Organization of medical and economic control of the volume and cost of medical care in the system of compulsory health insurance in 2021

The article is devoted to the current problem of interaction in fulfilling the obligations of all participants of compulsory health insurance to pay for and provide medical care in accordance with the amendments made to Federal Law No. 326-FL of 29 November 2010 (as amended on 08 December 2020) «On Compulsory Health Insurance in the Russian Federation» and entered into force on January 1, 2021. The authors focus on the issue of granting of the territorial compulsory health insurance fund new powers to conduct medical and economic control and abolishing these powers from medical insurance organizations. According to the amendments, all volumes of medical care provided to the insured population of the subject of the Russian Federation, both on the territory of insurance and outside it, as well as medical care provided outside the territory of insurance, are the subject of medical and economic control by the territorial fund. Starting from 2021, the form of the contract for the provision and payment of medical care for compulsory health insurance, approved by Order of the Ministry of Health of the Russian Federation No. 1417n of 30 December 2020, has also changed. Unlike the previous form of contract concluded between an insurance medical organization and a medical organization, the current document provides for the participation of three parties in contractual relations: the territorial fund, insurance medical organizations, medical organizations. The agreement contains provisions providing for the obligation of the territorial fund to carry out medical and economic control of registers of accounts and accounts submitted by medical organizations to pay for medical care provided within the framework of the basic and territorial compulsory health insurance programs. The article presents the results of the control carried out with the analysis of the identified violations in the provision by medical organizations of the Ryazan region of invoices and registers of invoices for payment of medical care provided for January 2021, identifies problematic points in the information interaction between participants of compulsory insurance in the implementation of this function of the territorial fund.

Features of health insurance: an analysis of the German experience

The article examines the models of health insurance in Western countries. A comparative analysis of forms of social insurance and sources of financing payments for four models of medical insurance is carried out. The practical aspects of the functioning of compulsory health insurance in Germany are investigated, its positive features are revealed. Attention is paid to medical insurance, which provides insurance in case of loss of health for any reason. It provides greater accessibility, quality and completeness to meet the diverse needs of the population in the provision of medical services, and is more effective than government funding of the health care system. In addition, the social and economic efficiency of health insurance related to reimbursement of citizens' expenses related to receiving medical care, as well as other expenses aimed at maintaining health, depends on how comprehensively the concept of developing insurance medicine in the country has been worked out. The positive and negative aspects of health insurance are analyzed. The forms of health insurance are considered: compulsory health insurance and voluntary health insurance. It was found that one of the first countries where health insurance was introduced was Germany. There are two types of health insurance in Germany: public and private. Germany's state health insurance is compulsory. That is, every employee, as well as persons trained in production (Auszubildende), are subject to compulsory state health insurance and must be members of one of their freely chosen state health insurance funds. At the same time, if a person wishes to receive medical services that are not included in the list of compulsory health insurance, he can conclude a supplementary health insurance contract with the insurance company. Voluntary health insurance allows you to choose an inpatient medical institution and the conditions of stay in it, special services of a personal physician.

Formation of public-private model in Russia health care organization

The pandemic of COVID-19, the threat of technogenic and anthropogenic character, brought to the foreground non-market aspects of the general, corporate branch culture and strategy in medicine and health care. Therefore, in many countries, despite differences in state and private property ratios in health infrastructure, the state priority is ensuring cooperation within the national health care system which capable quickly and well-coordinated work in the extremely dangerous epidemics conditions and other emergency situations. The purpose of this article is discussing a problem of public and private models of medical care organization in Russian health care system.Materials and methods. Content analysis methods, economical and statistical analysis, information and analytical materials of the Russian and foreign news agencies, a summary across Russia of Rosstat form No. 62 of the state statistical observation «Data on resource providing and on delivery of health care to the population» (legal entities - the medical organizations which are carrying out activity in the sphere of compulsory health insurance), analytical materials and statistical data of World Health Organization (The European portal of information of health care of WHO: https://gateway.euro.who.int/en/hfa-explorer/), statistical data and metadata on the countries of the Organization for Economic Cooperation and Development (OECD, https://stats.oecd.org/), the materials of monographic researches and periodicals including placed on the Internet were used in this article.Results: the system of compulsory health insurance is an ancestor of the program of the state guarantees of free medical care of in Russian citizens. The length of the text of this Program so far was increased in 130 times in comparison with initial edition of 1998. At the same time, there is still no clear delineation for the bases, volumes and conditions differentiation of free and paid medical care rendering. As a result, the major human right to free medical care remains not completely realized. The numbers of the non-state medical organizations to provide free of charge medical care to the population according to the policy of obligatory medical insurance (i.e. financed from the state sources) in the period of 2011 to 2019 – from 648 to 2423 organizations respectively were increased in Russia four times. This demonstrates the creation of the new, «integrated» model of health care in Russia in the mode of public and private partnership for deciding of social tasks. Although, free medical care for citizens in the private medical organizations is not mentioned in the Constitution of Russian Federation (Main Law). In emergency situations such integration allows private medical structures to involve capacities and also be coordinated with one of the tasks of the Ministry of health target program «Development of the Fundamental, Transmitting and Personalized Medicine».Conclusions. There is a formation of the integrated, public and private (hybrid) model of health care in modern Russia that needs developing of a new partnership and principles of management in the sphere of medical care organization. State policy in the health care financing sphere should be directed not only to the state guarantees of medical care specification, but also to a gap in social and economic inequality reduction. The social protection systems should be focused, first of all, on people who are most in great need of medical care. For the protecting population from catastrophic payments for medical care, it is necessary to bring the concept of the social standards - a number of the general rules, norms and standards which must guarantee the state ensuring constitutional rights of citizens to free medical care in the health care legislation.

Lithuania

This chapter examines health politics and the compulsory health insurance system in Lithuania and traces the development of its healthcare system. Since the country declared independence from the Soviet Union in 1990, Lithuanian health politics have revolved around restructuring and rationalizing the overcapacities of the inherited healthcare system, increasing levels of public finance to those sufficient to meet healthcare needs, and making good on the patient rights implied by a universal system. Despite those efforts, high out-of-pocket payments remain an obstacle to health solidarity, healthcare provision—which is predominantly public—is overly dependent on inpatient care, and public financing measured as a share of GDP remains low. As the chapter outlines, other issues include low levels of satisfaction with and trust in the health system and the persistence of informal payments to ensure quality care.

Albania

This chapter offers an in-depth look at health politics and the compulsory health insurance system in Albania. It traces the development of the Albanian healthcare system, characterized by the introduction of a universal and state-run health system during communism, which since the 1970s suffered underfinancing and outdated technology. Since the early 1990s, when Albania experienced a tumultuous transition from a communist to a democratic system, Albanian health politics focused on the legalization of private medical practice, the establishment and gradual expansion of compulsory health insurance, and, recently, the introduction of free primary care—reforms which were facilitated by the support of international organizations. Notably, the contracting of private services in the public system was not allowed until 2011. The main healthcare issues have been insufficient financing and extremely high out-of-pocket costs, people refraining from paying insurance contributions, and shortages of medical staff especially in rural areas.

Belgium

This chapter offers an in-depth look at health politics and the mutualism-based compulsory health insurance system in Belgium. It traces the development of the Belgian healthcare system, characterized by its very generous coverage and few restrictions on patient choice. Since 1980, the process of federalization of the Belgian state—which has been propelled by the divide between the Flemish-speaking North and the French-speaking South—has increasingly challenged the national basis of the Belgian health insurance system. Other healthcare issues have been cost containment and the privileged position of the mutual aid societies in health insurance provision which was subject to a European Court of Justice challenge.

North Macedonia

This chapter offers an in-depth look at health politics and the compulsory health insurance system in North Macedonia. It traces the development of the North Macedonian healthcare system, characterized by the establishment of decentralized free-for-all-at-point-of-delivery health system during communism, which served as a basis for the current system. Since the early 1990s, when North Macedonia declared independence and started a transition towards democracy and a free market economy, North Macedonian health politics focused on permitting private provision, establishing a compulsory health insurance system, and integrating private services in the public insurance. Despite support from international organizations, the reform process was hampered by economic difficulties, inter-ethnic conflict, and the conflict with Greece regarding North Macedonia. As highlighted in the chapter, the main healthcare challenges have been to ensure the insurance system’s fiscal solvency, the conversion of primary care provision from local public health centers into private practices, and, since 2012, the integration of higher level private hospital services into the public system in order to reduce out-of-pocket payments and ensure equal geographical access.

PRAVILA EUROPSKE UNIJE O TRŽIŠNOM NATJECANJU I DRŽAVNIM POTPORAMA I DOPUNSKO ZDRAVSTVENO OSIGURANJE U REPUBLICI HRVATSKOJ: KRIVO SRASTANJE?

Competition and state aid rules are not applicable to compulsory health insurance in the Republic of Croatia, since the latter does not constitute an economic activity as defined by EU law. On the other hand, complementary health insurance, as established in Croatia, constitutes an economic activity, due to the existence of real competition between undertakings. The illustrated situation with competition in complementary health insurance market allows for the statement that special rules applicable to Croatian Health Insurance Fund (HZZO) provide the latter with a privileged position when compared to its private competitors to whom these rules do not apply. Moreover, this privileged position is strengthened by the fact that HZZO, as a legal monopolist within the sphere of compulsory health insurance, utilizes respective infrastructure in the field of complementary health insurance, which enables it to reduce expenses to the detriment of its private competitors lacking such a privilege. A solution for the described situation could be for the state to establish a separate entity to provide complementary health insurance. This entity would have to provide open enrolment and community rating, regardless of age, sex or health of the insured persons. In order to prevent private competitors from jeopardising the exercise of service of general economic interest by taking over only the insured persons with a more favourable risk profile, a risk equalisation scheme would have to be set up. This would result in a transfer of funds from insurers with a favourable risk profile to those with an unfavourable risk profile on basis of objective and clear criteria, thereby making it possible for the latter to provide service to the higher-risk insured persons like the elderly and the ones with chronic illnesses. In this way, a balance between the necessity to provide a service of general economic interest to all insured persons, including those with a higher risk, and competition on the EU internal market, would be struck.

THE ROLE OF SELF-HELP IN PATIENTS SOLIDAR RESPONSIBILITY TO OWN HEALTH

Согласно Концепции Государственной программы улучшения здоровья населения на 2020-2025 годы в рамках дальнейшего внедрения системы ОСМС в РК одним из основных задач госудаства является повышение солидарной ответственности граждан за свое здоровье. Существующая солидарная ответственность должна побуждать пациентов развивать навыки самопомощи/самоменеджмента с целью лучшего управления собственным здоровьем. Цель исследования. Анализ роли самоменеджмента пациентов в системе солидарной ответственности за свое здоровье. Материал и методы. Данный обзор основывается на материалах ВОЗ и статей зарубежных и отечественных исследователей. Выводы. На сегодняшний день, в системе здравоохранения Казахстана одним из основных моментов является солидарная ответственность государства, пациента и работодателя. Ведь каждый гражданин должен принимать важные решения, которые оказывают существенное влияние на состояние его здоровья. Поэтому стратегии по повышению грамотности пациентов, их вовлеченность в процесс принятия решений и развитие самоменеджмента должны быть одними из фундаментальных стержней существующей системы ОСМС и политики здравоохранения. According to the Concept of the State Program for improving the health of the population for 2020-2025, as part of the further implementation of the compulsory health insurance system in the Republic of Kazakhstan, one of the main tasks of the state is to increase the joint responsibility of citizens for their health. The existing shared responsibility should encourage patients to develop self-help / self-management skills in order to better manage their own health. Purpose of the study. Analysis of the role of patients' self-management in the system of joint responsibility for their health. Material and methods. This review is based on WHO materials and articles of foreign and domestic researchers. Findings. Today, in the health care system of Kazakhstan, one of the main points is the joint responsibility of the state, the patient and the employer. After all, every citizen must make important decisions that have a significant impact on his health. Therefore, strategies to improve patient literacy, their involvement in the decision-making process and the development of self-management should be one of the fundamental pillars of the existing compulsory health insurance system and health policy.