difficult and confusing for the enforcement agency. Clause 5, Article 4 of the Decree clearly states that the fine prescribed in Chapter II of this Decree is the fine for individuals. For the same administrative violation, the fine for an organization is twice the fine for an individual. However, it has not clearly defined how to determine organizations and individuals in the sanction. Some remedial measures are not closely related to the actual implementation or do not have specific regulations on the methods, procedures and coordination between relevant agencies in the implementation. Such as the measure of forcing the refund of the difference in the amount collected for the acts of charging higher prices for medical examination and treatment services than the listed price, refunding the amount collected from the acts of selling drugs that have been paid by health insurance, non-commercial imported drugs, drugs that do not meet quality standards or drugs that have expired. The Decree stipulates that in cases where the refund cannot be made to the subject, it must be paid to the state budget. However, the coordination between relevant agencies such as the Department of Health, the State Treasury, etc. to implement these remedial measures is still unclear. This Decree has set out fines for administrative violations in medical examination and treatment from 200,000 VND to 80 million VND in Section 2, from Article 28 to Article 36. But in reality, this figure is still low compared to the profits earned, so despite being fined, some hospitals continue to re-offend.
2.2. Practical implementation of the law on the organization and operation of private hospitals
After more than 10 years of implementing the 2009 Law on Medical Examination and Treatment, the private hospital system has developed rapidly, many large corporations and enterprises have planned to invest in new large-scale hospitals, and in some provinces and cities, there are international hospitals invested by the private sector. It is estimated that in 2011, our country had only more than 100 private and semi-public hospitals with nearly 6,000 beds, but by December 2019, there were more than 248 private hospitals. The 2009 Law on Medical Examination and Treatment has created an
The legal framework for medical examination and treatment activities of private hospitals meets the requirements of regulating social relationships arising in the field of medical examination and treatment. However, in the process of implementing the law, some private hospitals have encountered difficulties, problems as well as violations.
Pursuant to Decision No. 216/QD-TTrB dated November 22, 2019 of the Chief Inspector of the Ministry of Health, from December 4, 2019 to February 12, 2020, the inspection team conducted inspections at 11 private medical examination and treatment facilities in Ho Chi Minh City. The inspection results showed that the inspected facilities all violated regulations on medical examination and treatment. At the time of inspection, Trieu An General Hospital (private hospital) had established a list of registered medical examination and treatment practitioners. However, it was not in accordance with the form prescribed in Appendix IV of Decree No. 109/2016/ND-CP dated July 1, 2016 of the Government. The hospital has not yet publicly disclosed the price list of medical examination and treatment services covered by health insurance. The medical record does not store the Paraclinical Order Form (testing, diagnostic imaging), only the Paraclinical results are stored; Some doctors and nurses only signed their names without clearly stating their full names. Some outpatient medical records that were inspected showed that the progress section only recorded the prescription, the medical order section only signed and stamped the name, and did not record the symptoms and progress of the disease. The consultation record book of Trieu An General Hospital was made according to the form of the Ministry of Health. However, the recording in the book was sketchy and incomplete, such as: Not recording the date and month of the consultation; not fully recording the full names of the doctors participating in the consultation; not fully recording the signatures of the doctors participating in the consultation. At the time of inspection, the hospital had an electronic information page on the Internet at http://www.trieuanhospital.vn to advertise medical examination and treatment services, but did not have an advertising license. Similarly, the Ministry of Health Inspectorate also pointed out the shortcomings and limitations of Hong Duc III General Hospital. The recording of medical records is not complete, the handwriting is bad, scribbled, abbreviated, many contents are unreadable, doctors and nurses only sign without writing clearly.
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full name or use of signature stamp. The recording in the consultation record book is sketchy and incomplete, such as: Not recording the date and month of the consultation; not recording the full name of the doctor participating in the consultation; not recording the full signature of the doctor participating in the consultation. The hospital advertises medical examination and treatment services on the Internet without an Advertising License. At Saigon Eye General Hospital, in addition to not ensuring the facilities during operation and the signboard is not implemented in accordance with regulations, the medical records do not record complete columns, such as: The treatment sheet does not record comments on symptoms when the patient is discharged from the hospital, the test form is not in accordance with regulations. All medical records of inpatients do not have a chest X-ray result sheet. There are also medical records that are checked with an eraser, erasing the content in the medical record. [14]
In Hanoi, the Ministry of Health inspectors discovered violations in the compliance with the law on medical examination and treatment of Bao Son General Hospital. Bao Son General Hospital belongs to Bao Son General Hospital Company Limited, licensed by the Ministry of Health since December 2017 but still does not have a Certificate of Approval and a Certificate of Fire Prevention and Fighting Eligibility according to the hospital model. The Fire Prevention and Fighting Approval Certificate in 2013 was issued by the Hanoi Fire Prevention and Fighting Police Department to Bao Son General Clinic, not the current hospital model. The records of monitoring and managing fire prevention and fighting have not been changed in accordance with the head.
Regarding human resource management records, at the time of inspection, Bao Son had 157 employees, of which 107 were working in professional positions such as doctors, nurses, midwives... However, there were 17 people without practice certificates including 6 nurses, 4 technicians, 2 midwives and 2 pharmacists. The results of the actual inspection of 14 human resource records belonging to Bao Son showed that 1 doctor's record and 2 technician records were signed contracts before having practice certificates. 1 female record
midwife, 2 technicians without practice certificates, Bao Son signed a practice contract but it was not clear that it was practice, and the terms of the labor contract showed the working position according to the professional diploma, violating Decree 109/2016/ND-CP. The Ministry of Health Inspectorate also noted a number of other problems at Bao Son General Hospital regarding medical records with bad handwriting, erasures, and many contents that could not be read. Some medical records did not perform drug monitoring numbering according to regulations, doctors only signed without stating their full names. The form recording the results of paraclinical tests posted in the medical record did not have the signature of the testing department, endoscopy or had them but used photocopies, which is against regulations. In addition, the records also did not have the indication for paraclinical tests posted in the medical record. [6]
There are cases of private hospitals being built without a license from the competent authority, such as An Sinh General Hospital in Hanoi. The An Sinh Private General Hospital project of An Sinh - Phuc Truong Minh Private General Hospital Company Limited is one of the leading private hospitals in terms of construction scale with 500 beds. The hospital has a total investment of thousands of billions of VND built on a total land area of 2.5 hectares in Phu Do ward, Nam Tu Liem district, Hanoi. Although it has not yet had a construction permit, it is still being constructed. On September 26, 2019, the People's Committee of Nam Tu Liem district continued to issue a document on urging the handling of violations of construction order by An Sinh - Phuc Truong Minh Private General Hospital Company Limited. In particular, Nam Tu Liem District requested An Sinh - Phuc Truong Minh Private General Hospital Company Limited to stop all construction activities and promptly remedy the consequences according to Administrative Penalty Decision No. 2853/QD-XPHC dated August 5, 2019 of Nam Tu Liem District People's Committee. At the same time, Nam Tu Liem District People's Committee requested Phu Do Ward People's Committee to coordinate with the Urban Construction Order Management Team to apply measures to prevent and suspend construction activities at the An Sinh Private General Hospital project. Although the Nam Tu Liem District People's Committee
Nam Tu Liem has requested to stop all construction activities at the An Sinh private hospital project, but the investor continues to let workers work. Currently, the hospital project has basically completed the initial rough foundation. Thus, it can be seen that the authorities of Nam Tu Liem district have discovered illegal construction at the An Sinh private hospital project since the end of July 2019, but so far there have been no drastic and effective measures to handle it. [9]
Some hospitals have encountered difficulties in the work of health insurance examination and treatment, such as Cua Dong General Hospital. In the work of medical examination and treatment under social insurance (HI) there have been many changes according to the Health Insurance Law, the guiding documents of the inter-ministerial, Ministry of Health, Vietnam Social Security are not timely, not specific, when the medical examination and treatment facilities have encountered difficulties in paying the costs of health insurance examination and treatment regarding the prices of some technical services. In the period of 2016-2018, the Hospital signed a contract for health insurance examination and treatment with the Social Security agency, the payment method is based on the service price. The hospital pays for technical services for patients according to the prices prescribed in Circular No. 37 of the Ministry of Health, but the Social Security agency has not yet paid the hospital such as: surgery, procedures performed by local anesthesia, spinal anesthesia. The failure to pay the above costs is not in accordance with current regulations, so it causes many difficulties for medical examination and treatment facilities in ensuring funding for operations.[11]
Many facilities do not organize contractor selection but purchase drugs according to the provisions of the Bidding Law, but the selection is also unreasonable, without notification and coordination with the Social Insurance agency during the procurement process. The selection and use of drugs is still not appropriate [23]. Some private hospitals have not attracted patients. "It is estimated that only about 1/3 of private hospitals operate profitably, 1/3 continue to operate moderately, 1/3 are facing difficulties. The majority of private hospital bed capacity is only below 50%. To make a profit in opening a private hospital, it takes 5-7 years to make a profit, the earliest is 5 years to have enough depreciation" [7]. Many
Private hospitals have had to close early due to unstable profits. According to the Private Hospital Association, many hospital investment businesses are new and inexperienced, and their operations are not close to reality. The main difficulties are lack of investment capital, lack of brand, inconvenient location, and high medical examination and treatment costs due to autonomy. “In terms of finance, only hospitals with 100 beds or more are supported with loan interest rates. Meanwhile, most private hospitals are invested by small, individual investors with little capital, so the number of beds is often less than 100. Private hospital investors must invest a high amount of capital in medical equipment, while calculating the capital recovery efficiency and fast depreciation (usually 5 years). All of these investment costs are calculated on patients, which is a disadvantage because not everyone can afford the high costs”[7]. For private hospitals, when investing in a certain equipment, the hospital must calculate the cost, consider which type of machine to buy that is suitable for the conditions and circumstances of medical examination and treatment in their unit, and use the full capacity of the machine. However, to calculate depreciation of the machine, it is mandatory to include it in the patient's price. Therefore, the patient's medical examination and treatment price will increase, which is a difficulty and limitation for private hospitals today. If there is a situation of unpaid wages and unpaid social insurance, it will damage the hospital's reputation.
In addition, the regulation that hospitals cannot be built in the inner city of Ho Chi Minh City forces private hospitals to go to the outskirts of the city, while patients who go to private hospitals are those with high demands, have the ability to pay but are reluctant to travel far. Regarding medical examination and treatment for the poor, according to Decision No. 14/2012/QD-TTg of the Prime Minister, only support for travel and meal expenses is provided when poor patients are inpatients at public hospitals. This makes many poor households not want to register for inpatient treatment at private hospitals. They only come for tests and regular check-ups when inpatient treatment is not supported. Regarding human resources, some private hospitals have developed and have enough resources to bring
Doctors study abroad, invite foreign experts to train doctors in Vietnam, but this number is still small.[7]
The reasons why private hospitals face many difficulties, most of which originate from the state's mechanisms and policies, and the lack of a specific legal corridor for private hospitals. These unclear mechanisms have unintentionally created barriers, limiting the development of private hospitals.
In terms of investment in facilities and infrastructure: Private hospitals (especially private hospitals in the North) are not supported with land rent or other taxes and fees at preferential prices. Private hospitals in Ho Chi Minh City enjoy more incentives in this regard. Choosing the location to build a private hospital is also very important because it is related to the market and the habits of patients. Hospitals take care of their own land while the land fund in the inner city is limited. Building and establishing a private hospital requires a larger total investment, and the investment mechanism and investment incentives for the health sector in provinces and cities are different, so investment in private hospitals is mainly concentrated in large urban areas.
Regarding insurance policy: The State has not created conditions to support social insurance beneficiaries to be paid when they come to see a doctor, receive treatment and receive treatment at the private hospital system. This leads to many patients with social insurance wanting to be treated at private hospitals but because they are not paid or are paid a very small part of the insurance, the treatment cost is too high, causing disadvantages for the patients themselves. Although the hospital has made many efforts in supporting work, they still have to balance the revenue and expenditure to be reasonable.
Regarding human resources: Many private hospitals lack human resources. The medical industry is a special industry directly related to human health, so the training time for human resources is long. In addition, although the treatment is very good, the salary paid by private hospitals is many times higher than the salary received from public hospitals.
Public hospitals, but young doctors who have just graduated and those with other professional qualifications are not "interested" in private healthcare. Many people consider private hospitals a temporary, unstable and unattainable place to work.
Private hospitals need professional coordination of skilled doctors, good doctors with deep expertise currently working at public hospitals to perform difficult surgeries, areas of expertise that private hospitals cannot yet undertake. However, this coordination mechanism is facing many difficulties and obstacles, especially in administrative procedures.
Besides the current policy mechanism and legal corridor, which still have many barriers, are not really clear and open for the private hospital system to develop, another difficulty that private hospitals are facing is the psychology of patients. Patients do not really trust the private health system. Besides the fact that some hospitals have lost the trust of patients due to economic problems and unhealthy competition, the communication problem is also negatively affecting the private hospital system.
2.3. Legal issues arising from the law on the organization and operation of private hospitals
The legal basis for the organization and operation of private hospitals currently has some issues as follows:
There are currently no specific regulations on the type of enterprise that can establish a private hospital. Although the regulations on investors have created favorable conditions for the establishment of hospitals, the lack of detailed regulations may cause confusion for investors in choosing the appropriate type of enterprise. Determining the appropriate type of enterprise will determine the direction of organization of activities to ensure efficiency and maintain long-term operations.
The procedure for establishing a private hospital must go through many steps such as applying for planning, applying for an operating license, and applying for an investment registration certificate.