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MINISTRY
OF HEALTH
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SOCIALIST
REPUBLIC OF VIET NAM
Independence-Freedom-Happiness
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No.: 04/2021/TT-BYT
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Hanoi,
on April 29, 2021
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CIRCULAR
PROVIDING GUIDANCE ON CAPITATION PAYMENT OF COSTS OF COVERED HEALTHCARE
SERVICES
Pursuant to the Law on
Health Insurance No. 25/2008/QH12 dated November 14, 2008 as amended in the Law
No. 46/2014/QH13 dated June 13, 2014;
Pursuant to the Government’s
Decree No. 146/2018/ND-CP dated October 17, 2018 elaborating the Law on Health
Insurance;
Pursuant to the Government’s
Decree No. 75/2017/ND-CP dated June 20, 2017 defining functions, tasks, powers
and organizational structure of the Ministry of Health;
At the request of the
Director of the Department of Planning and Finance;
The Minister of Health
promulgates a Circular providing guidance on capitation payment of costs of
covered healthcare services.
Chapter
I
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Article
1. Scope and regulated entities
1. This Circular provides
regulations on:
a) Determination of
capitation fund;
b) Allocation, advancing and
statement of capitation fund;
c) Capitation payment
monitor indexes.
2. This Circular does not apply
to health facilities that have just signed contracts for provision of covered
healthcare services in the previous year.
Article
2. Definitions
1. “capitation
fund” means a predetermined amount of money which is allocated to a
health facility providing covered healthcare services for covering costs of
outpatient services provided for health insurance card holders in the scope of capitation
within a given period.
2. “age
group” means the participants in health insurance as prescribed in
this Circular who are classified into 6 groups according to their year of birth
as follows:
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b) Group 2: 7 - 18 years old;
c) Group 3: 19 - 24 years
old;
d) Group 4: 25 - 49 years
old;
dd) Group 5: 50 - 59 years
old;
e) Group 6: 60 years old and
older.
3. “conversion
card” means a health insurance card issued when registering the
initial healthcare provider on which the period over which funds are allocated
is fully converted according to the age groups specified in Clause 2 of this
Article.
4. “equivalence
card” means a health insurance card that requires the same amount
of resources for each use of healthcare services within the scope of
capitation. The number of equivalence cards of a health facility is the total
number of outpatient services within the scope of capitation provided for
patients, who have health insurance cards and receive initial healthcare
services at the health facility or are referred to the health facility from
health facilities of other levels, of which costs have been adjusted according
to age groups and conversion cards of the health facility.
5. “base
capitation rate” means a fixed amount of money used for paying an equivalence
card. This base capitation rate will be applied nationwide or throughout a
province or central-affiliated city (hereinafter referred to as “province”).
6. “fund
allocation factor” means a factor used for adjusting a provincial capitation
fund (hereinafter referred to as “ktỉnh”) or a health facility’s
capitation fund (hereinafter referred to as “kcơ sở”).
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8. “increase
or decrease in costs due to changes in policies” means
an amount of money determined for each health facility when making statement of
costs of covered outpatient services in the year in which the capitation fund
is allocated according to changes in legislative documents which affect the
costs of covered healthcare services.
Article
3. Scope of capitation
1. The scope of capitation for
a health facility of district level or lower is total costs of outpatient
services to be covered by health insurance fund of participants in health
insurance, except the case specified in Clause 3 of this Article.
2. The scope of capitation for
provincial-level and central-level health facilities is applied to all health
facilities providing initial healthcare services for health insurance card
holders, and is total costs of outpatient services within the scope of
capitation provided for patients receiving initial healthcare services at the
health facility, except the case specified in Clause 3 of this Article.
3. The scope of capitation does
not include the following costs of healthcare services:
a) Costs of healthcare
services provided for health insurance card holders who are soldiers (code:
QN), cipher officers (code: CY), or police officers (code: CA);
b) Costs of transporting patients
who have health insurance cards;
c) Total costs of healthcare
services with use of regular hemodialysis or peritoneal dialysis technique or peritoneal
dialysis solutions;
d) Total costs of healthcare
services with use of anticancer drugs or medical interventions for cancer
treatment provided for patients who are diagnosed with cancer of codes C00-C97
and codes D00-D09 according to the International Classification of Diseases,
Tenth Revision (hereinafter referred to as “ICD-10”);
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e) Total costs of healthcare
services with use of immunosuppressive drugs provided for organ transplant
patients;
g) Total costs of healthcare
services with use of hepatitis C medicines provided for hepatitis C patients;
h) Total costs of healthcare
services with use of antiretroviral drugs or HIV viral load tests provided for
patients who have health insurance cards and are diagnosed with HIV.
Chapter
II
DETERMINATION OF CAPITATION FUNDS
Article
4. National capitation fund
1. The national capitation fund
(hereinafter referred to as “QUY_ĐStq”) of the allocation year is
calculated adopting the following formula:
QUY_ĐStq
=
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+
Difference
due to increase or decrease in conversion cards between the fund allocation
year and the previous year
+
Increase
or decrease in costs due to changes in policies
Where:
a) Total national capitation
fund settled in the previous year is total amount of money, within the scope of
capitation fund in the previous year of each health facility, settled in
accordance with regulations herein.
b) Difference due to
increase or decrease in conversion cards between the fund allocation year and
the previous year is calculated adopting the following formula:
Difference
due to increase or decrease in conversion cards between the fund allocation
year and the previous year
=
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x
Difference
(increase or decrease) in conversion cards between the fund allocation year and
the previous year
Decrease
in conversion cards, compared to the previous year
Where:
- National T_TTĐS = Sum of
capitation payments made to all provinces;
- T_TTĐS of a province = Sum
of capitation payments made to health facilities that provide covered
healthcare services with capitation payment in the province;
- T_TTĐS of a health facility
= (The annual capitation fund of the health facility settled according to
Article 11 hereof) + (Increase or decrease in costs due to changes in policies
as prescribed in Clause 8 Article 2 hereof).
2. Total national conversion
cards and national card conversion factor:
a) The number of national
conversion cards is equal to total conversion cards of provinces;
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Where:
- i: the age group i; i equals
1 - 6, corresponding to 6 age groups specified in Clause 2 Article 2 hereof;
- The ĐKBĐ năm giao quỹtỉnhi:
total cards used for registering initial healthcare services covered by health
insurance fund of the age group i during the full year in which the provincial
capitation fund is allocated;
- HSQĐTtqi: the
national card conversion factor for the age group i in the fund allocation
year, which is calculated adopting the following formula:
HSQĐTtqi
=
National
average cost per health insurance card of the age group i in the previous
year
National
average cost per health insurance card in the previous year
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National
average cost per health insurance card of the age group i in the previous
year
=
T_BHTT
used for making payments for the age group i in the whole country in the
previous year
Total
health insurance cards of the age group i in the whole country in the
previous year (a full year)
National
average cost per health insurance card in the previous year
=
T_BHTT
used for making payments for all age groups in the whole country in the
previous year
Total
health insurance cards in the whole country in the previous year (a full
year)
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- T_BHTT of the whole country
= Total payments of costs of covered healthcare services made to all provinces
in the country;
- T_BHTT of a province = Total
payments of costs of covered healthcare services made to all health facilities
that provide covered healthcare services with capitation payment in the
province;
- T_BHTT of a health facility
= Total payments of costs of healthcare services covered by health insurance
fund specified in the assessment record made by the relevant provincial social
insurance office.
Article
5. National base capitation rates
1. The national base capitation
rate (hereinafter referred to as “SPCBtq”) of the fund allocation
year is calculated adopting the following formula:
SPCBtq
=
QUY_ĐStq
The
TĐtq
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a) QUY_ĐStq: comply
with Clause 1 Article 4 hereof;
b) The TĐtq: The
number of national equivalence cards in the fund allocation year, which is the
sum of equivalence cards of all provinces in the fund allocation year.
2. The number of equivalence
cards of a province = (Number of intra-provincial equivalence cards of that
province in the fund allocation year) + (Number of inter-provincial receiving equivalence
cards of that province in the fund allocation year).
a) The number of
intra-provincial equivalence cards of a province in the fund allocation year is
the sum of intra-provincial equivalence cards of 6 age groups specified in
Clause 2 Article 2 hereof in the fund allocation year of that province. The
number of intra-provincial equivalence cards in the fund allocation year of the
age group i (hereinafter referred to as “The TĐ nội tỉnh nhóm
i năm giao quỹ”) is calculated adopting the following formula:
The
TĐ nội tỉnh nhóm i năm giao quỹ
=
Số
lượt nội tỉnh nhóm itỉnh ntlk
x
The
QĐ nhóm itỉnh năm giao quỹ
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Hệ
số quy đổi lượt nhóm itoàn quốc năm giao quỹ
The
QĐ nhóm itỉnh ntlk
Where:
- “Số lượt nội tỉnh nhóm itỉnh
ntlk” is total times patients of the age group i who have health
insurance cards and have registered for initial healthcare services in the
province (excluding health insurance cards issued by other provinces) receive
healthcare services from health facilities in that province in the previous
year;
- “The QĐ nhóm itỉnh ntlk”
is the number of conversion cards for the age group i of the province in the
previous year;
- “The QĐ nhóm itỉnh năm
giao quỹ” is the number of conversion cards for the age group i of the
province in the fund allocation year;
- “Hệ số quy đổi lượt nhóm itoàn
quốc năm giao quỹ” is the national conversion factor for times of use of
healthcare services of the age group i in the fund allocation year.
b) The number of
inter-provincial receiving equivalence cards of a province is the sum of
inter-provincial receiving equivalence cards of 6 age groups specified in
Clause 2 Article 2 hereof.
Number
of inter-provincial receiving equivalence cards of the age group i in the
fund allocation year
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Times
of use of covered outpatient services by patients of the age group i referred
from other provinces in the previous year
x
National
conversion factor for times of use of healthcare services of the age group i
in the fund allocation year
c) National conversion
factor for times of use of healthcare services of the age group i (hereinafter
referred to as “HSQĐLtqi”) in the fund allocation year is calculated
adopting the following formula:
HSQĐLtqi
=
National
average cost per use of healthcare services of the age group i in the
previous year
National
average cost per use of healthcare services in the previous year
Where:
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=
T_BHTT
used for making payments for the age group i of the whole country in the
previous year
Total
times of use of healthcare services of the age group i of the whole country
in the previous year
National
average cost per use of healthcare services in the previous year
=
T_BHTT
used for making payments for 6 age groups of the whole country in the
previous year
Total
times of use of healthcare services of all age groups of the whole country in
the previous year
Article
6. Provincial capitation funds
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QUY_ĐStỉnh
=
SPCBtq
x
Number
of equivalence cards of the province in the fund allocation year
x
k1tỉnh
x
k2đctqtq
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k3tỉnh
Where:
a) SPCBtq: comply
with Clause 1 Article 5 hereof;
b) Number of equivalence
cards of the province in the fund allocation year shall comply with Clause 2
Article 5 hereof;
c) k1tỉnh is the provincial
cost adjustment factor which is calculated according to the national general
average cost and ensures that the provincial capitation fund temporarily
calculated according to k = k1 (excluding k2) shall neither exceed 110% (one
hundred and ten percent) nor be lower than 90% (ninety percent) when having the
same number of conversion cards of the province, k1tỉnh is
calculated adopting the following formula:
k1tỉnh
=
TLHS x CPBQ thẻ TĐtỉnh
ntlk + (1-TLHS) x CPBQ thẻ TĐtq ntlk
CPBQ thẻ TĐtq
ntlk
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- TLHS is the rate of
application of cost coefficient according to the roadmap specified in Clause 2
Article 15 hereof.
- CPBQ thẻ TĐtỉnh ntlk is the provincial average cost
per equivalence card in the previous year and is calculated adopting the
following formula:
CPBQ
thẻ TĐtỉnh ntlk
=
T_TTĐS
of the province in the previous year
Number
of equivalence cards of the province in the previous year
- CPBQ thẻ TĐtq ntlk
is the national average cost per equivalence card in the previous year and is
calculated adopting the following formula:
CPBQ
thẻ TĐtq ntlk
=
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Number
of equivalence cards of the whole country in the previous year
d) k2đctqtq is
the adjustment factor which is used to ensure that the sum of capitation funds
allocated to all provinces equals the national capitation fund, and is
calculated adopting the following formula:
Where:
- n is the number of provinces
to which capitation funds are allocated;
- QUY_ĐStq: comply
with Clause 1 Article 4 hereof;
- QUY ĐStỉnh tt is
the provincial capitation fund which is temporarily calculated according to
coefficient k1 and has been adjusted to ensure that it neither exceeds 110%
(one hundred and ten percent) nor is lower than 90% (ninety percent) of the
provincial T_TTĐS in the previous year for the same number of conversion cards
(excluding k2) of the province;
- j is the province’s ordinal
number j; j equals 1 - n, corresponding to the number of provinces to which
capitation funds are allocated.
dd) k3tỉnh is
other adjustment factor of the province, and k3tỉnh = 1 in the first
year of application.
k3tỉnh shall be stipulated by the Minister of
Health in the following years. If the Minister of Health promulgates no regulation on k3tỉnh,
k3tỉnh = 1 shall apply.
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3. The provincial capitation
fund shall be fully allocated to health facilities in the fund allocation year.
Article
7. Provincial base capitation rates
1. The provincial base
capitation rate (hereinafter referred to as “SPCBtỉnh”) of the fund
allocation year is calculated adopting the following formula:
SPCBtỉnh
=
QUY_ĐStỉnh
The TĐtỉnh
Where:
a) QUY_ĐStỉnh:
comply with Clause 1 Article 6 hereof;
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2. The number of provincial
equivalence cards in the fund allocation year is the sum of equivalence cards
of all health facilities to which capitation payments are made in the province
in the fund allocation year.
3. The number of equivalence
cards of a health facility to which capitation payment is made in the fund
allocation year = (Number of equivalence cards used for initial healthcare
services at the health facility in the fund allocation year) + (Number of receiving
equivalence cards of the health facility in the fund allocation year).
a) The number of equivalence
cards used for initial healthcare services at the health facility in the fund
allocation year is the sum of equivalence cards used for initial healthcare
services by 6 age groups specified in Clause 2 Article 2 hereof of the health
facility in the fund allocation year.
The number of equivalence
cards used for initial healthcare services of the age group i at the health
facility in the fund allocation year is calculated adopting the following
formula:
Number
of equivalence cards used for initial healthcare services of the age group i
at the health facility
=
Số
Lượt KCBBĐ Nhóm icơ sở ntlk
x
Thẻ
QĐ nhóm icơ sở năm giao quỹ
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Hệ
số quy đổi lượt nhóm i toàn tỉnh năm giao quỹ
Thẻ
QĐ nhóm icơ sở ntlk
Where:
- “Số lượt KCBBĐ nhóm icơ
sở ntlk” is the number of health insurance card holders of the age group
i who have registered for initial healthcare services at the health facility
and used initial healthcare services at that health facility in the previous
year;
- “Thẻ QĐ nhóm icơ sở
ntlk” is the number of conversion cards for the age group i of the health
facility in the previous year;
- “Thẻ QĐ nhóm icơ sở
năm giao quỹ” is the number of conversion cards for the age group i of
the health facility in the fund allocation year;
- “Hệ số quy đổi lượt nhóm i toàn
tỉnh năm giao quỹ” is the provincial conversion factor for times of use
of healthcare services of the age group i in the fund allocation year. The
provincial conversion factor for times of use of healthcare services of the age
group i in the fund allocation year is calculated adopting the following
formula:
Hệ
số quy đổi lượt nhóm i toàn tỉnh năm giao quỹ
=
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Provincial
general average cost per use of healthcare services of 6 age groups in the
previous year
Where:
Provincial
average cost per use of healthcare services of the age group i in the
previous year
=
T_BHTT
used for making payments for the age group i of the whole province in the
previous year
Total
times of use of covered healthcare services by the age group i of the whole
country in the previous year
Provincial
general average cost per use of healthcare services of all age groups in the
previous year
=
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Total
times of use of healthcare services by all age groups of the whole province
in the previous year
b) The number of receiving
equivalence cards of a health facility in the fund allocation year is the sum
of receiving equivalence cards of 6 age groups specified in Clause 2 Article 2
hereof.
The number of receiving
equivalence cards of the age group i of the health facility in the fund
allocation year = (Times of use of healthcare services at the health facility by
patients of the age group i of other levels in the previous year) x (Provincial
conversion factor for times of use of healthcare services of the age group i in
the fund allocation year as prescribed in Point a of this Clause).
Article
8. Capitation funds of health facilities
1. The capitation fund of a
health facility in the fund allocation year is calculated adopting the
following formula:
The
health facility’s capitation fund
=
SPCBtỉnh
x
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x
k1cơ
sở
x
k2đctqtỉnh
x
k3cơ
sở
Where:
a) SPCBtỉnh:
comply with Clause 1 Article 7 hereof;
b) Number of equivalence
cards of the health facility in the fund allocation year shall comply with
Clause 3 Article 7 hereof;
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k1cơ
sở
=
TLHS x CPBQ thẻ TĐcơ
sở ntlk + (1-TLHS) x CPBQ thẻ TĐtỉnh ntlk
CPBQ thẻ TĐtỉnh
ntlk
Where:
- TLHS is the rate of
application of cost coefficient according to the roadmap specified in Clause 2
Article 15 hereof.
- CPBQ thẻ TĐcơ sở ntlk
is the average cost per equivalence card in the previous year of the health
facility and is calculated adopting the following formula:
CPBQ
thẻ TĐcơ sở ntlk
=
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Number
of equivalence cards of the health facility in the previous year
d) k2đctqtỉnh is
the adjustment factor which is used to ensure that the sum of capitation funds
allocated to all health facilities in the province equals the provincial
capitation fund, and is calculated adopting the following formula:
+ n: number of health
facilities to which capitation payments of costs of covered healthcare services
are made in the whole province;
+ QUY_ĐStỉnh:
comply with Article 6 hereof;
+ QUY_ĐScơ sở tt:
the health facility’s capitation fund temporarily calculated according to k =
k1 and has been adjusted to ensure that it neither exceeds 110% nor is lower
than 90% of the costs in the previous year for the same number of conversion
cards (excluding k2);
+ j: the health facility’s
ordinal number j; j equals 1 - n, corresponding to the number of health
facilities in the province to which capitation payments of costs of covered
healthcare services are made.
dd) k3cơ sở:
other adjustment factor of the health facility, and k3cơ sở = 1 in
the first year of application. The provincial Department of Health shall play the leading
role and cooperate with the provincial health insurance office in deciding k3cơ
sở in the following years. If no regulation on k3cơ
sở is available, k3cơ sở = 1 shall apply.
2. The health facility’s
capitation fund does not include increase or decrease in costs due to changes
in policies.
The increase or decrease in costs due to changes in policies
shall be determined according to the notice of the Ministry of Health. It
shall be zero if it is not notified by the Ministry of Health.
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ALLOCATION, ADVANCING AND STATEMENT OF CAPITATION FUNDS
Article
9. Allocation of provincial capitation funds
1. By January 15 of the fund
allocation year, Vietnam Social Security shall notify social insurance offices
of provinces of:
a) The capitation fund
temporarily allocated to the province in the fund allocation year after obtaining
approval from the Ministry of Health. Determination of the
provincial capitation fund temporarily allocated shall comply with Clause 2 of
this Article;
b) The provincial capitation
fund in the year preceding the fund allocation year.
2. The capitation fund which is
temporarily allocated at the beginning of year to a province shall be
calculated according to Article 6 hereof, in which figures are temporarily
calculated as follows:
a) Total national capitation
fund settled in the previous year is equal to total national capitation fund
temporarily allocated in the previous year;
b) The national base
capitation rate temporarily allocated at the beginning of year = (95% (ninety
five percent) of the national capitation fund temporarily calculated as
specified in Point a of this Clause) : (Number of national equivalence cards
specified in Point b Clause 1 Article 5 hereof);
c) Number of conversion
cards in the previous year of each province is temporarily calculated according
to the number of cards which are issued by the provincial social insurance
office and have been converted using the national card conversion factor;
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dd) The provincial T_TTĐS in
the previous year is temporarily calculated according to the capitation fund temporarily
allocated to the province for the full previous year and adjusted in Quarter IV
of the previous year;
e) Number of conversion
cards in the fund allocation year of a province is temporarily calculated
according to the number of health insurance cards which are issued in Quarter I
of the fund allocation year of that province, and have been converted according
to the national card conversion factor.
Article
10. Allocation of capitation funds to health facilities
1. Based on the notice of the
provincial capitation fund temporarily allocated as prescribed in Clause 1
Article 9 hereof, by January 30 of the fund allocation year, the provincial
social insurance office shall notify heath facilities of:
a) The capitation fund
temporarily allocated to the health facility in the fund allocation year after
obtaining approval from the provincial Department of Health. Determination
of the capitation fund temporarily allocated to each health facility in the
province shall comply with Clause 3 of this Article;
b) The health facility’s
capitation fund in the year preceding the fund allocation year.
2. Based on the capitation fund
temporarily allocated to each heath facility, the provincial social insurance
office shall quarterly allocate capitation fund to the health facility with
specific amounts and within the time limits as follows:
a) The capitation payment of
Quarter I shall be made by January 30 of the fund allocation year and equal to
22% (twenty two percent) of the temporarily allocated capitation fund;
b) The capitation payment of
Quarter II shall be made by April 15 of the fund allocation year and equal to
24% (twenty four percent) of the temporarily allocated capitation fund;
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d) The capitation payment of
Quarter IV shall be made by October 15 of the fund allocation year and equal to
27% (twenty seven percent) of the temporarily allocated capitation fund.
3. The capitation fund which is
temporarily allocated at the beginning of year to a health facility shall be
calculated according to Article 8 hereof, in which figures are temporarily
calculated as follows:
a) The provincial capitation
fund temporarily calculated shall be equal to total provincial capitation fund
notified at the beginning of year;
b) The provincial base capitation
rate = (95% (ninety five percent) of the provincial capitation fund temporarily
allocated at the beginning of year) : (Number of provincial equivalence cards
specified in Clause 2 Article 7 hereof);
c) Number of conversion
cards in the previous year of each health facility is temporarily calculated
according to the number of cards which are issued by the social insurance
office in the previous year and have been converted using the provincial card
conversion factor;
d) Number of times of use of
healthcare services and the T_BHTT of the health facility in the previous year
shall be temporarily calculated according to the times and costs of covered
outpatient services of which the payment is requested by the health facility in
the previous year on the information technology system for health insurance
assessment;
dd) The T_TTĐS of the health
facility in the previous year is temporarily calculated according to the
capitation fund temporarily allocated to that health facility for the full
previous year and adjusted in quarter IV of the previous year;
e) Number of conversion
cards of each health facility in the fund allocation year is temporarily
calculated according to the number of cards used for registering initial
healthcare services in Quarter I of the fund allocation year and converted
according to the provincial card conversion factor.
Article
11. Statement of capitation funds of health facilities
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2. The capitation fund of the
whole year of a health facility shall be equal to the one calculated in Article
8 hereof if the health facility meets the following conditions:
a) The inpatient admission
ratio within the scope of capitation is not higher than the one in the previous
year;
b) The frequency of referral
to other health facilities of patients registering for initial healthcare
services is not higher than the one in the previous year;
c) Ratio of referral of patients
referred to the health facility from other levels to outpatient departments of
provincial- or central-level facilities within the scope of capitation in the
fund allocation year is not higher than the one in the previous year;
3. If a health facility fails
to meet the conditions in Clause 2 of this Article, the capitation fund settled
for the full year of that health facility = (the capitation fund calculated
according to Article 8 hereof) - (an amount of money deducted according to
Article 12 and Article 13 hereof, depending on the increase rate).
E.g.:
- If the inpatient admission
ratio of a health facility is increased, the amount deducted shall be
determined according to Article 12 hereof;
- If the frequency of referral
to other health facilities of patients registering for initial healthcare
services is increased, the amount deducted shall be determined according to
Clause 1 Article 13 hereof;
- If both the inpatient
admission ratio and the frequency of referral to other health facilities of
patients registering for initial healthcare services are increased, the amount
deducted shall be the sum of the amount determined according to Article 12
hereof and the one determined according to Clause 1 Article 13 hereof.
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5. In case a health facility
terminates the contract for provision of covered outpatient services in the
year, the capitation fund shall be settled for the period during which
healthcare services are provided with capitation payments.
6. In case the capitation fund
allocated in the year is higher than the costs of covered healthcare services provided
(residual capitation fund is recorded):
a) The residual amount of
the capitation fund to be retained by the health facility shall not exceed 20%
(twenty percent) of total capitation fund allocated to it for the full year,
and shall be taken into account when determining the capitation fund allocated
to that health facility in the following year. The residual amount that
remains after 20% of which is retained by the health facility (if any) shall be
transferred to the provincial capitation fund and shall not be included in the
capitation fund allocated to the health facility in the following year;
b) The health facility shall
record the residual amount specified in Point a of this Clause as its revenues. This
residual amount shall be managed and used in accordance with regulations of
law;
c) If the capitation fund of
a health facility is used for covering costs of healthcare services provided by
its subsidiary facilities, it shall transfer a part of its residual amount to
such subsidiary facilities. The Provincial Department of Health shall play the
leading role and cooperate with the provincial social insurance office in
providing guidance on distribution of residual amount of a health facility to
its subsidiary facilities in conformity with actual conditions of each
province.
7. In case the capitation fund
allocated is lower than the costs of covered healthcare services provided
within the scope of capitation (the health facility faces capitation fund
deficit), the health facility shall use its revenues to cover the deficit as
prescribed.
Chapter
IV
CAPITATION PAYMENT MONITOR INDEXES
Article
12. Inpatient treatment ratio
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Inpatient
treatment ratio
=
Number
of inpatient treatments of the health facility in the year (n)
Number
of conversion cards of the health facility in the year (n)
With regard to a provincial-
or central-level health facility, the number of inpatient treatments shall only
include patients who have registered initial healthcare services at that health
facility.
In case the inpatient
admission ratio in the fund allocation year of the health facility to which the
capitation payment is made exceeds the one in the previous year, an amount
equivalent to the average cost of a covered inpatient treatment of the health
facility shall be deducted for each excessive case.
2. Number of excessive
inpatient treatments shall be calculated adopting the following formula:
Number
of excessive inpatient treatments
= (
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-
Inpatient
treatment ratio in the previous year
)
x
Number
of conversion cards of the health facility in the fund allocation year
Article
13. Initiation ratio and referral ratio
1. The initiation ratio of
patients registering for initial healthcare services (hereinafter referred to
as “initiation ratio”) at a health facility in the year (n) equals (=) times of
use of covered healthcare services by such patients at other health facilities (excluding
patients who receive covered healthcare services at district-level health
facilities in the province) of the year (n) divided by (:) the number of
conversion cards in the year (n) of that health facility.
Number of initiation cases
exceeding the initiation ratio in the previous year is calculated adopting the
following formula:
Number
of initiation cases exceeding the initiation ratio in the previous year
= (
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-
Initiation
ratio in the year preceding the fund allocation year
)
x
Number
of conversion cards the fund allocation year
If the initiation ratio of a
health facility to which the capitation payment is made exceeds that in the
previous year, an amount equivalent to the average cost of a covered outpatient
examination or treatment within the scope of capitation of initiation cases in
the fund allocation year of the health facility shall be deducted for each
excessive case.
2. The referral ratio of
patients referred to the health facility from other-level health facilities in
the year (n) is calculated adopting the following formula:
Referral
ratio of patients referred to the health facility from other-level health
facilities in the year (n)
=
Number
of patients who are referred to the health facility from other-level health
facilities are referred to outpatient departments of provincial- or
central-level health facilities within the scope of capitation in the year
(n)
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Where:
Number
of referral cases exceeding the referral ratio in the previous year
= (
Referral
ratio in the fund allocation year
-
Referral
ratio in the previous year
)
x
Number
of patients referred to the health facility from other-level health
facilities in the fund allocation year
This referral ratio does not
apply to provincial- or central-level health facilities.
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3. When transferring data to
the information technology system for health insurance assessment, the
receiving health facilities must provide adequate information about codes of initiating
health facilities (MA_NOI_CHUYEN) according to the format in Table 1 of the
Appendix enclosed with the Decision No. 4210/QĐ-BYT dated September 20, 2017 of
the Ministry of Health.
In case an application for payment of covered healthcare
services for an appropriate referral case does not indicate the code of the
initiating health facility, it shall not be considered an appropriate referral
case and payment shall be made according to regulations on payments for
inappropriate referral cases.
Chapter
V
IMPLEMENTATION
Article
14. Effect
This Circular comes into
force from July 01, 2021.
Article
15. Transition clauses and implementation roadmap
1. The capitation fund for the
year 2021 shall commence from January 01, 2021 and be calculated using the
following figures:
a) The number of equivalence
cards of the health facility or province due to increase or decrease in
conversion cards shall be determined according to the difference in conversion
cards in 2021 and those in 2019;
b) Total national capitation
fund in 2021 as prescribed in Clause 1 Article 4 hereof shall be calculated
adopting the following formula:
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=
(CP
x TL)
+
CP
x
(
Number
of conversion cards in 2021
-
Number
of conversion cards in 2019
)
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Where:
- CP: Costs of covered
healthcare services within the scope of capitation in 2019 settled according to
the Government’s Decree No. 146/2018/ND-CP dated October 17, 2018;
- TL: ratio of costs of
covered healthcare services within the scope of capitation to total costs of
covered healthcare services for which the payment is made by the social
insurance office in 2019.
c) T_BHTT in the previous
year is equal to T_BHTT in 2019;
d) T_TTĐS in the previous
year is equal to T_BHTT in 2019;
dd) Monitor indexes for a
health facility shall be determined according to figures of 2019, including:
- The initiation ratio and
referral ratio of the previous year shall be equal to those in 2019;
- The inpatient admission
ratio in the previous year equals (=) times of use of covered healthcare
services within the scope of capitation in 2019 of the health facility divided
by (:) times of use of covered healthcare services (including inpatient and outpatient
services) in 2019 of that health facility.
2. Roadmap for application of
cost coefficient:
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b) Since 2022: comply with
the notice of the Ministry of Health. If no notice is issued, the
rate of application of cost coefficient in the previous year shall apply.
Article
16. Reference clause
If any legislative documents
referred to in this Circular are superseded, supplemented or amended, the new
ones shall apply.
Article
17. Responsibility for implementation
1. Responsibilities of Ministry
of Health:
a) Before allocating
capitation funds to provinces, inspect and verify the national capitation fund,
fund allocation indexes and factors, and other factors related to provincial
capitation funds which are calculated by Vietnam Social Security;
b) Stipulate and notify k3tỉnh;
c) Play the leading role and
cooperate with Vietnam Social Security in calculating costs of covered
healthcare services within the scope of capitation in case there are changes in
policies on statement and payment for costs of covered healthcare services;
d) Direct health facilities
to strictly comply with specialized regulations and consistently implement
solutions for ensuring the rational, safe and efficient use of capitation
funds;
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2. Responsibilities of Vietnam
Social Security:
a) Play the leading role in
calculating the national capitation fund, conversion factor, fund allocation
factors and other factors related to allocation of capitation funds to
provinces; obtain the approval from the Ministry of Health before notifying
provincial capitation funds;
b) Provide the Ministry of
Health with data used in calculation, methods of calculation and allocation of
capitation funds for inspection;
c) In case total costs
within the scope of the national capitation fund in the fund allocation year
are higher than the allocated national capitation fund, Vietnam Social Security
shall prepare and provide consolidated reports thereof as prescribed in Clause
6 Article 25 of Decree No. 146/2018/ND-CP;
d) Notify capitation funds
to provinces;
dd) Direct provincial social
insurance offices to:
- Make capitation payments in
accordance with regulations herein;
- Play the leading role and
cooperate with provincial Departments of Health in determining the number of
health insurance cards used for registering covered initial healthcare
services, card conversion factors, provincial base capitation rates, fund
allocation factor of each health facility and other related factors according
to guidelines given by the Ministry of Health and Vietnam Social Security;
- Cooperate with health
facilities providing covered healthcare services in organizing the implementation
of this Circular;
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- Cooperate with provincial
Departments of Health in instructing health facilities entering into contracts
for provision of healthcare services with capitation payments to distribute
residual amounts or deficits of capitation funds (if any) to their subsidiary
facilities.
e) Develop assessment
methods which are appropriate for capitation payment method, and instruct
provincial social insurance offices to adopt capitation payment method and
inspect to ensure rights and benefits of patients having health insurance
cards.
3. Responsibilities of
provincial People’s Committees:
Instruct and promptly deal
with difficulties that arise during the implementation of policies and laws on
health insurance and other contents concerning this Circular within the scope
of their assigned tasks and powers.
4. Responsibilities of
Provincial Departments of Health:
a) Direct local health
facilities providing covered healthcare services to organize the implementation
of this Circular;
b) Before allocating
capitation funds to health facilities, inspect and verify the calculation and
allocation of provincial capitation funds by provincial social insurance offices;
c) Cooperate with provincial
Departments of Health in determining the number of health insurance cards used
for registering covered initial healthcare services, card conversion factors,
provincial base capitation rates, fund allocation factor of each health
facility and other related factors according to guidelines given by the
Ministry of Health;
d) Play the leading role and
cooperate with provincial social insurance offices in directing health
facilities to apply regulations of this Circular to their affiliated general
clinics and communal health stations;
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e) Play the leading role and
cooperate with provincial social insurance offices in instructing health
facilities entering into contracts for provision of healthcare services with
capitation payments to distribute residual amounts or deficits of capitation
funds (if any) to their subsidiary facilities in conformity with actual
conditions of provinces.
5. Responsibilities of health
facilities:
a) Direct entities under
their management to organize the implementation of this Circular;
b) Ensure rights and
benefits of patients having health insurance cards, promptly and adequately
provide them with covered drugs, chemicals and medical supplies;
c) If the residual amount of
capitation fund of a health facility exceeds 25% (twenty five percent) of the
capitation fund temporarily allocated at the beginning of year, the health
facility is required to provide written explanations to the relevant provincial
Department of Health and provincial social insurance office. The
provincial Department of Health and provincial social insurance office shall organize
assessment of treatment quality to ensure rights and benefits of health
insurance card holders;
d) Encode and transfer
electronic data concerning capitation payment method as prescribed;
dd) Deal with residua
amounts or deficits of capitation funds according to guidelines adopted by Provincial
Departments of Health;
e) A health facility shall
distribute the capitation fund to its subsidiary facilities provided total
amounts distributed shall not exceed its capitation fund;
g) Proactively use funding
sources determined in the year to cover costs of healthcare services provided
for patients having health insurance cards.
...
...
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PP. MINISTER
DEPUTY MINISTER
Tran Van Thuan