Overview
entire population and pays for the bulk of health care costs. Vietnam appears, in fact, 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. Compared to a statistical analysis of existing costs by case type, this has the merit of providing a “gold standard,” indicating the costs associated with care delivered according to best practice clinical decision making. Given the slow progress on developing clinical pathways, however, it might make sense 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, which lacks discharge-level data, including ICD-9-CM diagnosis and ICD procedure codes that are essential for DRG use. Vietnam may also want to explore rewarding hospitals with additional payments if they score well on a battery of quality indicators. This system, known as pay for performance, or P4P, is a supplementary payment method, not a replacement for case-based payments. Finally, on the issue of provider reform, the report looks at the issue of provider autonomy. The appropriate direction of reform depends crucially on the degree to which Vietnam is successful in its goal of universal coverage under a single payer. With a single payer that picks up the bulk of health care costs, patients have a strong champion of their interests. If the payer has a quality control mechanism in place and a payment system that incentivizes cost containment and high-quality care (for example, a mix of case-based payment and P4P), it makes good sense for health facilities to have a fairly strong financial incentive to treat more patients and improve quality. The payer would award contracts to facilities that meet the payer’s cost and quality standards, and the contracts would reward volume (extra cases not extra services) and high quality. In such a system, the scope for providers to earn additional income by delivering care that is medically unnecessary is limited. It is right and proper in such a system that providers should be incentivized to earn additional revenues, which they can do by treating extra patients and improving
19