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Health Financing and Delivery in Vietnam
Vietnam appears to be committed to case-based payments, and is exploring the feasibility of basing the rates on a cost analysis of the care associated with the clinical pathway for each case type (AusAID Study Team 2007). This approach has the merit over a statistical analysis of existing costs by case type of providing a “gold standard,” indicating the costs associated with care delivered according to best practice clinical decision making. If some care at present is medically unnecessary, the “gold standard” will produce a payment per case type that is below the current average cost for that case type. The introduction of case-based payments would then result in hospitals incurring losses and would meet fierce resistance. Korea’s strategy to get around this was to build in generous margins over the existing payment system (FFS) to overcome provider opposition (Kwon 2003). Over time, payment rates could gradually be reduced to their “gold standard” rates. There is, however, a risk to building up a set of “gold standard” case-based payments based on Vietnam-specific clinical pathways, not least of which is that unless the model of developing Vietnamese pathways changes, pathways for the conditions that account for the bulk of inpatient admissions will not be ready for decades. One option would be to speed up the development of pathways along the lines suggested earlier, and stick with the idea of coming up with a gold standard case-based payment based on the resources required to deliver care according to the pathway. Another would be to take a DRG system that has been developed for another country (most have their origins in the United States’ DRG system) (Schreyogg et al. 2006) and modify it to the Vietnamese setting. Over time, as the clinical pathways work proceeds in Vietnam and elsewhere, the DRG rates could be modified accordingly. One challenge here will be Vietnam’s hospital information system. At present, it appears to be only a hospital-level database. Dischargelevel records that include inter alia ICD-9-CM diagnosis and ICDOP procedure codes are not, it seems, available; hospitals are required to record this information, but the completed forms have never been computerized and their quality is unknown. There is a need to develop an efficient and effective primary care system in Vietnam that will ensure that people are not admitted to