NGHIEN c a u - TRAO DOI
Bai toan vien phi:
Vain de tang gia hay tinh du ?
Trirdc de xua't tang gia vien phi cua Bo Y te, bao chi va cac phifdng tien truyen thong da dUa nhieu y kien xung quanh van de nay. Chu yeu cac y kien tap trung vao khia canh tac dong xa hoi cua chinh sach: ganh nang cija ngu'di dan, dac biet la dan ngheo neu chinh sach nay dUdc thiic hien. Tuy nhien du'di mot gdc do khac, goc do kinh te: khong ddn thuan goi chinh sach nay la sU tang gia ma day la van de tinh dung, tinh du chi phi gop phan nang cao chat lUdng kham chiira benh.
Nha nudc cung cip midn phi cho toan dan ndn khoan chi tidu true tid'p tir tien tui ngudi dan la khong ding kd. Nhung tir nam 1989, ngudi benh phai chju (mdt phin) chi phi tai chinh do benh tat. Co sd phap ly eua phuang an niy la Quydi dinh 45-HDBT vd vide thu mpt phin vidn phi cua Chinh phii (sau dd dupc bd sung va sira ddi bing Nghj djnh 95-CP nam 1994
ThS. DANG THI LE XUAN Dqi hpc Kinh te Qudc ddn va Nghj djnh 33-CP nam 1995 dupc cu the hda bang Thdng tu sd
14/TTLB ngiy 30/9/1995) va dupc gpi la phuang in thu vidn phi (mpt phin). Cich thu mdt phin vidn phi nay chinh la phuong thiic trp cip vidn phi. Thue hien co chd' nay, Nha nudc se bao ca'p mdt phan chi phi kham chiia benh cho ngudi dan thdng qua vide trp cip cho cac benh vien, co sd khim chii'a benh cdng (trp cip bdn cung).
Mirc thu theo cic van bin phap ly trdn da da trd ndn khong phii hpp vdi tinh hinh chi phi tai chinh trong bdi canh hien nay. Miic thu niy so vdi mot sd nudc trong khu vuc thi se la rat thap (xem bang 1).
Tuy nhidn, d nhieu benh vidn cdng, miic phi nay khong cdn
VlfeN PHI VA MIJC THU VIEN PHI HIEN NAY
Cdng tac cham sdc sire khde luon la mdi quan tam hang diu cua mpi qudc gia vi sire khde vira la phuong tidn, vira la thudc do kdi qua ciia qua trinh phat trien. Cai each ITnh vuc y td la mdt boat dpng lim dau diu cac qudc gia dac biet la cic qud'c gia dang trong qui trinh phit trien bdi ngudn lire cd han cdn chi -phi y te va nhu ciu cham sdc siic khde thi ngiy mdt tang. Trude thuc trang ngan sich Nha nudc khong dii cho cong tac cham sdc sire khde, Chinh phii nhidu qudc gia trong dd cd Viet Nam da ap dung phuang an true tiep thu (mpt phin) vien phi tir ngudi benh. Phuong dn huy dong mpt phdn sif ddng gdp ciia ngifdi hinh Id cdch thifc md trong do ngifdi hinh vd gia dinh phdi trd trifc tiip cho cdc dich vu y ti' khi sif dung dich vu. nhif chi mua thudc, chi tru vien phi. phi .\it nghiem, chdn dodn can Idm sdng vd cdc chi phi khdc.
Trong thdi ky bao cap (trudc
ddi mdi), cac dich vu y te dUpc Lieu viec ndng vien phi cd Idm nang cao chdt lucmg kham chua henh ?
So 23/2010
28 Kinh t£' v a Dit b a o
NGHIEN CQU - TRAO DOI
dupc ap dung. Bd Y te dang cd kidn nghj tang vidn phi vira dd phii hop vdi tinh hinh mdi, va cQng l i dd hpp ly hoa mirc vidn phi dang ap dung. Hien nay, vidn phi cd vai trd, vi tri quan trpng trong he thdng tai chinh d cic benh vidn cdng: (xem bang 2)
Nhu vay, nam 2009 vien phi chidm ddn 33% trong tdng cac khoin thu ciia cac benh vidn. Tuy nhidn, day la con sd tinh chung cho hon mdt ngan benh vidn, bao gdm ca cac benh vien tuydn dudi gin nhu dupc nha nudc bao cap hoin toan. Nd'u tinh ridng thi khdng it benh vidn cd ngudn thu vidn phi gip nhidu lin so vdi kinh phi cip.
Ngay tir nhirng nam 2004, Benh vien Hiing Vuong (TP Hd Chi Minh) thu vidn phi dd'n khoang 60 ty so vdi 6,2 ty kinh phi cap, Benh vidn Nguydn Tri Phuong (TP Hd Chi Minh) thu 36 ty vidn phi so vdi
14 ty ngan sach cip; cdn vdi nganh y te Tp.HCM, ngan sach nam 2002 cip la 331 ty, nhung vidn phi thu dd'n 721 ty. Ndi chung, vidn phi thu dupc chidm ty Id tir 30% dd'n 70%
chi phi ciia benh vidn, nhung vdi nhidu benh vidn thi nd'u khdng cd vidn phi thi cac benh vidn khong thd duy tri dupc boat ddng (tai mdt sd benh vidn nhu Chp Riy, Viet Diic, Bach Mai... vidn phi va BHYT da chidm tdi 80-90% tdng chi phi thudng xuyen)
CHII TRUONG TANG V I 6 N PHI:
TANG GIA HAY TINH DU?
Dudi gdc dp kinh te, co sd san xuai hay cung iing hang hoa, djch vu dat hieu qua sin xuit khi Ipi ich bidn bing chi phi bidn (MB=MC).
Vd mat ly thuyet, mdt dieu kidn co ban dd cac co sd niy boat ddng cd hidu qua la phai bidi MC ciia co sd minh. Ve mat thuc tidn, vidn phi cd dupc tinh du cac co sd dd mdi bidi tudng tan cac khoan chi phi ciia minh dd' cd thd' hach toan ro
Bdng 1: SO SANH MCfC THU VI$N PHf QUY DJNH TAI THONG TU LI^N BO S6 14/nLB BAN HANH NAM 1995 VA MOT S6 NUGC TRONG KHU VUC
Nuac Viet Nam Singapore Philippines Malaysia Indonesia
Mot lan kham benh
0,2 - 0,7 1 0 - 6 5
2 - 5 0 , 5 - 12
1,5-17
Ngay giuong dieu tri 0,2 - 2,2
1 2 - 2 5 0 6 - 10 1,5 - 35 4,5 - 56
Qii phf phau thuat
1,5- 120 80 - 3500 20 - 300 2 0 - 1250 58 - 450
Xet nghiem 0.1 -0,5
3 - 125 1.5 - 7 1 - 4 0 1 - 2 6
iDon vi X quang 0,5 - 4 3 - 7 0 0 3 - 15 1 - 100
7 - 35
Dddoi t/ieo i'SD) CT
Scanner 2 0 - 6 0 400 - X15
25 - 250 Sieu
am 1 - X 6 - 20 4 - 4 0 1 4 - 3 2 Ghi chu: Chifci tinh chi phi ciia cdc veil tif thuy the iihif: ran tim. stend. o khap nhdn lao...
Nguon: Bdo cdo ciia Bp trudng Bg Y le'Nguyen Qudc Trieu tai ky hop rlu'f.^. QH khdu XII Bdng 2 .CO CAu N G U 6 N THU TU BENH V I $ N
Chi so tai chinh
Tong so benh vien bao cao
I. Tong cac khoan thu (khong ti'nh NS nha nuoc cap cho xay dung co ban)
1. Ngan sach nha nuoc c i p cho hoat dong KGB
-Trong do: ca'p d6 KCB cho tre em duoi 6 tuoi
2. Ngu6n thu ngoai NS 2.1. Thu BHYT 2.2. Thu tu vien phf Trong do
2.2.1. Thu tii nguoi ngheo khong co BHYT 2.2.2.Thu tii ngu6n XHH cong tac y te 2.2.3.Thu vien phf true tiep tCr cac doi tuong khac
2.3. Thu tu nguon khac
Don 17 : ryVND. 9c Nam
2005 731 9.207 3.178 229 6.029 1.963 3.407
- - -
659 2006
732 11.379
3.689 361 7.680 3.190 3.708
- - -
782 So sanh
(%)
123,6 116,1 158 127.4 162,5 108,8
- - -
118,7 2008
1009 23.649
7.318 1.108 16.331 7.605 7.653 171 730 6.752 1.073
2009 1009 30.811
8.515 1.428 22.296 10.623 10.228 210 955 9.063 1.445
So sanh
(%)
130,3 116,4 128,9 136.5 139,7 133,6 122,3 130,9 134.2 134,7 Ngudn: Tinh todn difa tren ket qua kiem tra
rang, duy tri he thdng kd' toan minh bach v.v..., mdi cd khuydn khich de tidi kidm, de sir dung cac khoan chi mdt each hidu qua.
Vide hach toan du chi phi hay tinh du gia thanh ciia djch vu (Gia thanh cua djch vu la tdng chi phi cho diu vao ma don vj cung irng djch vu phai bd ra de thuc hien djch vu dd) khdng nhung cd y nghTa ddi vdi ca sd cung cip m i cdn cd y nghTa ca vdi don vj quan ly va ben hudng thu djch vu (benh nhan) d mot gdc dp nio dd. Sau khi da cd gii thanh la co sd xac djnh gia cho cac djch vu, day se dupc coi la can cii kinh td' de so sinh va ydu ciu dan vj cung iing dich vu thuc hien diing chit lupng ciia djch vu: khdng phai l i cit chi phi cao thi
henh vien cdc ndm 2006-2009- Bp Y le
chit lupng mdi cao nhung khi da tinh diing va du gia thanh thi don vj cung irng dich vij phai ludn cd nghTa vu dim bao chit lupng dich vu va ngudi benh cd can cii dd yeu ciu don vj cung ung djch vu phai thuc hien djch vu ed chit lupng.
Nhu vay ngudi trong didn chinh sich, ngudi ngheo, tre em dudi sau tudi, ddng bao dan tpc thidu sd se dupc phuc vu tdt hon, ngudi cd kha nang chi tri cung dupc tao didu kien ddng gdp dd dupc hudng dich vLi tdt hon.
Khi gia cung cip djch vu dupc xic dinh theo gia thanh thi se giam dupc nhii'ng hien tupng tu xe rao vidn phi bing each cung cap djch vu theo ydu ciu nhu hien nay va tidn tdi xu hudng ap dung che dp
Kinh t e v a Dit bao So 23/2010 29
NGHIEN CQU - TRAO DOI
mdt gia vdi mdi loai djch vu cho tit c i cic ddi tupng. Day la co sd de cung cip dich \'u vai chit lupng ngang nhau cho cac ddi tupng khac nhau va la didu kidn dat dupc cdng bing trong cham sdc sire khde (CSSK) bdi nhieu gdi djch vu thuin tiiy y td' va lidn quan dd'n sinh mang (djch vu y td' thidi ye'u), khdng ndn phan chia thanh "gdi djch vu re tidn" dinh cho ngudi ngheo va "gdi djch vu dit tien"
dinh cho ngudi giiu. Nguydn tic nay cung lam cho Nganh y te dd thuc hien tu chii, cong khai, minh bach trong tai chinh va tranh nhirng tid'ng xiu do cd each biet trong ddi xir y td' vdi cic ddi tupng khac nhau trong xa hdi .
0 mdt gdc dp nao dd vide dat gii vi vide thu theo gii lai la hai vide khac nhau. Chi phi kham chira benh (KCB) hay muc vidn phi theo gia dd do ai chi tra se la phin vide ciia he thdng cip tai chi'nh. He thdng cap tai chinh hien nay bao gdm: Ngan sich Nha nudc (NSNN), cac quy bao hiem y td' (BHYT), tidn chi tra triJe tidp ciia gia dinh benh nhan, ngudn tir cac quy tir thidn khac. Nd'u mudn dam bao cong bing trong CSSK nhan dan, mudn ngudi ngheo dupc KCB thi can tang ngudn chi tra tir NSNN, BHYT va giam ngudn chi tra trirc tid'p tir ngudi dan. Khong the vi mudn giam sd tidn chi tri true tid'p tir ngudi dan ma ydu ciu cac benh vien dat miic vidn phi thip (trong khi nhidu benh vidn hien nay phai tu chu tai chinh), hay cung cip djch vu d miic dp thip tuong irng vdi chi phi.
MOT SO Ofi XU.AT GIAI PHAP Xet dudi khia canh kinh te, vidn phi cin dupc hach toan dii cic chi phi cung cip djch vu. Tuy nhidn dieu nay se tic ddng xiu tdi vin de xa hpi khi lam giam kha najig tid'p can va thu hudng djch vu
KCB ciia mdt bd phan khdng nhd ngudi dan cd dieu kidn kinh te han chd'. VT vay, de giam thidu tic ddng trii chidu dd, cin quy dinh cic miic vidn phi khac nhau vdi cic dd'i tupng, vimg mien khic nhau. Song song vdi chinh sach nay cdn cin thuc hien tdt chinh sach BHYT toan dan, md rdng didn dupc midn giam vidn phi vi thuc hien tdt chd' do midn giim vidn phi cho cic ddi tupng nay, cu thd nhu sau:
Sira ddi quy djnh vd vidn phi trdn CO sd tinh diing, tinh du cac chi phi true tid'p phuc vii benh nhan theo tinh than Nghj quydi 05/NQ-CP ngay 18/4/2005 ciia Chinh phii, trong dd quy djnh rd phin nao do Nha nudc hd trp, phin nao ngudi dan tu chi tra; thay ddi each thanh toan vidn phi hpp ly.
Khong quan nidm "vidn phi" la mpt loai phi, thuoc pham vi dieu chinh ciia Phip lenh phi. Id phi nhu hien nay ma quan nidm la "gia djch vu y td'".
Cd cac quy djnh cu the ve cac miic vidn phi khac nhau cho cac dd'i tupng, viing mien khac nhau.
Nguydn tic chung: cang Idn tuydn trdn vidn phi cang cao, KCB trai tuydn chi phi cao ban KCB diing tuydn. Ddi vdi ngudi KCB theo diing tuydn chuydn mon ky thuat do Bp y te quy djnh: vidn phi chi bao gdm nhirng chi phi trirc tid'p phiic vu cho ngudi benh (chi phi true tid'p sir dung cho ngudi benh nhu thudc, mau, djch truydn, vat tu tidu hao phuc vu cdng tac KCB, chi phi quan ly hanh chinh phuc vu cho KCB nhu : tien didn, nudc, xang diu, va cac chi phi quan ly hanh chinh khac), khdng bao gdm chi phi vd tien luong, tien cdng , khiu hao tii sin cd djnh (TSCD), sira chira Idn TSCD, dio tao va nghidn ciiu khoa hpc, chi phf didu hinh. Ddi vdi ngudi KCB trai tuydn, vupt tuydn, tu lira chpn ca
sd KCB, chpn thay thudc. chpn budng benh: mirc bao cap vien phi se tha'p ban ddi tupng thu nhit.
Ngoai nhirng chi phi true tidp phiic NTJ cho ngudi benh se tinh dii chi phi ve tien luong, tidn cong, khiu hao TSCD, sira chira Idn TSCD.
dao tao va nghidn ciiu khoa hpc, chi phi dieu hanh. Khdng tinh khiu hao nha cira hay khiu hao cac trang thidi bi khac khong trirc tid'p lidn quan den ngudi benh.
Timg budc thu hep quy md va ddi tupfiig phai nop phi trirc tid'p bing cich thirc hien BHYT toan dan, md rpng didn mien giam vidn phi va thirc hien sir midn giam nay mdt cich cd hidu qua. Hien nay, ngudi thudc dien chinh sach, ngudi ngheo, tre em dudi 6 tudi, dupc Nha nudc chi tri hoac hd trp mdt phin thong qua chinh sach cap midn phi BHYT. Can md rpng didn mien hoac giam vien phi ra ca ddi tupng can ngheo dac biet khi hp lam vao tinh trang gap tham hoa tai chinh do benh tat.
Vidn phi hien nay la mot miie gia bj bop meo nhieu nhit. Sir meo md nay, nhu mdt he qua da lam meo md nhidu khau ed lidn quan ddn nd: meo md trong cdng tac quan ly thu chi, hach toan ciia benh vidn, meo md trong vide sir dung ngudn liJc mpt each hidu qua, meo md trong quan he benh nhan - bac sy... Vi vay, van dd tang vidn phi hien nay khong ndn dan thuan nhin nhan nhu mdt sir tang gia lim anh hudng tdi khi nang sir dung djch vu ciia nhan dan ma cin nhin nhan day la vide cin thidi:
hach toan dii chi phi trong gia thanh djch vu, la dieu kidn yen quydi cho vide sir dijng ngudn lire hidu qua nham nang cao chit lupng kham chiia benh ddng thdi dam bao cong bing xa hpi. Tuy nhidn, thdi didm tang vidn phf cin dupc Bp Y td'tid'n hanh theo mpt Ip trinh hop ly. •
So 23/2010
30 Kinh te va Dit ban
