Nghiên cứu chi phí điều trị viêm ruột thừa cấp tại bệnh viện đa khoa tỉnh sơn la tt tiếng anh

MINISTRY OF EDUCATION AND TRAINING –
MINISTRY OF DEFENCE
VIETNAM MILITATY MEDICAL UNIVERSITY

NGUYEN DUC TOAN
PH VĂN BÁU

RESEARCH OF TREATMENT COSTS
FOR ACUTE APPENDICITIS AT SON LA
PROVINCIAL GENERAL HOSPITAL
Major: Medical Management
Code : 972 08 01

SUMMARY OF DOCTOR OF MEDICINE THESIS
Hanoi – 2019



1
INTRODUCTION
In Vietnam, The policy on partial collection fees in State-owned
medical examination and treatment establishments has been
implemented since 1989; Then was the health insurance policy
(1992). Revenue from hospital fees and health insurance is
considered a public finance source, the proportion is increasing
more and gradually becoming a major source of revenue,
contributing significantly to increased the investment for higher
capacity and quality to suppling the medical services of public
hospitals.
However, the cost bracket currently does not include the full cost
components that limit the autonomy of hospitals, while the

Government subsidizes both the rich and the poor people. This
requires some researches to find out the methods to calculate
service costs by evidence-based services for public hospitals.
Therefore, we choose cost analysis for the treatment of acute
appendicitis at Son La Provncial General Hospital, both from the
hospital as well as patients, to provide additional information for
the evaluation of medical services cost. The research question:
what is the actual cost for a patients of acute appendicitis
treatment at a provincial general hospital? What is the difference
between the actual cost of the hospital and the cost which patients
have to pay (direct or through health insurance)? Has the
Government budget subsidized the components that have not been
included in the service fee yet? To provide information that will
provide the basis guides for accurating calculation of the medical
services cost.
Objectives of the study:
1. To analyze the actual cost of surgical treatment for acute
appendicitis at Son La Provincial General Hospital (2012-2013).
2. To analyze the economic burden on patients with surgical
treatment of acute appendicitis at Son La Provincial General
Hospital (2012-2013)


2
THE NEW CONTRIBUTIONS OF THESIS
Scientific significance: Healthcare reforms aimed at
increasing the accessibility and quality of health services which
require transparency in both quality and service pricing. This
requires hospitals have to develop a good costing system and
procedures, and improve pricing models to more accurately

reflect the cost of providing services to patients. Finalization and
transparency of the costing system to determine the right price
helps the patient to make better informed choices in the use of
services, and helps the hospital manage the finances better.
Reducing costs to increase competitiveness in terms of price and
quality of services to improve the quality of health services in
health care facilities.
Practical significance: Applying the correct methodology to
calculate the actual costs of the hospital for medical services
which will help the clinic know and calculate the actual cost of
the hospital, the difference between the actual cost of hospital
and the cost of the patient must be paid (directly or through health
insurance); Government budget subsidies for components on
service charges; Health insurance pays for health care facilities
and the calculation methodology will help to form the basis
guides for package payments for health services (group of illness
cases), financial transparency and fairness in medical examination
and treatment.
New points of this thesis: Described the method of analysing
and calculating the actual cost of Son La Provincial General
Hospital (Level II) for a medical service (surgical treatment of
acute appendicitis) in 2012-2013, determined the actual cost of
services that has not previously been calculated, as the basis for
calculating actual costs for other services; Determining the cost
burden of surgical patients to treated for acute appendicitis at the
hospital, thereby obtaining the method of calculating the actual
cost of patients when seeking medical treatment at public health
facilities.
THESIS STRUCTURE
The thesis consists of 118 pages excluding references and

appendix with 44 tables, 04 charts and 06 pictures. Introduction: 2


3
pages. Overview: 34 pages; Methodology: 22 pages; Results: 31
pages; Discussion: 26 pages; Conclusion: 02 pages and 01 page
for recommendation.
CHAPTER 1: OVERVIEW
1.1. Some concepts of cost and medical costs
1.1.1. Medical costs
In health economics, the cost of a health facility is the
total resource that funds the health facility must spend to create a
particular health product or service.
Costs and prices of health services are two different but
have organic correlation with each other. Medical costs are the
basis to evaluate health services prices. Generally, the health
services prices = average cost for health services + profits of
health centers (subsidized or paid user).
1.1.2. Classification of medical costs
1.1.2.1. From the service provider
- According to the functions, medical costs are classified into
two groups, including direct costs and indirect costs;
- According to the nature of costs: fixed costs and variable
costs;
- By input types: capital costs or investment costs, recurrent
costs;
- According to the relationship between costs and products,
the total costs, average costs and marginal costs are often
referred.
1.1.2.2. From the health service users.

- From the perspective of the user, the cost of health implies
spending and is more costly than cost and can be divided into:
- Direct costs, including: direct medical expenses such as
expenses for examination, testing, surgical procedures, drug costs;
and direct medical expenses: expenses for travel, meals during
treatment, expenses for medical staff, etc.
- Indirect costs, including costs lost due to loss of income
because of premature death or reduced productivity, sickness,
illness.


4
- In addition, many authors also refer to another type of cost
that is intangible, related to distress, anxiety and the quality of life
resulting from illness, diseases or in the treatment process.
1.1.3. Cost calculation
1.1.3.1. Principles of calculating medical costs
The general principle: calculate correctly, adequately and
accurately.
- The cost calculation must be based on high quality data to
ensure the reliability of the calculation results.
- All expenditures of the health facility must be included in
the calculation to produce reliable and comparable results.
- The process of computation should show the link between
the activities and the resources used to create the health service.
- The calculation process must be transparent and allow for
detailed analysis.
- The cost calculation must focus on the material value of
resources.
- Ensuring consistently between services, allowing

comparisons of costs within the health facility and between health
facilities.
- There is coordination between the clinical and non-clinical
components and encourage the full use of information in the cost
calculation.
1.3.2. Approaches to calculate medical costs
There are many methods and techniques which were
applied to calculate healthcare costs. There are two main
approaches: top-down allocation (macro-method) and bottom-up
approach (micro-method):
- Top-down costing method (macro approach or total cost
approach) by allocating total budgets (expenditures) for each
department and service to estimate the average cost per service.
- Calculating costs from the bottom up (calculate micro
costs) through calculations, summing the cost for each input used
to create a service or otherwise calculate the cost from the
collection. Collecting data each cost item of each individual.
1.2. Health finance for public hospitals in Vietnam


5
Health financing is an important part of the health system
with four main objectives: (1) Mobilizing adequate resources for
health care; (2) Equitable and efficient resource allocation and
management; (3) Encourage improved quality and efficiency of
service delivery and (4) Protect people from financial risks caused
by medical costs.
1.3. Acute appendicitis and acute appendicitis treatment
Acute appendicitis is the most common surgical emergency,
with a rate of 4-5 people per 1000 people and about 6-7% of the

population throughout life. Acute appendicitis can occur at any
age, rarely in children under 3 years of age, increasing and most
common in adolescence, especially in the age group of 20-40, and
then aged according to age. The disease can be seen in both
genders, male is higher than female, male / female ratio is 3/2 in
young and 1/1 in elderly.
When there is a definite diagnosis of acute appendicitis,
the unique treatment is emergency surgical resection of the
appendicitis as soon as possible, because the more it is late, the
higher risk of complications patients get. At present, surgery for
appendectomy may be done by conventional open surgery or
Laparoscopic surgery.
1.4. Study on the cost of treating acute appendicitis in the
world and in Vietnam
- Worldwide: The cost of health care services has been
studied extensively, both in high-income countries as well as in
low- and middle-income countries, from providers and service
users. Among them, there were many studies on the cost of acute
appendicitis treatment, both macro and micro. These studies not
only addressed the cost of acute appendicitis but also analyzed
both the clinical outcome and the cost-effectiveness between two
methods: open surgery and Laparoscopic surgery.
- In Vietnam: There are not many studies on medical costs,
especially the systematic studies of the actual costs in a hospital
for a disease or a technical service. Some studies have calculated
the cost of residential treatment for some diseases but almost no
research is available for acute appendicitis. With other diseases,


6

there is not yet a single study that evaluates the costs
simultaneously in both of the healthcare setting and the service
user. Most studies only estimated the medical costs from the user.
1.5. About Son La Provincial General Hospital
1.5.1. Organizational structure and functions
1.5.2. Financial resources of the hospital
1.5.3. Surgical procedure for the treatment of acute appendicitis
Adhere to the surgical procedures of acute appendicitis issued
by the Ministry of Health
CHAPTER 2: METHODOLOGY OF STUDY
2.1. Time and place of study
The study was conducted in Son La province General
Hospital at two years in total (2012 and 2013).
2.2. Study subjects:
- 322 patients operated acute appendicitis surgery (including
open surgery and Laparoscopic surgery) at Son La provincial
general hospital from 01/01/2012 to 31/12/2013, excluding the
patients who do not agree to participate in the study.
- All records, accounting books, financial reports of the
hospital in 2012-2013, medical records, bills of treatment, ... of all
patients with surgery treatment.
2.3. Study method
2.3.1. Study design
A cross sectional study with retrospective available data
collection.
2.3.2. Data collection techniques
2.3.2.1. Collecting the available information
- Based on books of financial accounting, financial statements
of 2012 and 2013 to calculate the correct and full expenses of this
hospital from which to base the analysis of actual expenses of the

hospital for treatment. acute appendicitis surgery.
- Using the medical records of the patients to collect
administrative information, disease history, progression of
appendicitis as well as details of the patient's medical history and


7
surgery during stay hospital, treatment outcome and status of
hospital discharge, treatment costs of patients
2.3.2.2. Patient interview
Performed at the hospital during treatment or at home, within
3 months after patients discharge. The interview tool is a
structured questionnaire. In case the patient does not know the
cost information, the interviewers will interview patients's
primary care provider.
2.3.4. Framework theory and cost analysis methods
Applying Riewpaiboon's theory of hospital cost allocation;
Combining both methods of cost allocation from top to bottom
and bottom to top.
Direct and indirect costs for patients are aggregated and used
for descriptive analysis, comparative distribution and median
costs of patients in assessing the payment burden for different
groups of patients.
2.3.5. Contents and variables of study
2.3.4.1. Group of independent variables
Including
general
information
on
demographic

characteristics, socio-economic conditions, illness and treatment
of patients.
2.3.4.2. First objects’s variables
- Cost of capital, there is the cost of depreciation of buildings,
facilities and equipment of the hospital.
- Regular expenses for hospital activities: electricity and
water, wages ...
- Direct costs for treatment include expenses for medicines,
consumables, tests/tricks.
2.3.4.3. Second objects’s variables
- Direct costs for health services: expenses which the patients
(directly and through health insurance) pay to the hospital;
- Non-medical expenses are costs that patients and their
family members have to pay to other facilities outside the hospital
for patients's treatment at the hospital such as meals, rest, travel ...


8
- Indirect Costs: is the cost of lost earnings due to a leave of
absence for treatment (with patients) or visitation (with a family
member), estimated by the number of days off, multiplied by the
average daily income of each object.
2.4. Data management and analysis
Using HOSPICA cost analysis software, cost per item, each
service is calculated and presented in average; Stata software
version 14.0 and presented as descriptive statistics such as mean
and median (quartile ranged 25-27%). Mann-Wtihney nonparametric statistical tests were used to compare the distribution
and median costs in the assessment of the payment burden for the
treatment of the patient. The difference was statistically
significant with p <0.05.

9
CHAPTER 3: RESULTS
3.1. Actual costs in surgical treatment of acute appendicitis at
Son La provincal General Hospital
Table 3.8. Summary depreciation costs of this hospital in
2012-2013 (Unit: million VND)
Costs

2012

2013

Overall

Depreciation of
buildings
Depreciation of
medical
equipments
Other
depreciation

3,624.419

3,831.257

7,455.676

Percentage
(%)
20.8

9,840.266

10,634.065

20,474.065

57.1

2,809,209

5,124.776

7,933.985

22.1

Tổng

16,273.894

19,590.098

35,863.992

100

Table 3.9. ecurrent costs of hospital 2012-2013 (million VND)
Costs

Workforce
Electricity
Water
Stationery,
information, fuel
Maintenance
Conferences,
training
Total

2012

2013

Overall

26,737.980 32,690.285 59,428.265

Percentage
(%)

80.1

682.235

879.193 1,561.428

2.1

552.665

798.056 1,350.721

1.8

2,860.287 3,704.532 6,564.819

8.8

2,887.950 2,345.428 5,233.378

7.1

22.400

48.320

70.720

33,743.51 40,465.81 74,209.331
7
4

0.1
100

10
Table 3.10. Steps to allocate costs to departments of Hospital in
2012-2013
Unit: million VND
Costs

2012

2013

Overall

Allocating directly the
capital costs and
37,818.698 47,070.058 84,888.756
human resources to
each department (1)
Allocation of shared
capital costs and
12,198.713 12,985.853 25,184.566
recurrent costs (2)
Reallocation of
functional departments 12,135.113 16,050.541 28,185.654
costs (LS, CLS) (3) *
Total (1 and 2)
50,017.411 60,055.911 110,073.322
Note *: This section only reallocates between departments, so it is
not be included in the total)
The total cost allocated to facilties in two years is over 100
billion VND, of which nearly 84.888 billion VND is allocated

directly and over 25.184 billion VND is allocated indirectly for
general using. Of these, more than 28.185 billion VND was
reallocated by management, administration and functional
departments to clinical and paraclinic departments.
Table 3.19. Average cost for treatment services allocated by
departments
(Unit: million VND)
To surgical
To year
technique
Total
Services
2013
PTM
PTNS
(n=322)
2012
(n=156 (n=149 (n=173
(n=166)
)
)
)
Surgery
2.816
2.508
2.530
2.784
2.667
Bed days
0.752

0.997
1.046
0.720
0.871


11
Medical
0.031
0.039
0.035
0.035
0.035
examination
Total
3.599
3.544
3.611
3.539
3.573
Table 3.21. Mean of direct costs from patients in 2012-2013
Unit: million VND
By surgical
By years
techniques
Total
Types of costs
Open Laparoscopic
(n=322)
2012 2013

surgery surgery
(n=166) (n=156)
(n=149) (n=173)
Medicine costs
1.590 2.398 2.541
1.499
1.981
Consumables
0.091 0.123 0.097
0.115
0.106
costs
0.470 0.473 0.431
0.507
0.472
Tests costs
Total
2.151 2.994 3.069
2.121
2.559
Table 3.22. Costs for a treatment of acute appendicitis patient by
surgical method over years
Unit: million VND
2012
2013
Summary
Open
Open
Laparoscopic
Open

Services
Laparoscopic
Laparoscopic
surgery
surgery
surgery
surgery
(n=74)

Surgery
Bed days for
treatment
Examination
Direct costs
for patients
Total

surgery (n=92)

(n=75)

(n=81)

(n=149)

surgery (n=173)

2.966
0.839

2.696
0.682

2.100
1.251

2.885
0.762

2.530
1.046

2.784
0.720

0.031
2.241

0.031
2.080

0.039
3.886

0.039
2.168

0.035
3.069

0.035
2.121

6.077

5.489

7.276

5.854

6.680

5.660


12
3.2. The economic burden on patients with surgery for acute
appendicitis at Son La Provincial General Hospital (20122013)
3.2.1. Total costs
Table 3.23. Total costs for the treatment of acute appendicitis
Unit: million VND
Median
Proportion
Costs group
X ± SD
(25%-75%)
(%)
4.033
4.316 ±

76.8
Direct medical costs
(2.625-5.045)
2.592
2.537
2.856 ±
50.4
- Payment of health
(0-4.181)
insurance
2.973
0.696
1.460 ±
26.4
- Patients paid the
(0.3-2.256)
costs by themselves
1.632
0.650
0.768 ±
12.5
Direct non-medical
(0.430-0.980)
costs
0.463
0.450
0.577 ±
10.7
Indirect costs
(0-0.900)

0.702
5.363
5.661 ±
100
Total costs
(3.568-6.775)
3.128
The median cost of treatment for an acute appendicitis
patient was 5.363 million VND; Of this amount, direct medical
expenses were 4.033 million VND, direct non-medical expenses
was 0.650 million VND and indirect costs were 0.450 million
VND.
Total costs of treatment was 5.661 million VND per a
patient; of which, 76.8% are direct medical expenses, 12.5% are
out-of-pocket and 10.7% are indirect costs.


13
3.2.2. Direct costs for treatment of patients

*: The difference was statistically significant between total direct
costs and out-of-pocket costs mong groups
Figure 3.2. Mean value and direct cost structures for treatment of
patients
On average, each patient had to pay 5.1 million VND
directly for treatment (43.8% for self-payment). Total direct costs
for treatment and out-of-pocket spending were statistically
significant at p <0.05 by year, surgical method and pay.
Table 3.27. The proportion of direct costs for the treatment of
patients (Unit: million VND)

Proportion
Costs groups
X ± SD
%
Tests costs
0.474 ± 0.202
9.30
Medicine costs
1.889 ± 1.935
37.20


14
Surgical costs
1.656 ± 0.997
32.60
Consumables
0.078 ± 0.053
1.50
Examination fee and bed fee
0.219 ± 0.219
4.30
Other
0.768 ± 0.462
15.10
Total
5.084 ± 2.823
100
3.2.3 Out-of-pocket payments of patients
Table 3.33. Out-of-pocket costs for treatment of patients

according to target groups
Unit: million VND
Median (25%Objects
p*
X ± SD
75%)
1.408
2012
1.903±1.349.0
(0.852-2.795)
By year
<0,05
1.677
2013
2.575±1.945.
(1.238-4.340)
1.612
Open surgery
2.319±1.703
By
(1.181-3.346)
surgical
>0,05
laparoscopic
1.468
method
2.150±1.691
surgery
(0.925-2.648)
Having health

1.403
1.822±1.464
By
insurance
(0.913-1.973)
payment
<0,05
3.921
objects self-payment
4.119±1.399
(3.115-4.947)
1.564 (1.0272.228± 1.696
Total
2.902)
The median cost of treatment for acute appendicitis patients
was 1.564 million; mean value was 2.228 million VND. The outof-pocket expenses for 2013 (median: 1.677 million VND, mean:
2.575 million VND) were higher than those of 2012 (1.408
million VND and 1.903 million VND) about 3.921 million VND
compared with 1.403 million VND, 4.119 million VND compared
with 1.822 million VND, p <0,05). Out-of-pocket payment for


15
open surgery was higher than laparoscopic surgery but the
difference was not statistically significant (p> 0.05).
Table 3.37. Comparison of out-of-pocket payments for
treatmentwith the average patient income
Unit: thousand VND

Objects

Cost for
one
Average Cost/income
treatment income/day
ratio
state

Patients who was paid fully
costs by Health Insurance 650.0
36.0
18.1
(n=10)
Patients and Health insurance
1,959.5
94.4
20.8
paid the fee together (n=265)
Patients paid all costs by
4,478.0
107.7
41.6
themselves (n=57)
Total
2,270.7
94.9
23.9
On average, each patient must used 23.9 days of income to
pay the cost of treating acute appendicitis.
Table 3.38. Comparison costs between payment of patients

and payment of hospital
Unit: million VND
Payment of Payment
Costs of
Disparity
Costs
Health
of
Hospital
costs
insurance
patients
Examination
0.906
0.138
0.081
0.687
fee and bed fee
Medicine
1.981
1.324
0.564
0.093
Consumables
0.106
0.051
0.026
0.029
Clinic costs
0.472

0.296
0.178
-0.002


16
Surgical costs
2.667
1.045
0.610
1.012
Cộng
6.132
2.854
1.459
1.819
The difference between the cost of hospital and patient
and health insurance payments for an acute appendicitis case was
1.819 million VND. The difference mainly focused on two costs
for surgery (1.012 million VND) and expenses for examination,
bed (687 thousand VND).


17
CHAPTER 4
DISCUSSION
4.1. Actual costs of treating acute appendicitis at Son La
Provincial General Hospital (2012-2013)
4.2.1. Total mean cost of hospital for treatment
For the total cost, the results showed that the total cost of the

Son La hospital to treat a case of patients acute appendicitis in
two years (2012-2013) was 6.132 million VND.
In Viet Nam, there are few studies analyzing the cost of
medical facilities for the treatment of appendicitis, only two are
from the Policy Unit, the Ministry of Health (2005) and Duong
Huy Lieu (2012). The cost of treatment for acute appendicitis in
the Policy Unit (2005) was 1.456 million VND and Duong Huy
Lau (2012) was 3.417 million VND for the fee-for-service group
and 2.780 million VND for the payment by disease group were
lower than our results.
This difference, first of all, was due to the price devaluation
and the rise in the price of health services over time (The study
was conducted by policy Unit in 2004, study was conducted by
Duong Huy Lieu in 2009), especially that the cost of healthcare
was adjusted without on the basis of the hospital’s actual cost, but
according to the guidelines of the legal documents, which had a
great change compared to the previous time. In addition, previous
studies included only those patients who were treated by open
surgery, performed in a variety of hospitals, including district
hospitals. In addition, the difference was partly due to the method
of calculating costs, our study combines both micro and macro
method while the study of macro policy applied the macro
method and the research of Duong Huy Lieu applied the micromethods.
Meanwhile, there were quite a number of studies on the costs
of medical facilities for the treatment of acute appendicitis
abroad, but comparability was limited because of differences not
only in cost but also in price. pricing and payment mechanisms
among different countries. International studies have shown that
the cost of acute appendicitis treatment varies between countries

18
and between hospitals in the same country. With the low average
income of Vietnam, the cost of treating acute appendicitis in a
provincial general hospital in the mountainous region in this study
was generally lower than in most other countries in the world.
4.2.2. Costs of treatment by surgery methods
In our study, compared between two sugical treatment
methods, the median cost of treatment for a acute appendicitis
patient by laparoscopic surgery was 5.660 million VND, lower
than that of the two surgical treatments. The cost of open surgery
was 6.680 million VND.
Many studies have suggested that endoscopic surgery for
acute appendicitis wass more expensive than open-label surgery.
One of them was the combined the study of McGrath and et al.
(2011) on nearly 2.9 million cases of acute appendicitis who were
treated during 1998-2008. The results of the study showed that
although laparoscopic surgery reduced hospital stay and
complication rate, the cost of treatment was statistically
significantly more expensive than surgical treatment, both for
acute appendicitis cases have no complications as well as
complications. The difference in cost was reduced when the
patients have complications after surgery. After correcting for the
condition (simple or complex), the mean cost for a patient was $
19,978 for laparoscopic surgery alone, $28,103 for laparoscopic
surgery open surgery compared with only $15,714 with open
surgery (p <0.001).
4.2.3. The cost structure of the hospital
The results of the study showed that the cost of hospital
treatment for acute appendicitis treatment in the two years 20122013 was the cost of surgery (2.667 million VND), direct

expenses for patients (tests, medicine, blood, infusion, and
supplies with 2,560 million VND); bed days treatment costs (871
thousand VND) and medical examination costs (35 thousand
VND). The cost of laparoscopic surgery was higher than open
surgery; The cost of bed days and direct costs for patients at open
surgery was higher than for laparoscopic surgery.


19
With other studies in the world, the cost structure for
services constituted the total cost of acute appendicitis treatment,
not only in terms of value but also in the way services were
divided. Many studies have also shown that the costs of surgical
services was one of the largest expenditures in the total costs of
medical treatment for patients, especially for patients undergoing
laparoscopy.
4.3. The payment burden of the patient for the acute
appendicitis treatment
4.3.1. Total costs
The results showed that the median total cost of treatment for
a patient with acute appendicitis was 5.363 million VND; Total
cost is 5.661 VND / person. Thus, the cost from the payer,
including the direct costs not for health and indirect costs were
still lower than the hospital costs to spend 441 thousand VND
(accounting for 7,7% of the total costs of the hospital). The
difference between the cost of the hospital and the costs paid by
the patient due to the cost of services for treating acute
appendicitis in particular and the health services in general were
not fully accounted for the cost components.
Compared with previous studies on the cost of acute

appendicitis treatment, the total cost of treatment for patients in
our study was higher than that of Lu Van Trang et al. (2011) in
provincial hospital An Giang in 2010-2011 with 2.402 million
VND (for both open surgery and laparoscopic surgery)
Total cost of treatment in our study in 2013 increased
significantly compared to 2012, from 3.661 million to 6.661
million. This increase was mainly due to direct costs of health
(from 2.661 million VND to 4.884 million VND), especially the
cost of health insurance (from 1.645 million VND to 3.939
million VND). This was partly due to changes in the application
of health service pricing rules between these two years in Son La
province.
4.3.2. Direct costs for treatment
The average cost of treatment for acute appendicitis patients
was 5.084 million VND/patient. Of which, the direct medical


20
expense was 4.316 million VND; corresponding to 76.8% of total
costs and 84.9% of total direct costs.
The direct cost of acute appendicitis treatment in our study
was higher than that of Truong Tan Minh (4.427 million VND)
and Lu Van Trang (2.402 million VND).
The role of health insurance in reducing the burden of
payment for treatment was clearly demonstrated in health
insurance coverage for the vast majority of all direct expenses for
the treatment of patients, other than medical expenses.
4.3.3. Pay out of pocket for treatment
The burden of medical expenses was usually reflected in the
level of out-of-pocket payments. The results showed that the

median out-patient payment was 1.564 million VND and the
mean value was 2.228 million VND. Out-of-pocket costs for
acute apendicitis treatment in this study were lower than out-ofpocket expenses for a traumatic inpatient course of treatment of $
270 and higher than the average annual treatment cost for patients
HIV/AIDS (66 USD). Average out-of-pocket spending accounted
for 36.3% of total acute appendicitis treatment costs; Overall, the
share of out-of-pocket spending in total health spending in
Vietnam (2012) was 48.8%. The economic burden of out-ofpocket payments for acute appendicitis was not as great as for
other chronic diseases such as HIV / AIDS, hypertension, cancer,
etc.
However, to have a rough picture of the financial burden of
acute appendicitis treatment we compared the out-of-pocket
spending with the per capita income of the patients. Research
showed that on average, each patient must spend 23.9 days of
income to pay for the treatment of acute appendicitis. Health
insurance significantly reduces the burden of payment from
patients without health insurance coverage equal to 41.6 days of
income, this figure is 20.8 days in patients who pay health
insurance and only 18 One day's income in NB will be covered by
health insurance.
4.4. The difference between the costs of the hospital and the
costs of the patient


21
The difference between the actual total costs of hospital and
the rate of treatment for an acute appendicitis patient in this study
was 1.819 million VND, as currently there were no full-scale
medical facility available. It was not calculated correctly,
calculating all the factors constituting the cost. Specifically, at the

time of the study, Son La Procincial General Hospital was still a
partial autonomous unit and the price of general medical services
and surgical treatment services for patients with acute appendicitis
only up to 3/7 factors, applied in accordance with Circular
04/2012 of the Ministry of Health - Ministry of Finance and
Resolution 24/2012 of the People's Council of Son La province.


22
CONCLUSSION
1. Analysis of the actual cost of surgery for acute appendicitis
at Son La General Hospital (2012-2013).

The average actual cost of hospital for one case of acute
appendicitis treatment in two years was 6.132 million VND (in 2012:
5.751 million VND, in 2013: 6.538 million VND); The cost of open
surgery was 6.680 million VND (2012: 6.077 million VND, 2013:
7.276 million VND), the laparoscopic surgery cost was 5.660 million
VND (2012: 5.489 million VND, 2013: 5.854 million VND). Hospital
expenses included: medical fee (32.3%), depreciation of medical
equipment fee (20.0%), labor fee (14.8%), and bed fee (14.2%). With
Laparoscopic surgery: depreciation of medical equipment cost (1.559
million VND), tests cost (0.507 million VND), maintenance cost (0.305
million VND) were higher than open surgery (0.840, 0.431 and 0.186
million). With open surgery, some expenses accounted for the highest
rate, included: medicine cost (38.0%), bed cost (15.7%), labor cost
(12.6%). With laparoscopic surgery, depreciation of medical equipment
cost (27.5%), medicine cost (26.5%), bed cost (12.7%), labor cost
(12.4%).

2. Analysis of economic burden on patients with acute
appendicitis at Son La General Hospital (2012-2013)

The average cost for a patient was 5.661 million; indirect cost
was 577 thousand VND, accounting for 10.7% of total treatment costs.
The direct cost for a patient was 5.084 million VND, corresponding to
89,3% of total cost (2012: 3.658 million VND, 2013: 6.601 million
VND); patients with open surgery (5.659 million VND), laparoscopic
surgery (4.589 million VND); the patients had health insurance (5.292
million VND); the patients had no health insurance (4.118 million
VND). The rate of health insurance cost in total direct treatment cost
was 56.2% (2012: 48.0%; 2013: 52.0%); open surgery group (59.0%),
laparoscopic surgery group (53.1%); The patients had health insurance
(65.6%). Out-of-pocket spending for treatment was 2.228 million VND,
accounting for 43.8% of total direct costs; 2.319 million VND (with
open surgery), 2.150 million VND (with laparoscopic surgery); 1.822
million VND (with patients had health insurance) and 4.118 million


23
VND (with patients had no health insurance). The highest proportion of
out-of-pocket payments were direct out-of-pocket (786.2 thousand
VND, corresponding to 34.5%); Surgical cost (610.2 thousand VND,
corresponding to 27.4%), drug cost (564.3 thousand VND,
corresponding to 25.3%). Non-medical costs of endoscopic surgery
patients were lower. The cost of medicines and surgery was 6 times
higher in patients without medical insurance.
For each patient who was treated for acute appendicitis surgery
in two years 2012-2013, Son La General Hospital had to subsidize
about 1.819 million VND; The difference is mainly from the cost of

surgery (1.012 million VND) and examination fee, bed fee (687.000
VND).