In order to increase the manageability of the CMI system and the state control over targeted and rational employment of the CMI funds, the bill establishes the principle of subordination of the municipal CMI funds to the Federal CMI Fund. The head of a territorial CMI fund is appointed by the head of the Federal CMI Fund upon consent of the supreme executive body of the RF Subject. Thus created vertical is to ensure the integrity of the sys tem and its financial stability.
In addition to this, the proposed structural modifications ensure that the RF Subjects’ administrative bodies preserve control over the functioning of municipal CMI funds. The representative body of the RF Subject approves of the municipal CMI fund’s budget. The municipal CMI fund sets the standards of the per capita financing of insurers upon consent with the executive body of the RF Subject.
The bill provides for an introduction of social partnership institutions to the CMI sys tem’s administration. The RF agencies, associations of Russian trade unions and employ ers form the territorial CMI Fund’s supervisory board. The Supervisory boards control the performance of such Funds’ budgets.
The executive body of the respective RF Subject, basing on an agreement with the municipal CMI fund, as well as associations of medical organizations, professional unions RUSSIAN ECONOMY in trends and outlooks of employers and insurance medical organizations set tariffs on medical assistance of the medical institutions provide to the insurants.
The bill sets a number of requirements and mechanisms that ensure a balance be tween the CMI programs and financial resources. Insurance premiums of the RF Subject on CMI on behalf of the non working population should be set at an amount not lesser than that, which provides the balance of the amount formed by all sources designated for fi nancing the basic CMI program and its value. The procedure of calculation of the value of the basic CMI program in the RF Subjects and the methodology of calculation of amount of premiums on CMI on behalf of the non working population are approved by the RF Gov ernment.
The CMI tariffs that are pre set in the calculation of the price of the basic CMI pro gram cannot be lower than the values computed according to the methodology of compu tation of minimal tariffs on the guaranteed medical assistance approved by the federal ex ecutive agency in compliance with the law on public guarantees of medical assistance, providing the said agency conducts legal regulation in the health care area. As a result, this should increase requirements to the resource based provision of medical assistance and on this basis help overcome the regions’ eagerness to synthetically lower the value of the CMI program and, consequently, the amount of the CMI premiums on behalf of the non working population.
The equalization of conditions of financing of the basic CMI program in the RF Sub jects is made at the expense of both Federal CMI Fund and subsidies and subventions from the federal budget. The CMI financial resources are distributed at the expense of subsidies from the Federal CMI Fund in favor of regions that are unable to collect funds sufficient for the provision of the basic value of the CMI program due to objective social and economic reasons. One calculates the amount of subsidies with a due account of lev els of the RF Subjects’ budget sufficiency and sets it in the structure of the RF Federal CMI Fund’s budget expenditures across single regions.
The subsidies from the Federal CMI Fund are earmarked under the following condi tions:
• compliance of a CMI program in a given RF Subject with the requirements to its forma tion;
• absence of unsettled debts of the RF Subject on insurance premiums on CMI on behalf of the non working population.
The bill reads that it is insurance medical institutions (IMI) can serve as the CMI in surers. But at the same time the conditions of their functioning are subject to substantial modifications.
1. The bill grants insurants with the right to select an insurant company by themselves, rather than by their employer, as it de facto happens today. This right is fixed in the current legislation on medical insurance and it is secured by the current procedures of change of the insurer, as well as by personified accounting in the compulsory medical insurance system. As a result, the intensifying competition between IMI=s should en courage them to re galvanize their operations on protection of patients’ rights and control over the quality of medical assistance.
2. The bill increases IMI’s responsibility for organization of provision of medical assis tance: in the event the insurant finds it impossible to receive the necessary medical as sistance at a selected medical institution (in the frame of a territorial IMI program), the insurer is bound to immediately undertake steps on securing the provision of the insur ant with the required medical assistance.
The real sector 3. The bill sets the IMI’s obligation to plan volumes of medical assistance delivered as per contract on provision of the medical assistance by CMI, to ensure the consistency of overall volumes of medical assistance to insurants with indicators of volumes stipulated in the territorial CMI program. The insurers are accountable to the territorial office with respect to fulfillment of their contract on provision of medical assistance. These re quirements are aimed at an increase of efficiency of the use of CMI funds. Accordingly, the insurant’s operations are evaluated on the basis of his contribution to the increase of the efficiency of the use of CMI funds.
4. The bill introduces a system of division of financial risks between the territorial IMI’s fund and insurants: the latter will undertake the part of risks associated with the bias in actual spending on provision of insurants with medical assistance from the planned ones. Accordingly, while interacting with medical institutions, IMI=s will not be able to limit their respective functions with the “cashier” one. This should increase their moti vation to search for a more efficient structure of provision of insurants with medical as sistance.
The bill provides for a possibility of a targeted setting of additional guarantees in the CMI system. The basic CMI program can be complemented with federal and territorial programs of additional medical insurance funded at the expense of additional insurants premiums payable by the RF and/or the RF Subjects, as well as by other entities.
The framework of the effective law bears the problem of duplication of funding the compulsory and voluntary medical insurance and the departmental medical services. At many enterprises, the employers have to arrange a parallel system of medical assistance for their employees, either by using their own medical treatment basis and funding it out of the enterprise’ proceeds or by applying the voluntary medical insurance (VMI), thus paying twice for the same risks.
For the purpose of liquidation of the above mentioned duplication, the bill suggests an introduction of a mechanism of compensations for the part of insurance premium from the CMI funds payable by insurers according to medical insurance contracts.50The provi sion of premium is conditioned by the conformity between CMI and insurance programs to a medical insurance contract. The premium is provided at the amount of the per capita fi nancing standard per 1 insurant in CMI system. The provision of the premium in such an amount and the simultaneous reassignment of obligations to an insurer, who has entered in a medical insurance contract on financing medical assistance in the volume as per the basic CMI program, will not result in a financial destabilization of the CMI system and will not infringe upon the rights of other insurants under the CMI system. Moreover, the avail ability of VMI should rise considerably thanks to compensating for a part of the insurance premium as per the medical insurance contract. This will secure additional proceeds in the health care system and foster the transition to more solidary and legal forms of the popula tion’s participation in paying for medical assistance.
The CMI requirements, particularly, an introduction of the system of personified ac counting of insurants, control over the volume, quality, terms, conditions and validity of provision of medical assistance to insurants, protection of their rights, etc. apply to insur ers that exercise their mission in compliance with such medical assurance contract.
According to the noted medical insurance contract, an insurant has the right to resort to the CMI system in emergency cases, which require an urgent interference, while being IET introduced and developed this approach over years. (see: Shishkin S.V. Reforma finansirovaniya rossiyskogo zdra vookhraneniya. M.: IET; Teis, 2000 // www.iet.ru. P. 316 318; Gudkov A.A., Popovich L.D., Shishkin S.V. Perspektivy sochet aniya obyazatel’nogo i dobrovol’nogo meditsinskogo i sotsialnogo strakhovaniya v Rossii. Sotsial’noye obespecheniye eko nomicheskikh reform M.: Institute for the Economy in Transition, 2002. P. 128 150.
RUSSIAN ECONOMY in trends and outlooks away from their permanent residence, in the event they are in need for provision of a spe cialized high tech medical assistance and impossibility to receive the much needed medi cal assistance in medical institutions, with which the insurer has contractual relations as per to the respective medical insurance contract. In these cases medical services deliv ered in the CMI system are payable for to the given medical institution by territorial de partments with the consequent reimbursement for these sums by an insurer as per the re spective medical insurance contract.
The designing of the bills has been underway until the late 2004. They have not been presented to the Government for consideration. So, disagreements between the Ministry of Health Care and Social Development, the Ministry of Finance and the Ministry of Eco nomic Development across single positions were not removed.
A New Mechanism of Provision of Medicines to “Beneficiaries’ The design of mechanisms of implementation of provisions of Federal Law No. 122 of August, 22, 2004, which envisaged the modification of social benefits delivered in kind for an array of categories of the population (war invalids and participants, veterans; members of families of the deceased war veterans, survivors of the Leningrad blockade, disabled, etc.) became a priority task of the Ministry for Health Care and Social Development (MHCSD) in late 2004. Such benefits also comprise a beneficial provision of medicines (free or with the 50% discount) and the sanatorium and rehabilitation treatment. Since 2005 the mechanism of delivery of medicines, the sanatorium and rehabilitation treatment and traveling to the treatment spots has changed for the respective categories of the population. These kinds of services account for an independent set of social services (the so called “social package”) that is equal across all the above mentioned categories and amounts to 450 rubles per month. Expenses associated with provision of the given social package are compensated from the Federal Budget. In 2006, citizens will be able to opt for either compensation in cash, equivalent of the cost of the social package or receipt of ser vices included therein.
The main part of the social package is the provision of medicines equivalent of rubles per month. Free medicines are provided for all the respective categories of “benefi ciaries” (earlier just a part of the recipients of benefits enjoyed only the 50% discount for the purchased medicines). MHCSD approved a list of medicines that can be delivered to beneficiaries. It comprises 352 international unlicensed brands, or over 2,000 commercial brands. Basing on the method of qualified selection without tender, the Federal Service for supervision in the sphere of health care and social development under the Ministry se lected distributor pharmaceutical institutions that were assigned to supply medicines to distribution centers (drugstores) for the individuals entitled for benefits. The Federal Ser vice made the ability to supply all kinds of medicines included in the list the principal selec tion criterion. As many as 5 distributor companies matched the given criterion. Each of them has monopolized a given federal district and regional market and become a sole supplier of medicines to the recipients of benefits there. “Proteck” supplies medicines to the Central and North Western federal districts, “SIA – International” – to the Southern and Ural districts, “Biotech” – to Volga district, and ZAO ROSTA – to the Far Eastern and Sibe rian districts. “Farmimeks” company supplies medicines to Ingushetia and Chechnya’s drugstores. In late February 2005, ZAO “Apteka Holding”, the sixth distributor, was permit ted to participate in supplying medicines to beneficiaries.
The network of drugstores provides medicines to the beneficiary categories of the population. The networks are selected by the RF Subjects and local agencies. Medicines Section 3.
The real sector provided to beneficiary categories of the population should be paid for through the CMI system. The Federal Budget funds are forwarded to the Federal CMI Fund, which distrib utes them across territorial CMI funds as per their requests.
The federal agencies failed to explain to all participants the new mechanism of fi nancing the provision of medicines to beneficiaries. It is worthwhile noting that until No vember 2004 MHCSD mainly focused on designing the set of medicines, negotiations with their manufacturers and selection of suppliers. The procedures of interaction between all participants in the system have been quickly worked out over the two last months of the year. Legal acts that regulate the procedures of contracts on supply of medicines to indi viduals entitled for benefits and conduct of the respective calculations arrived in regions only in the last decade 2004.
Originally, it was intended to include insurers who participated in the CMI system in the system of payments. The insurers were to receive resources from territorial CMI. In surers were to sign contracts on supply of medicines to beneficiaries with the distributors and exercise control over validity of the respective prescriptions by medical institutions.