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Health Financing and Delivery in Vietnam
Should the supplementary package focus on amenities, such as allowing a patient the choice of surgeon, or the option of being treated in a private hospital? If so, does it need to be made available free to Decision 139 beneficiaries? A less controversial strategy for VSS in its efforts to contain costs would be to pay providers in such a way as to encourage cost consciousness, for example, by shifting from FFS to a case-based payment system in paying for inpatient care. Such efforts are unlikely to reduce the number of inpatient admissions or outpatient department visits (indeed one would need to be careful not to encourage them), but rather to reduce the cost per admission and the cost per visit by discouraging tests and other items of care that generate revenues for the provider (each brings additional revenue because they constitute a separate service item), even if there is no medical case for delivering them. VSS would be more successful in this regard if supply-side subsidies were shifted to the demand side, and if out-of-pocket payments were reduced. Then VSS becomes the main, if not sole, payer of hospitals, and this “monopsony” status provides it with considerable leverage over providers. This leverage would be greater if it is allowed to selectively contract (it could choose from which providers its members could get care), if it can contract with public and private providers (this becomes more viable if supply-side subsidies are reduced and are not creating a tilted “playing field” between public and private providers), and if there is some role for VSS and providers to negotiate over the amount of the case-based payment. The latter process need not be a free-for-all. The Health Ministry could set guidelines for case-based payment rates for different case types, and the negotiated rate could be required to be within, say, plus or minus 10 percent of the guideline rate. These issues are discussed further in chapter 6. With VSS financing the lion’s share of providers’ costs for the bulk of the population, it would have much greater leverage to bring about cost reductions by curbing the delivery of unnecessary care. Linked to the shift from FFS toward other payment methods would need to be the development of capacity within VSS to monitor and incentivize the delivery of appropriate health care. Care that is simply inappropriate, and hence ineffective, would need weeding out, but