The main causes underlying the inefficiency of medical services are extension of treatment term and hospitalization without sufficient medical diagnoses.
The health care system comprises a complex of fundamental economic problems that reproduced themselves over the last 10 years:
• financial insufficiency of the state guarantees of medical assistance to the population;
• unregulated replacement of the state expenses by private ones without revision of guarantees;
• incompleteness of introduction of the compulsory medical insurance system;
• considerable differentiation of the amounts of the state financing across regions;
• absence of economic mechanisms that encourage participants in the health care sys tem to increase the effectiveness of the use of public resources.
The volume of the government financing of the health care system that had reduced by more than one third in the 90 s began increasing since 2000, but has still failed to reach the level registered 15 years ago (Fig. 72). In addition to that, the public guarantees, as in the Soviet times, provide for medical assistance being free for the population at the public and municipal health care institutions, albeit the volume of such guarantees for single indi vidual has not been defined as yet. The divergence between the population’s expected volumes of their provision and real capabilities of the state is immanent for such guaran ties. Given the reduced government financing, this divergence transforms into the gap be tween the declared and real economic conditions of receiving medical assistance.
100 84 84 74 72 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Budget assignments on health care system and contributions to CMI Source: Calculated basing on the Russia’s Rosstat data Fig. 72. The Dynamics of the Government Expenses on the Health Care System (1991=100%) RUSSIAN ECONOMY in trends and outlooks 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Paid medical services Medicines Source: Calculated basing on the Russia’s Rosstat data Fig. 73. The Population’s Expenses on Health Care System, as Rb. billion in the 2000 prices Financing of the medical assistance to a greater extent is shifted onto households and employers. The population’s spending on medicines and medical services grows steadily at a high pace, which has not reduced over the last years, in spite of the growth of the government financing, but outstrip it (Fig. 72 and 73). The replacement of the govern ment expenses by private spending is a spontaneous process. The attempts to regulate the process are undertaken on the micro, rather than macrolevel. A high real level of the population’s contribution to paying for medical assistance does not go together with a re vision of inadequately fulfilled guarantees.
Compulsory Medical Insurance The existing system of compulsory medical insurance (CMI) suffers a number of se rious shortcomings that need to be overcome through changing the CMI model itself.
There is no coordination between the CMI programs and the amounts of insurance premiums. This is the fundamental shortcoming. The CMI system accumulates 46% of the aggregate volume of the public health care insurance, while the value of the basic CMI program accounts for 63% of the value of the government guarantees program on free medical assistance to the population. This problem is mainly associated with the breach of obligations with regard to insurance contributions for the non working population by RF Subjects and local authorities.
In 2004, the government proceeded with its 2003 experiment on the Pension Fund’s participation in co financing of the CMI contributions on behalf of the unemployed pen sioners. The amount of resources allocated from the Pension Fund’s budget for these purposes has grown from 1.5 billion rubles in 2003 up to 6 billion in 2004. It is intended to increase the amount up to 10 billion in 2005. The experiment and the process of intensifi Section 3.
The real sector cation of governors’ dependence on the federal center have recently contributed to a con siderable growth of the amount of contributions for the non working population, but that does not fundamentally change the situation in the CMI area.
The current CMI model has failed to exert an essential influence on the efficiency of the use of health care resources. The original expectations of the emergence of a competi tion between the insurers, which was envisaged to have a stimulating effect on their pro active stance in regard to protection of insurants’ rights and optimization of placement of orders among suppliers of the medical services, have vanished. The population can hardly choose an insurer. In addition to that, insurers are not subjected to any financial risks in regard to the payment of medical assistance. So they are not interested in selecting more efficient options of organization of provision of medical assistance for insurants.
The basic rate of the social tax that is directed in part to CMI was reduced from 3.6% to 2.8% but its centralized part was simultaneously increased from 0.2% to 0.8%. The 2005 federal budget provides for subventions at the amount of 3 Rb. bln. that are envis aged to be forwarded to the CMI Federal Fund to co finance insurance contributions on compulsory medical assistance for the non working population (children). In fact, this forms a compensation for the revenue losses of the CMI system resulting from the reduc tion of the social tax rate. So, the CMI Federal Fund receives considerable resources to equalize the financial sufficiency of the territorial CMI programs.
The economic mechanisms presently existing in the health care system do not create incentives for its participants to enhance the efficiency of use of public resources. The du ality of sources and methods of the public and municipal health care institutions’ financing for provision of medical assistance to the population that are envisaged by the basic CMI program pose a main problem, so long as procedures of their financing are concerned.
According to the CMI system’ s design, such kinds of assistance should have been paid only at the expense of the CMI funds, but in practice they continue to be financed both from the CMI system and from the budget. Public and municipal medical preventive insti tutions (MPI) receive approximately 50 60% of their resources in the form of the budget financing of maintenance of the institution, about 30–50% from the CMI system in the form of payment for the provided medical assistance and from 5 to 15% in the form of incomes from provision of the population with paid medical services. According to the federal rec ommendations, the budget and insurance resources should be employed for reimburse ment of different expenditure items. In practice, however, some single expenditure items of the MPI are simultaneously covered from the two above mentioned sources of financ ing. This creates the institutions’ eagerness to spend more, rather than to use the re sources in a more efficient manner.
Development of the Health Care Reform Guidelines The discussion on the guidelines of the much needed health care reform has been under way in the government since 1997. Between the 2000–2003 the Ministry for Eco nomic Development played a leading role in designing of the respective proposals. The bill on CMI had been developed by March, 2004. It was coordinated with all the agencies con cerned48. The consequent government reform has changed the configuration of positions.
The new leadership of the RF Ministry for Health Care and Social Development began to play a principal role in the preparation of the health care reform proposals.
In 2004, the preparation of the health care reform developed into a new phase. It is worthwhile noting that in official documents the wording “health care reform” was substi For the Concept of this bill see: Rossiyskaya Ekonomika v 2003 godu. Tendentsii i perspektivy. M.: IET, 2004. P. 282–RUSSIAN ECONOMY in trends and outlooks tuted by “health care modernization”. In 2004, the Presidential Address highlighted some key avenues of the health care modernization:
• specification of guarantees of free medical assistance basing on development of stan dards of medical services, which include an array of medical diagnostic procedures and medicines, and minimal requirements to conditions of provisions of medical assis tance;
• transition from the estimate based principle of maintenance of medical institutions to the payment for the provided volume and quality of medical assistance produced in compliance with the principles of the compulsory insurance;
• fostering incentives for voluntary insurance.
During 2004 the RF Ministry for Health Care and Social Development with the assis tance of experts of the Center of Strategic Development was working on the preparation of two bills designated to form a legal base of the health care modernization:• “On state guaranties of medical assistance”;
• “On compulsory medical insurance”.
The first bill sets kinds of the guaranteed medical assistance. Their current array that should be provided at no cost remains almost invariable. In contrast to the current system of state guarantees of medical assistance, the bill provides for specification of these guar antees across volumes, conditions and procedures of provision of medical services at dif ferent stages of medical assistance.
The guaranteed volumes of medical assistance are specified on the basis of stan dardization of medical technologies. Clinical protocols (sectoral standards) are designed for every kind of morbidity on the federal level. They comprise lists of medical services suggested (doses and application recurrence, levels of provision of medical assistance, etc.). In the framework of the respective list and algorithms of fulfillment of the protocols are common for the whole country.
Basing on the clinical protocols the RF Subjects design clinical economic standards (CES=s), which specify requirements of clinical protocols and comprise an assessment of the value of the pre set “package”. CES=s determine actual volumes of medical assistance across every illness with account of peculiarities of the employed medical technologies (both what to do and how to do) and prices of resources. Every RF Subject adopts and employs its own clinical economic standards.
Clinical protocols and CES=s comprise two parts. The fixed part is formed by a set of medical services and medicines that is compulsory for all patients with a given illness. A volume of services of the fixed part is equal for all patients with the same illness. The vari able part is formed by a set of medical services needed for the part of patients with a given illness, depending on peculiarities of its anamnesis. The volume of services of the variable part is computed on account of an aggregate of patients (for example, 60 ultrasonic ex aminations are required per 100 patients with the diagnosis “Cholecystitis”).
The fixed part of services is guaranteed to every patient, while the variable one is de livered according to medical diagnoses. So far the variable part is concerned, the medical doctor takes a decision in an order that is set by a head of a given medical organization. In case of medical contra indications to the use of services and medicines included in CES, medical assistance, which is not envisaged by the standard, is guaranteed. But this implies a higher level of decision making – by a clinical expert commission under the medical in stitution.
The real sector Such a structure of the standard, on the one hand, provides for a specification of the set of medical services and medicines its patients receive, while on the other, it ensures a medical doctor freedom necessary to take decision under conditions of the variety of manifestation of the same illness by different patients.
The procedures of provision for medical assistance in the framework of the public guarantees are based on the following principle: the provision of medical assistance is guaranteed, providing there exists a pre set “route” of the patient across the levels of pro vision of medical assistance. A local medical doctor and a general practice doctor play the roles of an organizer and coordinator, respectively, of provision of medical assistance on other stages. The planned particularized medical assistance on an outpatient basis and in hospital conditions is delivered according to their prescriptions. In case of the absence of the respective prescriptions, the planned medical assistance provides for a direct payment by the patient.
The procedures set a “queue” of the planned particularized medical assistance and maintenance of a list of patients. The queue is to be kept under control.
The bill envisages setting quotas on high tech kinds of medical assistance delivered both at the federal medical institutions (for the RF Subjects) and at the RF Subjects’ medi cal institutions of the tertiary level (for municipal institutions). The RF Subjects can intro duce additional guaranties in regard to such kinds of assistance – on the basis of direct agreements with federal medical organizations at tariffs that are set for the medical assis tance subject to quotas. The lists and amounts of quotas of the respective kinds of pro vided medical assistance and lists of medical organizations are set annually, according to the federal and territorial programs of state guaranties.
The government agencies of the RF Subjects set the guaranteed conditions of provi sion of medical assistance on the level not lower than the one set by the federal program of state guarantees of medical assistance. The latter sets requirements to standards of pa tients’ length of stay and provision with food in hospitals, as well as to the marginal term of waiting for the planned medical assistance.
The state guaranties of medical assistance should be implemented through the compulsory medical insurance system. The bill “On compulsory medical insurance” envis ages its modernization.