Công văn 6403/BYT-KCB

In recent times, the Ministry of Health has received many feedbacks from some healthcare facilities providing medical services covered by health insurance, Departments of Health of provinces and the Vietnam Social Security (Official Dispatch No. 2797/BHXH-CSYT dated August 01, 2019) on a number of difficulties during implementation of policies for medical services and health insurance. In order to promptly resolve these difficulties and ensure proper and consistent implementation and reimbursement of medical fees covered by health insurance throughout the country, the Ministry of Health hereby provides the following guidelines:

1. Reimbursement of medical fees covered by health insurance for inpatient units or inpatient departments of district-level hospitals or district-level medical centers:

a) Difficulties:

- According to the existing Government’s Decree No. 155/2018/ND-CP dated November 12, 2018 on amendments to some Articles related to business conditions under state management of the Ministry of Health:

+ Clause 5 Article 11 amending Article 23 of the Decree No. 109/2016/ND-CP dated July 01, 2016 on issuance of practice certificates to healthcare practitioners and operating licenses to healthcare facilities specifies that “a) Departments, rooms and hallways must be conveniently arranged for specialized activities in an interconnected, self-contained and complex manner within the hospital premises;”.

+ Clause 12 Article 11 supplementing Clause 5 Article 50 of the Decree No. 109/2016/ND-CP stipulates that “The regulations hereof are applicable to areal polyclinics with inpatient treatment established and operating before this Decree takes effect, located in mountainous areas and remote and isolated areas and permitted in writing by the People’s Committees of Provinces and Departments of Health.”

- In reality: many localities have converted their areal polyclinics into inpatient units or inpatient departments affiliated to district-level general hospitals or district-level medical centers according to the guidelines specified in the Official Dispatch No. 618/BYT-KCB dated January 25, 2018 by the Ministry of Health. However, such inpatient units/departments are all located outside of the premises of district-level general hospitals or district-level medical centers, some of which are even dozens of kilometers away from their hospital’s premises. Hence, social security authorities have no grounds to reimburse the inpatient costs of inpatient units or inpatient departments whose establishment is against regulations of laws.

b) Guidelines:

- Every areal polyclinic with inpatient treatment has to be established and operate before November 12, 2018 (the effective date of the Decree No. 155/2018/ND-CP) in mountainous areas and remote and isolated areas and permitted in writing by the People’s Committees of Provinces and Departments of Health.

- If an inpatient unit/department (previously an areal polyclinic) located outside of the premises of a district-level hospital or district-level medical center satisfies the requirements for one of the healthcare facility forms (e.g. general hospitals, polyclinics, etc.) according to regulations of the Law on Medical Examination and Treatment, the Department of Health of its province or a health unit of a Ministry/regulatory body shall appraise and grant it the operating license before November 30, 2019.

2. Conclusion of insured medical service contract with Bach Mai Hospital's second branch.

a) Difficulties: according to the report from the Vietnam Social Security, it is against regulations of Article 23 of the Decree No. 109/2016/ND-CP and Article 11 of the Decree No. 155/2018/ND-CP for Bach Mai Hospital's second branch to be granted license to operate in the form of a “General Medicine Department”. In addition, Bach Mai Hospital's second branch is yet to be ranked and classified by the Ministry of Health. Therefore, social security authorities are unable to conclude the 2019 insured medical service contract with Bach Mai Hospital's second branch.

b) Guidelines:

- As it is against regulations of Article 23 of the Decree No. 109/2016/ND-CP for Bach Mai Hospital's second branch to be granted license to operate in the form of a “General Medicine Department”, the Ministry of Health shall make amendments to the form of organization in such operating license according to regulations of laws.

- As Bach Mai Hospital's second branch is lacking a license to operate as a hospital, it is not qualified for hospital ranking.

3. Conclusion of insured medical service contracts with hospitals affiliated to medical universities

a) Difficulties:

- According to the existing regulations of Point 5 Article 11 of the Government’s Decree No. 155/2018/ND-CP dated November 12, 2018 amending Point a Clause 2 Article 23 of the Decree No. 109/2016/ND-CP dated July 01, 2016: “The number of full-time (tenured) practitioners in each department must account for at least 50% of the total number of practitioners in such department”.

- In reality:

+ According to the reports of the social security authorities of Thai Nguyen and Thai Binh, tenured practitioners of Medicine University Hospital - Thai Nguyen University and Thai Binh Medicine University Hospital comprise less than 50% of the total number of personnel of these hospitals.

+ The Medical Service Administration received the Official Dispatch No. 175/CV-BV dated March 22, 2019 from Thai Nguyen Central Hospital on its tenured practitioners. On June 11, 2019, the Medical Service Administration sent the Official Dispatch No. 611/KCB-QLHN to reply to Thai Nguyen Central Hospital regarding such matter, which clearly states: “According to regulations of Clause 3 Article 3 of the Decree No. 109/2016/ND-CP , a full-time healthcare practitioner is a person working consecutively for 8 hours per day within the operating time registered by his/her healthcare facility or working during the whole healthcare facility’s working time if such time is less than 8 hours per day in compliance with regulations of labor laws.” As Thai Nguyen Central Hospital registers to operate 24/24, its tenured practitioners must work consecutively for 8 hours per day. Thus, lecturers of Thai Nguyen Medicine and Pharmacy University are unable to spend 8 hours per day working in Thai Nguyen Central Hospital, because either they are not permanently employed or they have signed a teaching contract with Thai Nguyen Medicine and Pharmacy University. Therefore, these lecturers are not tenured practitioners of Thai Nguyen Central Hospital.”

b) Guidelines:

- Departments of Health of provinces shall review and ensure that operating license of hospitals affiliated to universities is issued according to regulations of the Decree No. 155/2018/ND-CP and relevant regulations.

- Hospitals affiliated to universities shall review and assign personnel as prescribed in the Decree No. 155/2018/ND-CP.

- If a hospital cannot guarantee sufficient personnel as regulated, it shall request the Ministry of Health to make changes to its operating license, hospital scale and list of available technical services/medical procedures according to its personnel availability.

4. Medical services provided by general practitioners

a) Difficulties:

- The Circular No. 41/2015/TT-BYT lacks guidelines on the specialties and technical services/medical procedures that general practice certificate holders are permitted to practice.

- Clause 5 Article 7 of the Circular No. 40/2015/TT-BYT specifies that “Each polyclinic must have at least two specialties for internal medicine and surgical medicine; each polyclinic providing pediatric healthcare must also have a pediatric specialty.” In some polyclinics, general practitioners are also assigned to provide services concerning surgical medicine, pediatric healthcare, ENT care, oral healthcare, etc.

- Social security authorities do not have sufficient grounds to specify the scope of work of general practitioners according to regulations of the Law on Medical Examination and Treatment.

b) Guidelines:

- According to regulations of Annex 4b of the Circular No. 41/2015/TT-BYT dated November 16, 2015 by the Minister of Health, doctors at district-level and commune-level who are general practice graduates shall have “general practice” written on their practicing license.

- Article 6 of the Circular No. 50/2017/TT-BYT dated December 29, 2017 by the Minister of Health amending and supplementing regulations on reimbursement of costs of covered medical services stipulates that “The person in charge of technical and professional aspects of a healthcare facility shall consider and decide in writing which technical services/medical procedures a healthcare practitioner may provide at that health facility according to the scope of practicing specified on the practicing certificate, degree, diploma or other qualification and capacity of that healthcare practitioner”.

- Clause 7 Article 4 of the Circular No. 52/2017/TT-BYT dated December 29, 2017 by the Minister of Health providing for prescription of modern drugs and biologicals in outpatient treatment specifies that “Doctors and physicians working in level-4 healthcare facilities may provide general medical services and make up prescriptions for all specialties in the list of technical services/medical procedures in level-4 health facilities (which has been approved by a competent authority).

Therefore, the person in charge of technical and professional aspects of a healthcare facility shall permit a healthcare practitioner to perform specific technical services/medical procedures in that facility on the basis of the scope of practicing of that facility and the scope of practicing specified on the practicing certificate, degree, diploma or other qualification and capacity of that healthcare practitioner.

5. Arrangement of technical services/medical procedures of departments

a) Difficulties:

- Article 6 of the Circular No. 50/2017/TT-BYT dated December 29, 2017 by the Minister of Health stipulates that “A practicing certificate holder shall provide technical services/medical procedures of the specialty specified in his/her practicing certificate…”

- In the list of technical services/medical procedures enclosed with the Circular No. 43/2013/TT-BYT dated December 11, 2013 and Circular No. 21/2017/TT-BYT dated May 10, 2017 by the Minister of Health, many technical services/medical procedures of medical imaging, functional diagnostics and testing specialties are placed in the lists of technical services/medical procedures of internal medicine, surgical medicine, ophthalmology, etc., which gives rise to difficulties during implementation and reimbursement of covered medical fees.

b) Guidelines:

- Clause 2 Article 4 of the Circular No. 43/2013/TT-BYT dated December 11, 2013 by the Minister of Health specifies that “2. The list of technical services/medical procedures promulgated together with this Circular includes technical services/medical procedures licensed to be performed in Vietnam. A technical service or medical procedure may be performed in different specialties/departments but herein it is sorted into the most appropriate specialty/department.”

- Article 6 of the Circular No. 50/2017/TT-BYT dated December 29, 2017 by the Minister of Health stipulates that:

 “2. A practicing certificate holder shall provide technical services/medical procedures of the specialty specified in his/her practicing certificate, except surgical operations/medical procedures of the special types prescribed in the Circular No. 50/2014/TT-BYT dated December 26, 2014 by the Minister of Health, which requires such holder to possess appropriate additional certificates.”

The person in charge of technical and professional aspects of a healthcare facility shall consider and decide in writing which technical services/medical procedures a healthcare practitioner may provide at that healthcare facility according to the scope of practicing specified on the practicing certificate, degree, diploma or other qualification and capacity of that healthcare practitioner.

Therefore, a technical service or medical procedure may be performed in different departments but shall be sorted into the most appropriate specialty; and the person in charge of technical and professional aspects of a healthcare facility shall consider and decide in writing which technical services/medical procedures a healthcare practitioner may provide at that health facility according to the scope of practicing specified on the practicing certificate, degree, diploma or other qualification and capacity of that healthcare practitioner.

7. Regulations on personnel for the artificial kidney service:

a) Difficulties:

- According to the applicable Decision No. 2482/QD-BYT dated April 13, 2018 by the Minister of Health providing for the artificial kidney service, a nurse or medical assistant of the Artificial Kidney Department must possess a certificate of 6-month training in dialysis care.

- In reality: As reported by the Vietnam Social Security and some healthcare facilities: many nurses or medical assistants of the Artificial Kidney Department only possess a certificate of 3-month training in dialysis care while hospitals only provide training contents and programs concerning the artificial kidney service for a training period of 3 months to nurses and technicians.

b) Guidelines:

- Request the Vietnam Social Security to direct social security authorities of provinces to reimburse the expenses for the artificial kidney service provided by nurses or medical assistants who possess a certificate of 3-month training in dialysis care.

- The Ministry of Health is reviewing and making amendments to the Circular No. 2482/QD-BYT dated April 13, 2018 to ensure its legality and suitability with the realities and professional requirements.

Herein are the guidelines of the Ministry of Health for resolution of a number of difficulties arising during provision of medical services covered by health insurance for your reference and compliance.

With sincere thanks!