Financing of the Program of state guarantees of free medical care: how to solve the deficit problem?

Introduction. The critical problem of Russian health care is the deficit of funding for the program of state-guaranteed medical care for citizens of Russia. Purpose of the study. To search for solutions to the problem of financing the deficit of the program of state guarantees of free medical care in the Russian Federation. Material and methods. Retrospective data analysis was carried out to analyse the reasons for the deficit in the financing of the program of state guarantees of free medical care and search for solutions in the experience of other countries. Results. The analysis showed that the reasons for the deficit of the program of state guarantees of free medical care are the shortcomings of the mandatory health insurance (MHI) income system: linking contributions for the working population to the wages fund; the vagueness of the definition of the non-working population and the payment of contributions for its MHI by the constituent entities of the Russian Federation; non-participation of the solvent population in the co-financing of medical care; deficit of economic integration between the payment of MHI treatment and the health care system; the absence of formalized mechanisms for reimbursing the expenses of the MHI system by the federal budget to pay for aid in catastrophic situations. Discussion. The authors see the solution to the problem of the deficit of the program of state guarantees of free medical care in the modernization of the MHI income system: replacement of the MHI contributions paid by employers with an additional “medical” part of the value-added tax; replacement of the MHI contributions paid by the constituent entities of the Russian Federation for the non-working population with a targeted “medical” tax on retail sales; creation of a system of additional income based on the principle “the guilty person pays for causing harm to health”; recognition of the cost of medical care to the population in catastrophic situations as an unconditional obligation of the federal budget. Conclusion. a systemic solution to the problem of the financing deficit of the program of state guarantees of free medical care for the citizens of Russia seems to be the modernization of the MHI income system.

Price trends of reimbursed oncological drugs in Switzerland in 2005–2019: A descriptive analysis

Increasing oncological treatment costs are a major global concern with the risk of entailing two-tiered health care. Among cost determining factors is the price of individual drugs. In recognition of the central role of this factor, we present a comprehensive overview of the development of monthly prices of oncological drugs introduced over the last 15 years in Switzerland. We identified all oncological drugs newly reimbursed by mandatory health insurance in 2005–2019, and searched public repositories for their package prices, indications with approval dates, and treatment regimens for the calculation of (indication-specific) monthly prices. We found 81 products covering 77 different substances (39.5% protein kinase inhibitors, 21.0% monoclonal antibodies). Most indications related to the topography “blood”, followed by “lung and thorax” and “digestive tract”. From 2005–2009 to 2015–2019, the median monthly product price over all distinct indications of all products decreased by 7.56% (CHF 5,699 [interquartile range 4,483–7,321] to CHF 5,268 [4,19–6,967]), whereas it increased by 73.7% for monoclonal antibodies. In December 2019, six products had monthly prices over CHF 10,000, all approved for hematological or dermatological cancers. Our analysis suggests that individual price developments of oncological drugs are presently not the major driver of rising cancer treatment costs. However, rising launch prices of some new, mostly hematological drugs are of concern and require continued monitoring.

Switzerland

This chapter offers an in-depth look at health politics and the mandatory health insurance system in Switzerland. It traces the development of the Swiss healthcare system, characterized by the strong role of the cantons and private stakeholder organizations in managing the system as well as the reliance on voluntary private insurance for most of the twentieth century. Since 1994, when a law on mandatory health insurance was adopted, the main issues in Swiss healthcare politics have been increasing costs, managed competition, the introduction of case-based payment, and healthcare governance. Switzerland’s consociational political system, with its instruments of direct democracy, federalism, and corporatist interest representation, impedes the development of consensus across the left–right divide about whether the health system should rely more on market mechanisms and individual responsibility or on state control and universal coverage.

Potentially inappropriate medications and medication combinations before, during and after hospitalizations: an analysis of pathways and determinants in the Swiss healthcare setting

Background A hospitalization phase represents a challenge to medication safety especially for multimorbid patients as acute medical needs might interact with pre-existing medications or evoke adverse drug effects. This project aimed to examine the prevalence and risk factors of potentially inappropriate medications (PIMs) and medication combinations (PIMCs) in the context of hospitalizations. Methods Analyses are based on claims data of patients (≥65 years) with basic mandatory health insurance at the Helsana Group, and on data from the Hirslanden Swiss Hospital Group. We assessed PIMs and PIMCs of patients who were hospitalized in 2013 at three different time points (quarter prior, during, after hospitalization). PIMs were identified using the PRISCUS list, whereas PIMCs were derived from compendium.ch. Zero-inflated Poisson regression models were applied to determine risk factors of PIMs and PIMCs. Results Throughout the observation period, more than 80% of patients had at least one PIM, ranging from 49.7% in the pre-hospitalization, 53.6% in the hospitalization to 48.2% in the post-hospitalization period. PIMCs were found in 46.6% of patients prior to hospitalization, in 21.3% during hospitalization, and in 25.0% of patients after discharge. Additional medication prescriptions compared to the preceding period and increasing age were the main risk factors, whereas managed care was associated with a decrease in PIMs and PIMCs. Conclusion We conclude that a patient’s hospitalization offers the possibility to increase medication safety. Nevertheless, the prevalence of PIMs and PIMCs is relatively high in the study population. Therefore, our results indicate a need for interventions to increase medication safety in the Swiss healthcare setting.

Are weak or negative clinical recommendations associated with higher geographical variation in utilisation than strong or positive recommendations? Cross-sectional study of 24 healthcare services

ObjectivesWhen research evidence is lacking, patient and provider preferences, expected to vary geographically, might have a stronger role in clinical decisions. We investigated whether the strength or the direction of recommendation is associated with the degree of geographic variation in utilisation.DesignIn this cross-sectional study, we selected 24 services following a comprehensive approach. The strength and direction of recommendations were assessed in duplicate. Multilevel models were used to adjust for demographic and clinical characteristics and estimate unwarranted variation.SettingObservational study of claims to mandatory health insurance in Switzerland in 2014.ParticipantsEnrolees eligible for the 24 healthcare services.Primary outcome measuresThe variances of regional random effects, also expressed as median odds ratios (MOR). Services grouped by strength and direction of recommendations were compared with Welch’s t-test.ResultsThe sizes of the eligible populations ranged from 1992 to 409 960 patients. MOR ranged between 1.13 for aspirin in secondary prevention of myocardial infarction to 1.68 for minor surgical procedures performed in inpatient instead of outpatient settings. Services with weak recommendations had a negligibly higher variance and MOR (difference in means (95% CI) 0.03 (−0.06 to 0.11) and 0.05 (−0.11 to 0.21), respectively) compared with strong recommendations. Services with negative recommendations had a slightly higher variance and MOR (difference in means (95% CI) 0.07 (−0.03 to 0.18) and 0.14 (−0.06 to 0.34), respectively) compared with positive recommendations.ConclusionsIn this exploratory study, the geographical variation in the utilisation of services associated with strong vs weak and negative vs positive recommendations was not substantially different, although the difference was somewhat larger for negative vs positive recommendations. The relationships between the strength or direction of recommendations and the variation may be indirect or modified by other characteristics of services. As initiatives discouraging low-value care are gaining attention worldwide, these findings may inform future research in this area.

The advice they give: Knowledge transfer of international organisations in countries of the former Soviet Union

This article tests the assumptions of the literature regarding the neoliberal agenda (‘Washington Consensus’) promoted by international organisations through knowledge transfer and about the power they supposedly have through loan conditionality to impose their will on countries in financial need. In addition, it examines ‘avant-garde measures’ of neoliberal reforms exceeding the requirements from international organisations. Looking at the social policy concepts and advice these organisations give countries in the former Soviet Union, it utilises the example of healthcare reform in Kazakhstan, Kyrgyzstan and Russia. The article examines the general advice these organisations gave between 1991 and 2018 for the reorganisation and management of the countries’ healthcare systems, especially concerning the introduction of a mandatory health insurance system.

Education and training in clinical psychology and psychological psychotherapy in switzerland

Switzerland offers Education in Clinical Psychology in the German and French language and training in Psychotherapy in German, French and Italian. Both education and training are structured along centralized guidelines and recognized at a federal level. After finishing one’s studies, becoming a Psychological Psychotherapist requires between two and six years of postgraduate training and a financial investment of tens of thousands of Swiss Francs. Historically, it is quite common for Swiss psychotherapy trainings to incorporate a mix or combination of several psychotherapy schools such as cognitive behavioral, psychodynamic, systemic and humanistic. Foreign degrees obtained in EU countries are generally recognized, and the fulfillment of criteria is evaluated on an individual basis. Graduates find a diverse job market with opportunities to work in clinics and psychotherapeutical practices, but the absence of direct reimbursement via mandatory health insurance plans for psychological psychotherapists (not psychiatrists) lead many to work on patients’ private payments or as a psychiatrist’s employee. The ordering model, a potential new regulation allowing for the direct reimbursement of psychological psychotherapists’ work, is planned to be decided upon throughout 2020.

SOCIAL INSURANCE IN RUSSIA: STATE, CURRENT CHALLENGES AND RESPONSES TO THEM

The article deals with the issues of functioning of the social insurance institution, the organizational-legal and financial forms of which are presented by the state extrabudgetary social funds - Pension Fund of Russia, Mandatory Social Insurance Fund and Mandatory Health Insurance Fund. It considers the main characteristics of social insurance: a) scope of covering the employed population by insurance protection; b) contribution rates as related to wages; c) level of protection of population incomes (pensions and benefits as related to wages and subsistence minimum); d) availability of quality medical assistance and rehabilitation services. There are analyzed the present social risks and problems of the RF insurance system. The main problem is that the amount of financial expenditures on all types of social insurance per beneficiary is about half that of most developed and developing countries. The primary cause is lacking motivation of both employees and employers to participate in the mandatory social insurance and to legalize their earnings. In the conclusion there are formulated a number of proposals for improvement of the institution of social insurance in Russia. It is proposed to expand the range of insurance cases concerning unemployment insurance and care for elderly people, to increase the total amount of compulsory contributions to extrabudgetary insurance funds from 30.2% up to 42.5% from three sources - employees, employers and the state.