Direct drug payment insurance: Making things difficult for patients?

People buy medicine at the hospital pharmacy - Photo: NAM TRAN

To be paid for health insurance, the buyer needs to present to the social insurance agency a valid prescription and medical supplies prescribed by a doctor as a basis.

It was thought to be beneficial for patients, but in reality, many payment conditions and document regulations make people wonder if it can be implemented?

Have health insurance but still pay out of pocket

Due to the lack of drugs and supplies at medical facilities, the Ministry of Health has repeatedly affirmed that "hospitals must be responsible for the lack of drugs and supplies for medical examination and treatment for people", but so far no hospital has accepted responsibility for this problem. People have health insurance, but their rights when examining and treating patients are not guaranteed.

Not long ago, Ms. Hoan (60 years old, Phu Tho province) discovered she had a mediastinal tumor and was scheduled for surgery at a hospital in Hanoi .

Before the surgery, the doctor shared with Mrs. Hoan's family the difficulties the hospital was facing in purchasing medicine and supplies and instructed the family to purchase some medicines and supplies used in the surgery from outside.

“As a patient hoping to be treated soon, when the doctor suggests buying, the family must buy it without daring to question it. If they don’t buy it, they won’t be able to have surgery, the patient has no choice. The cost of buying medicine and supplies for the surgery also costs 6-7 million VND,” Ms. Hoan confided.

Mr. NVG (65 years old, Tay Ninh province) has diabetes complications to the heart, every month he has to take the bus to Ho Chi Minh City for check-ups and buy medicine. Recently, when he went to the doctor, he was diagnosed with signs of kidney failure, he had to take prescription medicine and had to buy it outside.

For many months now, Mr. G. has had to pay an additional 1-2 million VND for medicine each month. “Because of my age, having to pay additional hospital fees each month will put a lot of pressure on my family’s financial life,” Mr. G. said. The money for medicine and supplies that people should have received from participating in health insurance has to be paid out of pocket, and it takes more effort to buy.

Insurance pays but how less hassle?

Recently, the Ministry of Health issued Circular 22 regulating the direct payment of medicine and medical equipment costs for health insurance card holders going for medical examination and treatment. The Circular is considered one of the solutions to ensure the rights of health insurance participants when hospitals lack medicine.

This Circular also clearly stipulates that drugs and supplies that are paid for are only on the list of rare drugs and medical equipment of type C or D... That is, if the hospital lacks a certain drug, the patient will not be directly paid for that drug. If the drug is not rare and still on the list of drugs covered by health insurance, the patient still has to buy it himself.

Talking to Tuoi Tre about this regulation, Ms. Vu Nu Anh, Deputy Director of the Health Insurance Department (Ministry of Health), said that currently the list of rare drugs includes 442 active ingredients and vaccines/a total of more than 1,200 active ingredients in the list of drugs and biological products covered by health insurance.

Ms. Anh affirmed that the policy of patients having to go to the Social Insurance to receive money after purchasing medicine is not a priority policy in accessing medicine and medical supplies. This is only a temporary solution in case of medicine shortage due to objective reasons.

“This circular only provides guidance for rare drugs. The Ministry of Health has developed a strict direct payment policy and emphasized the hospital’s purchasing responsibility to ensure drugs and treatment supplies,” she said.

Ms. Anh explained that for common drugs and active ingredients, hospitals can use alternative active ingredients. The most important thing is to ensure treatment according to the regimen, not forcing patients to go out to buy drugs and supplies. Particularly for rare drugs, these are drugs that are less likely to be supplied on the market and less likely to be replaced.

In objective cases, if the hospital cannot purchase due to supply or bidding, and has to assign patients to buy outside, the patient will be paid directly. “This policy does not create conditions for medical examination and treatment facilities to widely prescribe for patients to buy outside,” she said.

The leader of the Health Insurance Department said that when patients come to a medical facility, the hospital must ensure that the treatment drugs are available, and the patients do not have to buy them themselves, which is the most convenient. In reality, if patients have to buy the drugs themselves and submit their own payment documents, it will cause inconvenience and difficulty.

Many shortcomings, not feasible

Speaking with Tuoi Tre, a representative of the local Social Insurance agency said that Circular 22 of the Ministry of Health regulating the payment of medicine and medical equipment costs for health insurance patients, which has just been issued, ensures the rights of patients with health insurance.

Especially after the COVID-19 pandemic, shortages of drugs and medical supplies have continuously occurred in many hospitals across the country due to problems with bidding.

But this person also commented that the payment requirements are unreasonable, have many shortcomings that cause inconvenience to people, and are not feasible. "People spend money to buy medicine and medical supplies but have to go to the Social Security agency to do payment procedures, which takes a lot of time and effort. Social Security must appraise before paying" - this person said.

Not to mention the condition that if the hospital has that active ingredient and buys it outside, the patient will not be paid. Or if the hospital buys the same active ingredient but under a different name, the patient will not be paid either. Even if the patient buys it at a higher price, they will only be paid according to the bid price…

“Not all patients have money, not all people have relatives to ask to go out and buy medicine, many patients are single. Not to mention the possibility of negative exploitation of the health insurance fund,” he said.

According to this person, the current social insurance human resources are still limited, when assessing the organization to pay people, it leads to a bloated apparatus because it has to assess each file. Typically, with the number of patients from the provinces flocking to Ho Chi Minh City, Ho Chi Minh City Social Insurance has to assess insurance files for the whole country.

Hospital can not buy must pay for patients?

People have to buy medicine and supplies from outside when hospitals lack medicine and supplies - Illustration: DUONG LIEU

Ms. Vu Nu Anh said that recently, there have been many documents regarding policies related to bidding and purchasing of drugs to help hospitals purchase in accordance with regulations, ensuring drugs and treatment supplies for patients.

“Drug shortages due to supply or objective reasons are very rare, only with a very few types of drugs, the cause of shortages is mostly subjective, hospitals do not have enough reserves or organize bidding appropriately. There are even hospitals that should have bid in June but only did it in August, leading to supply disruptions,” Ms. Anh said.

Agreeing with the viewpoint of the Health Insurance Department, a doctor working at a hospital in Hanoi also said that the hospital must try every way to have enough medicine and treatment supplies for patients.

“Patients and their families know where to buy the medicine when the hospital has to bid for half a year to get the medicine. In addition, patients have to pay in advance, find a source with full records and invoices, and then have to go to the Social Security agency to pay. If they are not paid, it is a waste of time and money. In particular, the quality of the medicine is not guaranteed,” said this doctor.

Representatives of local social insurance agencies also said that it is best to let hospitals directly reimburse health insurance patients for drugs and supplies, possibly through drug transfers between hospitals, for example.

The remaining problem is that health insurance and hospitals must deal with drug shortages due to bidding. “This is only a temporary solution, the root of the problem is that hospitals must bid and purchase enough drugs and medical supplies in accordance with the Law on Medical Examination and Treatment,” he said.

To ensure the rights of health insurance participants who have to buy medicine and supplies from outside, Ms. Anh said that the revised Law on Health Insurance is proposing another solution, which is to pay directly to medical facilities.

With this regulation, patients no longer have to submit their own documents to the Social Insurance, but only need to send their documents to buy medicine and supplies to the hospital, the hospital must pay the costs that the patient has to buy himself. If the law is passed, the Ministry of Health will continue to amend the guiding circular.

Source: https://tuoitre.vn/bao-hiem-tra-tien-thuoc-truc-tiep-day-kho-cho-nguoi-benh-20241025075905811.htm