Compulsory Health Insurance System Research Articles

Изменения в направлениях и предельных размерах использования средств обязательного медицинского страхования с 2024 года.

The economic independence of medical organizations as legal entities presupposes their right to determine the direction of their expenses. However, the targeted nature of compulsory health insurance funds imposes restrictions on the freedom to use the income received from the provision of medical care in the compulsory health insurance system. And although the legislation defines the structure of expenses (tariffs), limiting them to the framework of compulsory health insurance programs, in practice, attributing expenses to certain groups often presents great difficulties, accompanied by sanctions and lawsuits. In this regard, recent changes in the legislation on compulsory health insurance, which expand the possibilities of using funds, seem to be very significant. This is also facilitated by an increase in the marginal cost of purchased equipment from 100 to 400 thousand rubles. However, such opportunities are due to a large number of restrictions and reservations, which requires a more detailed analysis of new legislative norms and an assessment of their impact on the conditions of medical organizations, which determined the relevance of this publication.

Availability and quality of primary health care in the compulsory health insurance system in Kazakhstan

Availability and quality of primary health care in the compulsory health insurance system in Kazakhstan

Socio-economic burden of respiratory syncytial viral infection of the lower respiratory tract in children aged from birth to 5 years in the Russian Federation: modeling results

Background. Respiratory syncytial virus (RSV) is a common virus causing lower respiratory tract infections (LRTI), including acute bronchiolitis and pneumonia, in children in the first 5 years of life.Objective: to estimate the annual socio-economic burden for the Russian Federation (RF) due to RSV-LRTI in children aged under 5 years.Material and methods. Based on published results of meta-analysis of epidemiological data for RSV-induced infections, the annual number of RSV-LRTI cases, the number of hospitalizations, and associated lethal outcomes were calculated in the model for groups of children aged 0 – <12 months, 12 – <24 months, and 24 – 60 months. The costs of medical care were determined according to the current tariffs of the Compulsory Health Insurance system and published Russian data on the distribution of the number of RSV-LRTI cases by severity. The damage to gross domestic product (GDP) associated with fatalities was estimated taking into account life expectancy and employment.Results. According to the estimates, 397.2 thousand children aged under 5 years in the RF fall ill with RSV-LRTI during a year, including 44.6 thousand cases requiring hospitalization, and in 268 cases, the infection becomes lethal. Medical costs for treatment exceed 2.2 billion rubles, and the damage to GDP as a result of lethal outcomes reaches almost 10 billion rubles. The main damage is related to RSV-LRTI cases in children aged under 1 year, the share of which is over 50% among those hospitalized and over 70% among those who died.Conclusion. RSV significantly affects morbidity and mortality among children aged under 5 years. According to modeling data, it causes up to 3.5% of deaths in this age group, and the associated economic losses exceed 12.2 billion rubles, which justifies the need for RSV-LRTI immunoprophylaxis.

Государственно-частное партнерство в системе здравоохранения Хабаровского края

Relevance The tasks set for the healthcare system require the attraction of significant resources, primarily financial ones. Public-private partnership (hereinafter referred to as PPP) can become an effective tool for solving some of the tasks set, attract investments and become a serious inductor in the implementation of infrastructure projects, the construction of modern medical organizations. Some forms of PPP may make it possible to raise additional funds for the provision of medical care and the expansion of paid medical services. All this requires a more detailed scientific study of the forms of interaction between PPPs in the healthcare sector. Purpose and objectives of the study The purpose of the study is to increase the effectiveness of interaction between the state and business in the health care of Khabarovsk Krai by developing a set of measures using public-private partnership tools. The objectives of the study included the study of publications and the legal framework, the structure of financing in the system of compulsory health insurance, the study of the level of awareness and willingness to involve healthcare organizers of medical organizations in Khabarovsk Krai in PPP processes, as well as the study of infrastructure facilities subordinate to the Ministry of Health of Khabarovsk Krai. Materials and methods The study used data from open sources, including regulatory legal acts, publications and articles on PPP issues, studied open data from the territorial fund of compulsory medical insurance of Khabarovsk Krai, data from the unified state register of real estate. Also, a survey of health care organizers was conducted using a questionnaire specially designed for the study. Results A classification of public-private partnerships in healthcare has been developed, and the main forms of interaction have been identified. It was determined that from 2020 to 2022, funding for non-state medical organizations increased by 15 %: from 1.001.741.1 thousand rubles to 1.151.886.0 thousand rubles. There is a predominance of funding, including in 2022, of organizations of the Russian Railways system (627.552.0 thousand rubles), as well as organizations providing hemodialysis services (195.913.0 thousand rubles) and radiation diagnostics (219. 265.0 thousand rubles) PPP forms are actively used to solve social problems under the “Older Generation” program, funding for ophthalmology has been significantly increased, the dynamics compared to 2020 is +1975 %. According to the results of a survey of healthcare organizers, 2/3 of the respondents see development prospects, 44 % consider outsourcing to be the most promising, 26 % – concession agreements, 92 % indicate an insufficient level of awareness on PPP issues, 90 % expressed their willingness to take part in educational events. In total, the subordinate organizations of the Ministry of Health of Khabarovsk Krai have 1.369 premises and buildings, 419 (30.1 %) of them are used to provide the main function of medical organizations, and 950 are auxiliary. 187 (44.6 %) out of 419 have over 80 % wear and tear, need either reconstruction, major repairs, or are subject to demolition and construction of new facilities. Conclusion The results of the study allow us to fix the main parameters of the healthcare industry, determine ways for further improvement, and develop a set of measures for the development of public-private partnerships in healthcare. It is necessary to conduct an in-depth scientific study of PPP with the involvement of economists, specialists in the field of state and municipal administration, healthcare organizers, undergraduates and graduate students. A comprehensive comprehensive study will significantly increase the effectiveness of measures to develop public-private partnerships in Khabarovsk Krai.

Healthcare provider – effective guarantor of the realization of the rights of the insured person in the compulsory health insurance system

Medical services are an essential component of our modern society, with a direct impact on the health level of the population. Healthcare providers play a crucial role in this process, providing medical care, diagnosis and treatment for a variety of conditions.Healthcare providers are the main interface between insured persons and the compulsory health insurance system, and are responsible for providing quality medical care in accordance with the obligations established by normative acts. They also play an important role in managing public health issues such as epidemics and pandemics, being responsible for diagnosing, treating and monitoring infectious diseases and providing valuable information to the population.This scientific article highlights the main objectives and attributions of medical service providers wich are directly related to the insured person, without questioning the importance of pharmaceutical service providers. The reason was to not complicate the informational content of the article and reserve, this way, a research object for another scientific article. This article aims to systematize in a laconic form all types of medical service providers in the coun-try. We examined all types of medical service providers in the country and identified medical service providers with specific duties. However, the vast majority of providers have similar tasks and legal obligations, given that they have the same objective: ensuring the health of the population.

The diversity of legal relations within the compulsory health insurance system

The adoption and subsequent implementation of Law No. 1585 dated 27.02.1998, concerning compulsory health care insurance, have generated a series of legal relationships that were previously unfamiliar to the healthcare system of the Republic of Moldova. Given that every legal relationship follows a certain course – it is initiated, may undergo modifications and/or suspensions, and eventually concludes – the legal relationships arising from the compulsory medical insurance system follow the same logical trajectory. However, it is essential to mention that within the com-pulsory medical insurance system, there exists a diversity of legal relationships which, both structurally and in terms of content, can be entirely distinct. This article addresses this diversity of legal relationships, which simultaneously form an integral part of medical legal relationships but only encompass those individuals directly involved in the compulsory health care insurance system: the insured, the insured persons, the insurer, and, correspondingly, the providers and suppliers of services and goods within this intricate social framework.

Порядок и источники финансирования здравоохранения в субъектах Российской Федерации

Introduction. Currently, human rights to medical care and health protection in our country are regulated by the Constitution of the Russian Federation, federal laws and by-laws. And, accordingly, to realize these rights, the state needs to form, allocate and effectively spend a sufficient amount of financial resources. The purpose of the study is to analyze the procedure and sources of healthcare financing in the constituent entities of the Russian Federation. Methods. The analysis of modern scientific literature, as well as the regulatory framework on the procedure and sources of healthcare financing in the Russian Federation is carried out. For this purpose, the methods of bibliographic, informational and semantic search of sources in various databases are used. Results. The sources of financing the healthcare system in the Russian Federation are employers’ insurance premiums for Compulsory Health Insurance (CHI) of the working population, insurance premiums from the budgets of the constituent entities of the Russian Federation for CHI of the non-working population, as well as expenditures of regional budgets and inter-budgetary transfers. The CHI system is currently the main source of funding for the state healthcare system in the Russian Federation. Single-channel financing made it possible to increase the efficiency of the healthcare system and played a positive role during the pandemic, which allowed the system to compensate for epidemiological risks quite quickly, but currently there are problems that require the reform of the healthcare system. The disadvantages of the CHI system are the complexity of the medical care financing chain, as well as the problems of distributing the capacity of medical care between medical organizations within the framework of the territorial CHI program. From the standpoint of the objective situation of insufficient financing of healthcare in the Russian Federation, it is advisable not so much to increase financial resources as to increase the efficiency of the use of allocated funds, which requires the legislative consolidation of responsibility for their irrational use, as well as strengthening the state control of resources allocated to healthcare. Conclusions. The activities of the Compulsory Health Insurance system require strengthening public control measures.

Performance Indicator System for Medical Organizations: A Case of Moscow Polyclinics

Background. The performance assessment of medical organization’s activities has taken on great significance as the whole world tends to implement the model of value-based healthcare and the system of compulsory health insurance is focused on increasing the financial support of medical organizations.
 Purpose. To analyze methodological approaches and to design a performance indicator system for medical organizations.
 Materials and Methods. The author conducted the content analysis of research articles on the study topic published in the Russian Science Citation Index, and analyzed statistical and accounting data of Moscow polyclinics providing primary health care to the adult population from 2016 to 2021.
 Results. The author analyzed the methodological approaches of Russian researchers and practitioners to assessing the performance of medical organizations and to choosing the relevant performance indicators. Based on a thorough approach to selection, a set of performance assessment indicators was created by analyzing the performance of Moscow polyclinics providing primary health care to the adult population from 2016 to 2021. The recommendation is to use the developed indicator system for rating medical organizations in order to improve management process and to achieve desired outcomes.

카자흐스탄 의무의료보험제도 도입 과정 연구

In November 2015, Kazakhstan introduced the “Compulsory Social Health Insurance System (the System) in the social insurance format,” first among the Central Asian countries, including Russia. By introducing the system, the country shifted from the previous government-led medical insurance system that had originated from the era of the former Soviet Union to that in the “social insurance format.” Under the new system, every citizen pays health insurance premiums and bears the collective responsibility for public health. The process of introducing the System was quite abrupt, which was possible because Kazakhstan is an authoritative nation where the president of the country exerts enormous power. In this regard, this study alters and modifies Kingdon's multiple streams framework model, which is useful for analyzing such an abrupt process of policy change by period, and applies the revised version as the analysis framework. The analysis period was classified into three periods based on the national mood, the presence and direction of policies, etc. In addition, the intensity of the three streams(problems, politics and policies), and the extent of the policy entrepreneur’s role were set as the specific components of the analytical framework. As a result of the analysis, the policy change succeeds in the third period(Jan. 2014-Jan.2020). The results confirmed that when the aforementioned model is applied, policy entrepreneurs played the most important role in the policy change process in Kazakhstan for the introduction of the compulsory social health insurance system. Nazarbayev, a policy entrepreneur, first recognized the necessity of improving the public health budget indicators, which had been deteriorating since 2010, from the perspective of the flow of policy problems. Based on his realization, Nazarbayev tried to strengthen the country's financial soundness by resolving the identified policy problems and further, he intended to achieve the advancement and modernization of the country. Aggressive and enthusiastic efforts and firm and decisive willingness of the policy entrepreneur finally led to the successful policy change. Consequently, the System was established and implemented nationwide in Kazakhstan from January 2020, starting with partial implementation in July 2017.

Faktori koji utiču na razvoj dobrovoljnog zdravstvenog osiguranja u Republici Srbiji

Voluntary health insurance enables a higher level of healthcare services for users and provision of healthcare services not included in the compulsory health insurance system. One of the main advantages of further development and growth of voluntary health insurance in the Republic of Serbia is a significant reduction of expenses of citizens in the entire healthcare system. A key argument in favour of voluntary health insurance is that, in the context of limited public resources for healthcare, it can advance healthcare policy goals by easing fiscal pressure on the healthcare sector. The situation and trends in the real sector influence development of the insurance sector. In order to improve voluntary health insurance, it is necessary to establish cooperation within compulsory and voluntary health insurance, work on connecting state and private healthcare institutions, provide better promotion of services and influence the increase in health literacy of citizens. Better connection of private and public healthcare institutions, compulsory and voluntary health insurance, better promotion of service packages, better information provided to citizens about this type of health insurance, as well as increasing the standard of living, influence development of the basic factors of voluntary health insurance.

ОКАЗАНИЕ МЕДИЦИНСКОЙ ПОМОЩИ СВЕРХ УСТАНОВЛЕННОГО ОБЪЕМА: ВЫПОЛНЕНИЕ ОБЯЗАТЕЛЬСТВ ПО ДОГОВОРУ ОБЯЗАТЕЛЬНОГО МЕДИЦИНСКОГО СТРАХОВАНИЯ ИЛИ С ПАЦИЕНТОМ

Significance. The issue of medical care delivery in excess of the established volume, including by private health sector operating under compulsory health insurance remains a challenge to the medical community. The subject of the study, on the one hand, was the overview of the current situation regarding medical organizations that submit registers of bills and invoices for medical services provided to the insured under the territorial program and insurance medical organizations that refuse to reimburse services in excess of the established volumes. On the other hand, the inability of a medical organization to refuse to provide medical care to citizens who have applied for care. The purpose of the study was to analyze the normative and legal acts that regulate legal relations between participants and subjects of the compulsory health insurance, indicating impossibility or difficulties for the parties to fulfill their obligations to ensure care delivery to the insured under the compulsory health insurance program. Material and methods. Material and methods of the study included an analytical review aimed at studying and analyzing the legal policy, current legal practice, current situation regarding place in the medical service market, including the private health sector, in order to answer the research question. Results. The conducted analysis shows that the main function of medical organizations is to provide medical care to the insured. At the same time, territorial funds are responsible for providing medical care to the insured under the federal compulsory health insurance program, and are to create all conditions to ensure availability of services. The federal legislation does not make the provision of free medical care to a citizen under the compulsory health insurance program dependable upon the planned total volume of services and guarantees the provision of free medical care to the insured in the compulsory health insurance system. When the planned volumes of medical care under the program of compulsory health insurance do not correspond to the actual demand, the excess of these volumes provided by a medical organization cannot be attributed to the financial results of its performance. Conclusion. The foregoing confirms the conclusions that medical services provided in excess of the established volumes are to be considered as insured events and are subject to reimbursement in the stated amount. Accordingly, they cannot be a restriction to realizing the powers to provide medical care to citizens under the program of state guarantees in cases where the volume of medical services provided exceeds the planned one, envisaged by the compulsory health insurance contract. This position will help avoid risks, including reputational ones, and prevent the organizations from filing a lawsuit.

Informational aspects of improving the regulatory framework of compulsory medical insurance

Among the most significant reasons for the change in the regulatory legal framework of compulsory health insurance (CHI) should be recognized the emergence of new opportunities in the field of information processing, capable on the one hand to significantly increase the convenience and accessibility of medical care for citizens, on the other – to ensure transparency and efficiency of spending of the budget system of the Russ ian Federation, control over this by the state. Being at the intersection of healthcare and finance, CHI with the advent of new technologies has received a unique chance to radically simplify and optimize the procedures for financing healthcare, allow medical professionals to focus on providing medical care, minimize their participation in bureaucratic procedures.Changes in the approach to information processing in the compulsory health insurance system not only ensure the optimal use of public funds to improve the health and quality of life of citizens, but also stimulate changes in the processes themselves in the healthcare sector, providing new opportunities for the state, doctors and patients, rethinking the functions of participants in the compulsory health insurance system.

The first results of changes in the financing of federal centers in the system of compulsory health insurance on the example of the Bakulev National Medical Research Center for Cardiovascular Surgery

Until 2021, there were problems with the ability of citizens to receive medical care in organizations subordinate to federal authorities, especially those located in Moscow. Since 2021, the federal centers have been funded by the Federal Compulsory Health Insurance Fund (CHI).Goal. To study the impact of the new system of payment for specialized medical care under the CHI program on its volume in the A. N. Bakulev NMICSSH.Results. Number of outpatient consultations in the first half of 2021 has almost reached the level of 2019, despite the pandemic of a new coronavirus infection. The number of patients hospitalized for receiving high-tech medical care under the CHI program exceeded the indicator of 2019, for residents of the subjects of the Russian Federation, except Moscow, – for all types of specialized care.Discussion. In the regions, measures were taken to limit the referral of patients to medical institutions that are not subordinate to the region. The possibilities of federal clinics were not fully used, citizens were limited in the possibility of receiving timely highly qualified medical care, waiting for it in regional institutions. In the worst situation were federal medical organizations located in Moscow, where payment was carried out at the tariffs of Moscow, which are significantly higher than in the absolute majority of other subjects of the Russian Federation. In this connection, the regions faced the question of paying for medical care for 10 patients in “their” medical organizations or 6–7 patients in federal clinics in Moscow.Conclusion. The transition to the new system of payment for medical care in federal clinics directly from the Federal CHI Fund has significantly improved the implementation of citizens ‘ rights to choose a medical organization, reduced the waiting time for specialized, including high-tech, medical care, increased the efficiency of using the capabilities of federal centers both in terms of the use of modern technologies and personnel potential.

EE215 Pharmacoeconomic Analysis of Adjuvant Nivolumab for Patients With Resected Esophageal or Gastroesophageal Junction Cancer in Switzerland

Switzerland recently approved and reimbursed nivolumab as the first adjuvant treatment for patients with resected esophageal cancer (EC) or gastroesophageal junction cancer (GEJC). A phase 3 randomised controlled trial (CM577) comparing nivolumab with placebo in patients with resected EC or GEJC found that nivolumab was associated with 31% lower risk of recurrence or death and double the median disease-free survival compared with placebo. We evaluated the cost-utility of nivolumab compared with placebo from a Swiss compulsory health insurance system perspective.

Клинический случай акантамёбного кератита. Трудности диагностики и лечения

Acanthamoebic keratitis (AK) is a serious disease caused by the simplest acanthamoeba. Often it is associated with the wearing of contact lenses (CL) (80 –90 %). The article describes a clinical case of AK of both eyes associated with wearing soft contact lenses (MCL). The diagnosis was based on the patient's complaints, medical history and clinical presentation. Treatment was performed both topically and systemically and long-term follow-up on an outpatient basis. As a result, the active inflammatory process was stopped. Subsequently, in a calm period, the patient underwent through keratoplasty, reconstruction of the anterior chamber of the right eye. At the moment, the patient's vision allows him to lead a full life without any restrictions. Conclusions were drawn from this example: 1) determining the etiology of keratitis is extremely difficult; 2) CL users are obliged to know the risks and rules of wearing CL; 3) AK treatment is a long, difficult, not always successful and experimental process. The issue of patient routing and timely operative treatment under the compulsory health insurance system remains relevant. Keywords: аcantamoeba, acanthamoebic keratitis, clinical case, contact lenses, drug treatment

Ensuring the Financial Stability of the Compulsory Health Insurance System

The negative influence of environmental factors on the stability of the health care system necessitates the development of theoretical provisions and methodological basis for monitoring the stability of regional systems. One of the most important criteria for assessing the sustainability of the healthcare system in the Russian Federation is the indicator of the financial stability of the mandatory medical condition system, which assumes, first, the sufficiency of funding for medical care in accordance with its necessary dynamics. The results supported the author's ideas about the possibility of ensuring the financial stability of the regional health care system providing the required level of sustainability based on the sufficient funding through the Compulsory Health Insurance System.

Patient executive control (PEC) in the primary health care system on the example of idiopathic scoliosis in children

The publication highlights the concept of patient executive control (PEC) in pediatric and adolescent orthopedics, as well as the means of achieving it, which is proposed for use in the domestic health care system. The authors identified the key areas of modernization of primary care in the provision of orthopedic and traumatological care to children and adolescents with idiopathic scoliosis. Among them, a special place is occupied by the development and testing of checklists and scales for assessing the orthopedic status for primary care specialists, planning and implementation of a pilot project on early detection of pathology, prescribing and conducting conservative brace treatment in order to reduce the degree of scoliotic deformity of the spine in growing patients, clinical justification for the inclusion of compensation for the costs of implementing this treatment in the compulsory health insurance system (CHI).

Is the Russian system of compulsory health insurance an insurance one?

The subject of the article is a discussion of the grounds for qualifying the system of compulsory health insurance (CHI) created in Russia as an insurance system, which is questioned by many experts. The article sys tematizes theoretical and methodological approaches to the description of social health insurance systems. A comparative analysis of the evolution of national systems of compulsory health insurance and systems of budgetary financing of health care was carried out from the standpoint of considering institutional changes as strengthening or weakening three types of regulation (state, societal, private), which ensure the performance of the functions of revenue collection, pooling of funds, purchasing of services. On this basis, general characteristics of modern models of social health insurance, which distinguish them from budgetary systems, are highlighted. The Russian CHI system can be qualified as a social insurance system in terms of the formation and pooling of financial resources, but as a hybrid, combining elements of the insurance and budgetary systems, in terms of the purchase of medical care.

Improving the efficiency of the medicine provision system for patients with malignant neoplasms

Background. One of the priorities of health care is the balance between the financial resources and the availability of effective medical care. The current approach of access to cancer medicines limits the timeliness and availability of treatment. At the same time, financial support from the government provides great costs on cancer drugs. However, these great costs are not rational.Objective: to assess the financing needs of the complete transfer of financial support of medical care in the field of oncology to the Compulsory Health Insurance (CHI) system by means of optimizing the functions of the day hospital.Material and methods. The achievement of the goal is planned to be reached by eliminating the unusual functions of oncological day hospital. We analyzed the regulatory legal documents regulating drug care and drug provision in the Russian Federation, data from depersonalized (anonymized) registers of the structure of hospitalizations in a day hospital for 2021. The methods of expert assessments, mathematical modeling, as well as literature data analysis were used. The study developed a model for assessing the need to finance the full transfer of medicine provision to the CHI system, including taking into account the hidden deficit.Results. The total amount of funds released from the reduction of irrational hospitalizations in day hospital conditions amounted to 2.08% of the funding level of the analyzed schemes. Taking into account the data of hospitalizations in oncological day hospital for 2021, the number of irrational hospitalizations in case of transfer of selected schemes to the outpatient stage will decrease by 16.1%. The transfer of all the medicine therapy to financing from the CHI funds will require significant additional budget expenditures in the amount of 62.5 billion rubles or 2.65% of the total costs of the State Guarantees Program for Provision of Free Medical Care to Citizens.Conclusion. Despite the rationality of the proposed changes in the field of improving access to medicine provision concerning cancer drugs and the identified justifications for changing the distribution of financial resources within the State Guarantees Program, there are difficulties. In order to solve this problem, a coordinated consideration of potential strategies to address the access to cancer medicines is needed.

Public-private partnership in the system of compulsory health insurance: features and trends

Public-private partnership projects can act as a growth driver for healthcare both at the federal and regional levels. The inclusion of investment projects based on the principles of public-private partnership in the system of compulsory health insurance has a number of features. First of all, it is declarative in nature, and the volume of medical care is distributed by the commission at the regional level. There are discrepancies in the position of the relevant departments on the participation of public-private partnership projects in the system of compulsory health insurance, which brings dissonance to the industry and explains the reluctance of investors to participate in its development. While the Ministry of Health of the Russian Federation declares the “softening” of barriers to the integration of the private sector (concessions) into the public sector, the Mandatory Health Insurance Fund declares the need to stop including private medical organizations in the system of payment for compulsory health insurance. The exclusion of the private sector from financing through the compulsory health insurance system will in fact be equated on the part of the investor with the absence of any guarantees of profitability. Payment through the system of compulsory health insurance is not a mechanism that guarantees income, but the existing monopoly of the state in healthcare on the distribution of medical care creates a situation in which the amount of financial resources directly depends on the state authorities.