CHNG TRNH CI T
Y T MEDI-CAL

BC S TRNH NGC HUY, MD.
Trong mt vi thng na, nhng bnh nhn c Medi-Cal dܧi chng trnh AFDC s nhn ܮc giy thng bo v chng trnh ci t ny v khuyn co bnh nhn s phi chn la bc s iu Tr Chnh (Primary care physician) ca mt trong hai t chc ni trn. Trong mu n, bnh nhn s phi in tn bc s m h la chn, nhm (medical group) m bc s ca h lm vic vi v d nhin l tn ca mt trong hai t chc...
Tiu bang California dn u v Health Maintance Organization ܮc gi l HMO, tm dch l chng trnh bo him y t c qun tr vi khong 38% hay 10 triu bnh nhn nm trong chng trnh bo him ny. V th, khng c g ng ngc nhin khi tiu bang California bt u ci t chng trnh Medi-Cal ca ton th tiu bang qua chng trnh Managed Care, tm dch l iu Tr C Qun Tr. Vi chng trnh ny, vn NJ tr liu y t phi ܮc kim sot s dng cho chnh ng v ng mc, trnh s lm dng hay li dng. Trong chng trnh Medi-Cal hin nay, bnh nhn c th i khm ti bt c bc s hay bnh vin hoc phng cp cu no, d au nhiu, au t hay c au cp cu hay khng. V theo lut, cc bc s, nha s, nh thng, phng cp cu, dܮc s phi khm bnh v cho toa hay bn thuc cho bnh nhn v chnh ph tiu bang phi tr tin cho cc dch v ny. V bnh nhn ch cn a th Medi-Cal l ܮc khm bnh m khng phi tr tin ti ca mnh nn i khi bnh nhn s dng cc dch v y t ba bi, khng cn thit; v ngܮc li, cc nhn vin phc v trong ngnh y t ܮc chnh ph tr tin cho cc dch v h cung cp nn cng lun sn sng phc v ht mnh. Thnh ra, vi s cung cu khng c gii hn v kim sot, chi ph cho y t ca Medi-Cal ti tiu bang California tr thnh mt con s khng l. Ti tin ca chnh ph lin bang khng phi l mt ti tin khng y v phi b gii hn v khng th tip tc tng thu ca dn chng ln hoi ܮc Nj chi ph cho chng trnh Medi-Cal min ph. cho qu v Ƕc gi c ܮc khi nim v chi ph khng l ny: chng ti xin trch dn tng s chi ph v tt c dch v y t t bc s, nha s, dܮc s, thuc men, th nghim, quang tuyn, nh thng, phng cp cu, v dܫng ܩng lao... cho 167,213 bnh nhn Medi-Cal ti qun ht Santa Clara vo nm 1992 l 362,335,139 M kim. ng vy, trn 360 triu M kim cho qun ht Santa Clara khng m thi. Tnh ra khong 194.42 M kim mi thng hay 2,381 M kim mt nm cho mi bnh nhn Medi-Cal ti qun ht ny. y ch l mt chi ph ca mt qun ht trong qun ht ca California. V chi ph ny nm 1996 tng ln gp bi. l l do ti sao chnh ph tiu bang phi tm cch Nj kim sot chi ph ny.

Nhng th im u tin ca chng trnh Medi-Cal Managed Care l qun ht Santa Barbara v San Mateo ܮc trn 5 nm. Trong vng hai nm nay, qun ht Orange, Sacramento v Stockton bt u. Qun ht Alameda v San Francisco bt u khong hai thng nay. V qun ht Santa Clara s bt u vo thng 10 ny. Tuy nhin, v y l ln u tin chng trnh ny ܮc p dng ti Santa Clara, nn h cng bt u mt cch t t v c th ljn thng 12, bnh nhn mi phi chnh thc gia nhp vo chng trnh Qun Tr Y T ny. Thm na, ch c nhng bnh nhn trong chng trnh AFDC (Aid to Family with Dependent Children -tc gia nh c tr con) v Refugee (T nn) l bt buc phi gia nhp vo chng trnh ci t y t ny. Nhng bnh nhn c Medi-Cal qua chng trnh ngܩi gi (Aged Public Assistance), tn tt (Disabled), m ci (Foster care) v ngܩi ln b bnh (Medically Indigent Adult) th khng bt buc vo chng trnh ny nu h khng mun. Tuy nhin, trong tng lai, chnh ph tiu bang d nh tt c bnh nhn c Medi-Cal NJu nm trong chng trnh Qun Tr Y T. Hin nay, qun ht Santa Clara c khong 190 ngn bnh nhn trong chng trnh Medi-Cal, trong s , khong 27,000 hay 22% l ngܩi Vit Nam.

trnh tnh trng Ƕc quyn v cng Nj bo v quyn li ca bnh nhn cho h c s la chn chng trnh Qun Tr Y T, qun ht Santa Clara s c hai t chc (plan). Hn na, chnh ph tin rng, vi s cnh tranh ca hai t chc, s khin c hai lun lun c gng v tranh ua phc v bnh nhn Nj hy vng bnh nhn v bc s, cng nh cc c quan y t, s la chn t chc ca h. Mt t chc c tn l Local Initiative ܮc ǥt dܧi quyn qun tr ca Santa Clara county of board supervisors. T chc ny gm nhng c quan y t nh community clinics, nh thng Valley Medical Center, Alexian Brothers Hospital, Packards Children Hospital v cc bc s, nhn vin y t phc v cc bnh nhn Medi-Cal t xa ljn nay, ܮc s tr gip v bo v ca qun ht Santa Clara cng nh ca chnh ph tiu bang Nj h c th tip tc sn sc cho nhng bnh nhn Medi-Cal ca h. T chc th hai l do cc hng bo him t nhn u thu v Blue Cross l hng bo him sc khe trng thu qun ht ny. Hin nay, c hai t chc NJu ang ro rit Nj c th bt u chng trnh Qun Tr Y T ny vo khong thng 10. Tuy nhin, Local Initiative l chng trnh mi ܮc thnh lp, nn c th b tr hon mt vi thng trong khi Blue Cross c t lu ri nn c th sn sng bt u vo ng thng 10. Bnh nhn c th ghi danh vi chng trnh Blue Cross vo thng ti. Tuy nhin, theo lut nh, bnh nhn s khng bt buc gia nhp vo chng trnh Qun Tr mi ny cho ljn khi c hai t chc Local Initiative v Blue Cross cng tin hnh.

Trong mt vi thng na, nhng bnh nhn c Medi-Cal dܧi chng trnh AFDC s nhn ܮc giy thng bo v chng trnh ci t ny v khuyn co bnh nhn s phi chn la bc s iu Tr Chnh (Primary care physician) ca mt trong hai t chc ni trn. Trong mu n, bnh nhn s phi in tn bc s m h la chn, nhm (medical group) m bc s ca h lm vic vi v d nhin l tn ca mt trong hai t chc. Nu trong vng 30 ngy m bnh nhn khng la chn v gi mu n li, bnh nhn s t Ƕng ܮc ghi danh (default enrollment) vi mt trong nhng bc s c giao ko trong chng trnh Qun Tr Y T. bo v bnh nhn, lut tiu bang nh rng, trong trܩng hp bnh nhn khng la chn bc s th chng trnh t Ƕng ghi danh s phi la ngܩi bc s y nhim ni ܮc th ting ca ngܩi bnh nhn v khong cch t nh bnh nhn ljn phng mch bc s khng ܮc qu 5-10 dm. im ny rt quan trng v nu bnh nhn khng la chn bc s trܧc, i khi bnh nhn c th b ng k vi mt bc s xa hay ngn ng bt ng, ti lc au bt t th khng ܮc i bc s mnh mun. V theo chng trnh iu tr qun tr, bnh nhn s lun qua bc s iu Tr Chnh ca mnh cho tt c cc vn NJ sc khe y t t khm tng qut, chch nga ljn th nghim, chp hnh, nhp vin khi au nng hay gii thiu qua bc s chuyn khoa khi cn.

Nh ni trn, chng trnh ci t qua Qun Tr Y T bt u cc qun ht khc v chc chn s bt u Santa Clara trong vng hai thng ti y. D nhin, cng nh vi bt c s ǰi mi no, nht l ln u tin ܮc p dng, s c nhiu im thiu st v ln xn, v vy, bnh nhn phi Nj theo di Nj c th lm th tc cng nh la chn theo mnh Nj trnh b thit thi v quyn li cng nh v sc khe ca mnh.

Nhng cu hi thng thܩng m bnh nhn thܩng gp:

Khi no chng trnh Qun Tr Y T Medi-Cal bt u?

Qun ht Santa Clara s bt u chng trnh ci t ny vo thng 10. Tuy nhin, lut tiu bang nh rng phi c hai t chc HMO Blue Cross v Local Initiative bt u cng lc v t lc , bnh nhn mi bt buc phi gia nhp vo mt trong hai chng trnh HMO trn. V chc chn Local Initiative c th s khng sn sng kp lc vo thng 10 ny, thnh ra ch c Blue Cross bt u m thi. V th, khong thng 10 bnh nhn c th t do ghi danh tham gia chng trnh qun tr y t nhng cha phi bt buc.

Bnh nhn c Medi-Cal v Medicare (y t cho ngܩi gi) c phi bt buc ǰi qua chng trnh ci t ny hay khng?

Khng. Hin nay ch nhng ngܩi c Medical trong chng trnh AFDC, tc l nhng gia nh c tr con dܧi 21 tui v trong chng trnh t nn (refugee) mi phi ǰi qua. Ti lc ny, vn cha c d nh hay thi hn no cho bnh nhn c Medicare; tuy nhin, theo d on tt c mi chng trnh ca medical k c medicare-medical s phi chuyn sang chng trnh Qun Tr Y T trong vng vi nm ti.

Sau khi la chn, bnh nhn c quyn i bc s (medical groups) hay t chc HMO (Blue Cross v Local Initiative)?

C v l quyn li ca bnh nhn v l l do ti sao tiu bang mun c hai t chc HMO thay v mt. Tuy nhin, v vn NJ th tc v giy t, bnh nhn c th mt mt thi gian trung bnh khong mt thng khi thay ǰi mt bc s mi hay mt nhm bc s mi v c th l t 1 ti 3 thng khi mun thay ǰi HMO.

Nu bnh nhn khng la bc s iu Tr Chnh th s b thit thi g?

Theo lut nh, bnh nhn s ܮc la mt bc s cho h. C hai t chc s c gng la mt bc s ch nh c th ni cng ngn ng vi bnh nhn v phng mch gn nh bnh nhn. Tuy nhin, v vn NJ th tc, bnh nhn c th s b ch nh cho mt bc s ch nh ny m mnh khng thch hay qu xa. Thnh ra, lc au bt t bnh nhn s phi i ngܩi bc s m h khng thch hoc qu xa, khng tin di chuyn hoc khng th m thoi ܮc v ngn ng bt ng. V h s tip tc i ngܩi bc s ny cho ti khi h c th i ܮc ngܩi bc s theo mun. iu ny xy ra kh nhiu cho bnh nhn Vit Nam qun Cam (Orange County). H b ch nh cho bc s M hay M v khng dm i khm khi b au yu v phi tr tin mc Nj i khm bc s Vit Nam gn nh.

Mt gia nh vi hai v chng v cc con ci c phi la mt bc s khng?

Khng. Mi mt bnh nhn: chng, v hoc mi a con c quyn la chn bc s khc nhau. Tuy nhin, Nj tin cho c gia nh, c th la mt bc s cng ܮc. V nu nh vy, h nn la bc s m c th sn sc cho c tr con v ngܩi ln v c nhiu bc s ch trng lo cho tr em m thi (bc s nhi ng) v ngܮc li bc s ch chuyn khoa v ngܩi ln m khng sn sc tr con ܮc.

Nu bnh nhn mun la chn bc s ca h th phi lm sao?

Trong vng thng ti, h s nhn giy bo v mu n ca t chc Health Choice, l mt t chc bt v li do tiu bang giao ko Nj thng bo v yu cu bnh nhn la chn bc s v t chc HMO. Bnh nhn cn in mu n ny vi tn bc s v t chc v gi tr li theo a ch. Hoc gin d hn, bnh nhn c th ly mu n phng mch bc s m h ang chn v in vo gi i. Bnh nhn sau s nhn ܮc th trn c tn bc s v t chc HMO.

Nu bnh nhn ch ܮc i mt bc s th trong trܩng hp na m bc s khng c phng mch hay bc s i vng m bnh nhn au th sao?

Theo lut nh v iu kin ca cc t chc HMO, tt c cc bc s iu Tr Chnh trong chng trnh qun tr y t phi lun lun sn sng cho bnh nhn. Thnh ra, ngoi gi ca phng mch, bc s s phi c nhng thu xp chng hn nh s in thoi hay trao ǰi Nj bnh nhn c th lin lc khi b au khn cp. Khi bc s i vng, h phi c bc s khc trc th Nj lo cho bnh nhn nu chng may h b au bt t.

Nu bnh nhn ch ܮc i mt bc m khng c trong t chc HMO Nj ly thm kin v bnh l th c ܮc i th khng?

Trong trܩng hp ny, HMO c th s chu chi ph cho bnh nhn ty thuc vo 2 iu kin. Th nht l bnh nhn c bnh tht s v cn mt bc s chuyn khoa v cn bnh . Th hai l trong t chc HMO khng c bc s chuyn khoa Nj cha tr cho ngܩi bnh. Trong trܩng hp ny, HMO s gii thiu bnh nhn i bc s chuyn khoa m h c giao ko ǥc bit hay t chc s chu i th tt c chi ph cn thit Nj cha bnh cho bnh nhn. Th d nh mt bnh nhn b ung th mu cn thay ghp ty (bone marrow transplant), bc s iu Tr Chnh s thu xp vi t chc HMO Nj a bnh nhn qua Stanford hay UCSF Nj tr liu.

Nu bnh nhn i xa nh m b au th chi ph y t c ܮc i th khng?

Cng nh cc chng trnh qun tr y t t nhn, bnh nhn Medical trong chng trnh qun tr y t s ܮc i th nu h chng may b au cp bch khi xa nh. Cc trܩng hp au bt ng hay khn cp tht s s ܮc bao tr. Tuy nhin, trܩng hp nh mt bnh nhn c bnh tim Santa Clara v qun ht Orange chi, nghe ting bc s A gii v tim, nn i khm th th t chc HMO s t chi i th chi ph cho bc s A.

Chng trnh HMO c ngha l bnh nhn s khng phi tr thm bt c khon tin g v mi vn NJ y t, phi khng?

Trong chng trnh iu tr c qun tr, bc s hay mt nhm bc s ܮc tr khon Nj lo cho bnh nhn. V ܮc tr khon trܧc cho nn bc s hay nhm v t chc HMO phi c iu khon cn bn v b rng buc l nhng dch v y t no h phi lo cho bnh nhn. iu khon ny Nj bo v cho bnh nhn ln bc s v t chc HMO. Nu khng c nhng iu khon cn bn, bc s c th khng lo y cho bnh nhn v ngܮc li bnh nhn c th i hi qu mc cc dch v y t vܮt qu s tin khon cho bc s. Mt th d tng t l nh thu ܮc khon Nj xy mt cn nh v ch nh v nh thu phi hoch nh tiu chun v vt liu cn thit Nj xy cn nh trܧc khi nh gi khon. Nh thu phi xy cn nh y ng theo tiu chun nh. Tuy nhin, nu ch nh mܧn xy cn nh tt hn nh lm thm tt, lt cm thch m khng c trong giao ko th ch nh phi tr thm.

Trong chng trnh Qun Tr Y T, bc s s phi lo cho bnh nhn v cc vn NJ y t cn bn hu nh l hon ton cc y t cn thit t khm tng qut ljn chch nga ljn tt c cc bnh nh hay him ngho m bnh nhn khng phi tr thm ng no c. Tuy nhin, nu dch v y t khng c trong iu khon, chng hn nh thuc bc, chm cu (cha ܮc cng nhn bi HMO), sa sc p, chch thuc nga Nj i du lch v Vit Nam... th bnh nhn phi tr t tin ti ca mnh. Trong nhng trܩng hp ny, bc s s phi thng bo cho bnh nhn l h phi tr bng tin ring trܧc khi bnh nhn bng lng lm.

Bnh nhn qun ht Alameda c quyn la chn bc s qun ht Santa Clara khng?

Khng. V mi qun ht ܮc tin ca tiu bang ty thuc vo s bnh nhn ܮc hܪng Medical sng qun ht . Thnh ra qun ht Santa Clara s khng nhn ܮc tin cho nhng bnh nhn qun ht Alameda v ngܮc li cho nn bnh nhn qun ht no phi la chn bc s trong qun ht . Tuy nhin, nhng bnh nhn gn bin gii khong 5 dm gia hai qun ht c th la chn bc s qun ht k. Th d bnh nhn vng Milpitas c th la bc s Santa Clara hay Alameda v ngܮc li, bnh nhn vng Fremont Mission c th la bc s qun ht Santa Clara.

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