
0.2
Changes after piloting capitation
payment method (9)
• Increase rate of hospital service provision in the year piloting
compared to previous year (%)
Hospital
Nam
Sách
Thanh
Miện
Bình Lục
Phủ Lý
Mường
Lát
Hà
Trung
Tân Lạc
Mai
Châu
Outpatient
consultation
Lab
test
X-ray
CT-Scan
Ultrasound
Inpatient
referral
Outpatient
referral
-2.6
55.8
6.3
0
13.9
43.5
-12.7
-2.6
15.6
57.3
0
13.4
5.9
3.6
7.4
19.5
8.3
0
-1.8
-10
40
19.2
28.9
2.2
0
83.2
26.5
25.2
3.1
0.5
-21.6
0
28.2
0
0
33.7
31.8
0
0
35.2
16
14.2
0
0
0
0
0
0
0
-13.4
8.7
18
14.4
6.2
-53
29.3
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
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)
• 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)
• 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)
• 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)
• 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 multiplelevel payments when hospitals could not control
expenditures
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)
• 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)
• 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)
• 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