Mandatory Medical Insurance Research Articles

Primary healthcare services' accessibility and quality under compulsory social health insurance in Kazakhstan.

Between 2020 and 2022, there was a rise in employment and entrepreneurial activity, despite some unemployment growth. In the Compulsory Social Health Insurance (CSHI), insured individuals, especially privileged and wage workers, increased. However, certain contributors, like those exempt from contributions and single social taxpayers, decreased, possibly due to legislative changes or the economic climate. The study aimed to evaluate the effectiveness and accessibility of medical services within the frameworks of Compulsory Social Health Insurance and the state Guaranteed volume of free medical care based on data regarding waiting times and the volume of services provided. This retrospective study analyzed data from 2020 to 2022 on patients receiving care under Kazakhstan's Mandatory Social Medical Insurance System (MSMIS) and Guaranteed Volume of Free Medical Care. Data included insurance status, labor market indicators, and medical service procurement. Descriptive statistics were calculated, and t-tests, with p-values indicating statistical significance (p < 0.05). It has been identified that overall, the execution of the plan for all types of medical care in Kazakhstan, including Almaty, reaches 100.0%, indicating sufficient financial support for the healthcare system. Rehabilitation centers and COVID-19 testing services stand out with shorter waiting times, whereas comprehensive diagnostic and advisory services require significantly longer waiting periods. The Guaranteed Volume of Free Medical Care typically offers a greater number of services with shorter waiting times compared to MSMIS, except for specialized medical care services in diagnosing new formations, where the Guaranteed Volume of Free Medical Care also has shorter waiting times but provides a greater number of services. The study has allowed us to identify differences in the availability and volume of medical services provided between Compulsory Social Health Insurance and the state Guaranteed volume of free medical care.

The analysis of need in medical care of elder able-bodied women with diseases of blood circulation system

The purpose of the study is to analyze demand in medical care at diseases of circulatory system in women in age groups of 50-64 years old. The database of cases of medical care support of population age groups 50-64 years (the database of calls of Territorial Foundation of Mandatory Medical Insurance of the Moscow region) was used as primary information source. After correlation analysis of dependencies between indicators of demand in modeling, four indicators were left, three of them were volumetric and one frequency. Three blocks were used as basic causes included in Class IX "Diseases of the circulatory system" (ICD-10 version 2014-2016): 1. I10-I15 (Hypertensive diseases [Diseases characterized by high blood pressure]); 2. I20-I25 (Coronary heart disease); 3. I60-I69 (Cerebrovascular diseases). The study demonstrated that dynamics of frequency and volume indicators of medical care demand among women in age groups of 50-64 years testifies that in age range of 50-60 years there is linear or close to linear increase of demand, after which trend of increasing demand changed to downward one. The data obtained testify that age (as variable) explains considerable proportion of all fluctuations of volume of medical care in demand in women of 50-64 years. This result can be considered quite satisfactory for applying proposed model in planning volumes of medical care. It is noted that decreasing of demand increase rate is observed at age of termination of employment of majority of female population.

ԱՌՈՂՋՈՒԹՅԱՆ ՀԱՄԱՊԱՐՓԱԿ ԱՊԱՀՈՎԱԳՐՈՒԹՅԱՆ ՀԱՄԱԿԱՐԳԻ ԱԶԴԵՑՈՒԹՅՈՒՆՆԵՐԸ ՀՀ ԲՆԱԿՉՈՒԹՅԱՆ ԵԿԱՄՈՒՏՆԵՐԻ ՆԵՐԱՌԱԿԱՆ ԲԱՇԽՄԱՆ ՈՒ ԱՆՀԱՎԱՍԱՐՈՒԹՅԱՆ ՀԱՂԹԱՀԱՐՄԱՆ ՀԱՄԱՏԵՔՍՏՈՒՄ / THE EFFECTS OF THE UNIVERSAL HEALTH INSURANCE SYSTEM IN THE CONTEXT OF INCLUSIVE DISTRIBUTION OF INCOME OF THE RA POPULATION AND OVERCOMING INEQUALITY

The purpose of the article is to discuss the possible social consequences of the implementation of the universal health coverage (UHC) system in the Republic of Armenia from the point of view of ensuring inclusiveness and to evaluate their possible effects on the incomes of different strata of the population. The problems of the research are related to the study of the issues of both quantitative and qualitative assessment of the effects caused by the introduction of UHC and the development of relevant recommendations for reforms in that context. During the research, statistical, inductive and deductive, analytical, simulation analysis methods were used. According to the results of the research, the introduction of UHC in the form proposed by the draft law will significantly increase the tax burden of taxpayers included in the lowest income groups of the population, in some cases even reaching up to the entire income. Within the framework of the research, it was substantiated that the Gini coefficient of income inequality before taxation in the Republic of Armenia is 0.5724, after taxation, taking into account only income tax, 0.5722, with the effects of other regressive components of labor taxation: social and stamp fees, 0.5911. And here, if we take into account the impact of the introduction of the Universal health coverage rate, the Gini coefficient after taxation will be 0.6088, which means that the inequality from the viewpoint of income distribution will be deepened even more with the introduction of this framework of the system. In order to solve the problems, identified within the framework of the research, it is proposed to introduce a progressive scale of mandatory medical insurance premiums, as well as to provide somewhat different mechanisms of state copayments (subsidies) for socially vulnerable and low-income groups of the population.

COMPOSITION OF SOCIAL INSURANCE COSTS AND GUIDELINES FOR EFFECTIVE USE

The article explores the financial analysis of Uzbekistan's social insurance system, encompassing economic-statistical analyses of different social insurance types and the results of pension and allowance disbursement software. It discusses the rise in recipients of social benefits and material assistance for low-income families, along with their financial sources. The implementation of the social insurance system necessitates financial resources, making social funds integral to economic mechanisms for income redistribution. These funds, whether state or non-state, depend on factors like the national economic development model. Acknowledging their role in financial relations, social funds have a specific financial purpose, crucial in priority areas. Ongoing research focuses on effective organization and financing of the social protection system, emphasizing the development of voluntary and mandatory medical insurance, improving unemployment benefit procedures, and enhancing pension system stability. Recent initiatives in Uzbekistan include the revision of pension procedures, fundamental pension system reform, laws on compulsory health insurance, and the development of the "Law on Social Insurance." Scientific research aims to strengthen social protection for specific groups and enhance the existing social insurance system.

AVAILABILITY OF MEDICINES AS A RESULT OF REIMBURSEMENT MECHANISMS AND MEDICAL INSURANCE IS AN ISSUE FOR DISCUSSION

Availability of medicines, their quantity, quality, and appropriate documentation organization regarding distribution, storage, and sales – is one of the priority tasks of the healthcare system of each country. In European Union countries, a significant portion of expenditures for ensuring pharmaceutical supplies is covered by the state, implementing the principle of equal access of the population to effective medicines at an affordable price, which underlies the mechanisms of pricing and reimbursement. To achieve these goals, requirements are outlined in Directive 89/105/EEC of December 21, 1989, «On the transparency of measures regulating the pricing of medicinal products for human use and their inclusion in the system of national health insurance», aimed at promoting the development of the pharmaceutical industry both in the direction of developing expensive innovative drugs and in providing patients with quality generics. Thus, the main mechanism for ensuring the availability of medicinal products and medical devices for the population is the reimbursement program – the complete or partial refunding to entities engaged in retail trade of medicinal products, of the cost of medicinal products or medical devices dispensed to patients based on prescriptions, at the expense of the State Budget of Ukraine. The main objective of regulatory activities remains comprehensive regulation. Individual healthcare questions, including the provision of medicinal products, have been explored in the works of Yu. Bytiak, V. Kolpakov, R. Maidanyk, O. Myronets, I. Seniuta and others. The purpose of this publication is to review the normative and legal regulation of the reimbursement mechanism and practical implementation issues. Different countries establish their own reimbursement mechanisms, which vary in terms of funding sources, reimbursement conditions, price regulation methods, selection criteria for medicinal products, and key nosologies for treatment. The recipients of such systems may include socially vulnerable segments of the population, individuals suffering from severe or chronic illnesses, as well as various types of pharmaceutical assistance such as inpatient and outpatient care. Depending on the specifics of healthcare systems in different countries, different compensation mechanisms may be used. For example, this may involve the reimbursement of the cost of medicines for insured individuals, where the patient’s treatment expenses are covered by the insurance company or compensated to pharmacy establishments, with settlements being made between the insurance fund, healthcare facility, and pharmacy based on contracts. In Ukraine, in the absence of a mandatory medical insurance system, the reimbursement process operates in the form of the state program «Accessible Medicines», where the state compensates pharmacy establishments for the full or partial cost of medicines from the respective list.

Парадигма розвитку медичного права в Україні

The article formulates the paradigm of the development of medical law in Ukraine, and also considers the constituent elements that form it. We believe that the legal relations included in the subject of medical law should be divided into two groups. The first group is represented by those relations that arise during the implementation of medical activities in the process of providing medical assistance. That is, the relationship between the doctor and the patient during the implementation of the first diagnostic, treatment and preventive measures. We believe that they are the basis of relations in the field of medicine. The second group of relations includes relations related to the provision of medical care, in particular, in the field of internal organization of the provision of medical services, mandatory medical insurance, control and supervision in the field of health care, licensing and accreditation of medical organizations, etc. We propose to call such relations organizational and legal in the field of medicine, since they are the basis of the emergence of relations in the process of implementing medical activities regarding the provision of medical assistance and ensure its quality provision. It is proved that medical law is an independent complex branch of law, which was formed on the border of profiling branches of law (which, in our opinion, are civil, administrative law, social security law), the subject of which is social relations that arise in the process of implementing medical activities in relation to provision of medical care and organizational and legal relations in the field of medicine. Their legal regulation is based on the combined (imperative-dispositive method). Thus, awareness of the independent sectoral affiliation of medical law will contribute to its further development, improvement of legal regulation of individual sectoral institutes, introduction of new mechanisms of protection and protection of the rights and interests of subjects in the field of health care.

MEDICAL INSURANCE DURING THE STATE OF MARTIAL IN UKRAINE: A PRACTICAL IMPLEMENTATION

The organization of the healthcare sector in every country aims to provide the widest possible access to quality medical services for a broad range of citizens. A widespread practice globally is the involvement of citizens or potential patients through an insurance system. Changes initiated during the healthcare reform in 2017 have launched the development of insurance medicine processes. The fact of military invasion in Ukraine, stagnation in the country’s economic sector, and new needs in the field of medical services once again correlate with the vector of development of medical insurance and the functioning of the healthcare sector as a whole. The state of martial in Ukraine has altered the principles of the insurance system’s operation in the country and changed the provision of medical services for certain categories of citizens. The article provides an analysis of the changes in Ukraine’s regulatory framework that ensure the functioning of various types of health insurance in the healthcare sector. It highlights the existing problems with the provision of medical services related to Russian aggression and the imposition of martial law in Ukraine. The changes in the procedure for providing medical assistance under voluntary insurance contracts and in the field of mandatory solidarity health insurance under the medical guarantees program are analyzed. War is defined as a «force majeure», which is always stipulated in insurance contracts. This clause may be the basis for postponing the performance of an obligation without accruing penalties or fines, but it does not release from obligations under the contract. Insurance contracts remain in effect regardless of the state of war. War risks are not covered (except in cases of specific policies that exist but are very expensive and exceptional), and areas of military operations and temporarily occupied territories are excluded from the coverage zone. One of the problematic issues without a precise legal definition is the question of online medical consultation. The challenges of wartime create new types of relationships in the field of medical insurance, requiring a prompt response from the state and the preservation of the principles of universality, accessibility, and quality of medical services. The absence of a Law on Medical Insurance, a list of individuals who can be subject to mandatory medical insurance, and the absence of insurance for professional risks of medical workers, combined with the economic problems of the insurance market caused by the actions of the Russian Federation during the war, create new problems for private sector insurers. The share of insurance companies’ decreases and the National Health Service remains the main insurer. This article is the result of an analysis of the processes and mechanisms for providing medical services within the framework of voluntary and solidarity-based health insurance during wartime, as well as the changes that require a prompt response from the legal system.

НАПРЯМКИ РОЗВИТКУ МЕДИЧНОГО СТРАХУВАННЯ В СИСТЕМІ НАЦІОНАЛЬНОЇ ЕКОНОМІКИ КРАЇНИ

The article examines modern theoretical and practical features of insurance and defines its role and functions in the economy of the state; the place of health insurance in the financing system of the state economy is revealed; a conceptual approach to the organization of health care financing on the basis of medical insurance was developed; analyzed the qualitative and quantitative signs of effective financial support of the healthcare industry by determining the level of its financing in Ukraine; the role of voluntary health insurance as an element of financing the state economy is assessed; the impact of socio-economic factors on the financial potential of the social insurance market is investigated. The degree of development of insurance is an indicator of the maturity of market relations. A well-established insurance system contributes to business development and solving social problems. A conceptual approach to the organization of health care financing based on medical insurance has been introduced, which is complemented by a methodical approach to determining the financial potential of the health insurance market, a mechanism for building an optimal health care financing model, and the stages of implementation of this mechanism, which will contribute to the development of additional sources of financing economy of the state to ensure effective social protection. interests of the population. The model of financing the health care industry based on medical insurance was substantiated, taking into account the key functions of the financial system of the state; a methodical approach to establishing the optimal size of the insurance contribution in the mandatory health insurance system using simulation modeling is proposed; a scientific and methodological approach to the formation of mechanisms for the effective development of medical insurance in the financing system of the country's economy was developed in order to ensure the restoration of its health and working capacity by means of the guarantee and availability of medical services within the framework of mandatory medical insurance and voluntary medical insurance, which complements these guarantees.

Вирусный гепатит С в эпоху элиминации: выбор терапевтических схем с учетом фармакоэкономики на примере Ленинградской области

Objective. To characterize the dynamics of the epidemic situation of chronic hepatitis C (HCV) in the Leningrad region (LR) for the period 2015–2022 and establish the most promising for therapy in LR schemes. Materials and methods. The data of Form No 2, the Federal Register of Patients with viral hepatitis, the Reference Center for Monitoring Viral Hepatitis, the chief freelance specialist in infectious diseases of the LO were used. To assess the effectiveness of various tactics of HCV therapy, the method of pharmacoeconomical analysis – "cost-effectiveness" was used. As a criterion for evaluating the economic effectiveness of therapy, the cost of one cured patient was shown, calculated according to the formula: the cost of one cured patient = the cost of the course / the effectiveness of the regimen. Results. Based on the cost-effectiveness analysis, it was revealed that in patients with HCV genotype 3, it is advisable to use pangenotype schemes, and patients with HCV Gt1b can be effectively treated with genotype-specific combinations. Stable positive dynamics in the main epidemiological indicators (morbidity, mortality, cumulative number, coverage of therapy) HCV is not traceable in the LO. Following the draft passport of the strategy to combat HCV and based on the cumulative number of patients in the LO, by 2025 It is necessary to cover more than 4,000 people with therapy, primarily about 1,700 patients with a late stage of the disease (F3–F4). In the LO, persons with the 3 genotype of the virus (48%), requiring the use of pangenotype regimens and with the 1b genotype (41%), who are able to be treated with genotype-specific schemes, predominate. Conclusion. In order to achieve the goal of elimination in the LO, it is necessary to increase screening. To improve the quality of examination of patients with HCV (PCR, genotyping, elastometry, etc.), it is necessary to develop and implement an outpatient diagnostic tariff of Mandatory Medical Insurance. Key words: Leningrad region, chronic hepatitis C, direct antiviral drugs, pangenotypic schemes, genotype-specific schemes, pharmacoeconomical analysis

The analysis of human resources of medical workers by profile "Stomatology" providing out-patient medical care to population of megalopolis within the framework of mandatory medical insurance

The statistical report for 2017-2020 demonstrated that in outpatient conditions of multidisciplinary dental clinic providing services under compulsory medical insurance of population of megalopolis, there is increase in the number of physicians of the analyzed profile up to 304.5% and paramedical personnel up to 256.3% at the expense of young personnel. The direct relationship between increasing of the number of top- and middle-level dentists and quality of medical care provided within the framework of compulsory medical insurance was established.

The importance of the system of obligatory medical insurance in improving the availability and quality of cancer care in the Chelyabinsk region

Reducing mortality from major chronic non-communicable diseases is a priority direction for the development of the healthcare system. At the state level, the task has been set to combat oncological diseases as one of the main causes of mortality of the population. Rational and sufficient financial provision of oncological care at the expense of mandatory medical insurance largely determines the use of modern medicines, effective treatment regimens and compliance with the established deadlines for providing medical care to patients.The purpose of the work is to this study analyzes the volume and quality of cancer care and its financing in the Chelyabinsk region on the basis of information from the regional foundation of obligatory medical insurance.Materials and methods: personalized accounting of insured persons, analytical reports, tables, databases, financial and methodological documents in the field of obligatory medical insurance. In the course of the research, the following scientific methods were used: system analysis, comparing, generalization.The results of the study show that the modernization of the approach to financial provision of oncological care in the Chelyabinsk region has increased its availability and quality for the population. The development of medical science in the field of oncology follows the path of targeting therapy, which makes it possible to successfully treat patients for whom standard treatment methods are ineffective, and allows finding ways to correct the identified pathology.Сonclusion: the development of the pharmaceutical market leads to the emergence of new, often expensive, medicines. In this regard, we can only expect a further increase in the need for chemotherapeutic drugs and, as a result, an increase in costs. In this regard, the improvement of the drug supply system, including obligatory medical insurance, is one of the priority areas in ensuring the availability and quality of medical care.

Our experience of regulatory justification of using donor material for keratoplastic operations in the Udmurt Republic

Purpose: to share our experience of regulatory justification to supervisory authorities of performing keratoplastic operations using native donor cornea.Methods. A comprehensive analysis of legal and regulatory framework of the Russian Federation on transplantation.Results. The Nomenclature of Medical Services includes several types of services which contain the word “transplantation” in their names. However, not all of them require a license to perform such procedures as “surgery (organ and (or) tissue transplantation)”. The procedure for providing medical care in “surgery (transplantation of organs and (or) human tissues)” is not applicable to the “ophthalmology” profile, since the equipment and staffing requirements contained therein are not necessary to perform keratoplasty. The list of medical organizations of the subjects of the Russian Federation performing transplantation of human organs and (or) tissues contains no medical organizations of the ophthalmological profile. According to methodological recommendations on ways to pay for medical care at the expense of mandatory medical insurance, keratoplasty is classified as “st21.005. Operations on the organ of vision”.Conclusion. A comprehensive analysis of existing regulatory documents demonstrates that keratoplasty is exclusively related to ophthalmology, it can be performed if there is a license for ophthalmology, transportation of human organs and (or) tissues for transplantation. A healthcare organization also needs to hold a license for removal and storage of human organs and (or) tissues for transplantation. However, if any healthcare organization in the region has such a license, it may donate a donor cornea to an ophthalmological hospital if the latter does not hold such a license.

The organizational legal forms of noncommercial organizations in health care of The Russian Federation.

One of the goals of development of health care system is to increase availability and quality of medical care of population. To achieve this goal is possible by continuous improvement of health care system, search of new solutions to assigned tasks, development of medical care of population. Over the past 20 years, health care system of the Russian Federation underwent a number of significant changes. In the Strategy of Development of Health Care of the Russian Federation for the Long-Term Period 2015-2030 it is noted that to achieve highest possible level of development of health care with coordinated application of all national resources it is necessary to form health care system that integrates all medical services and organizations, regardless of their form of ownership and affiliation. This system is to function within single regulatory and legal framework (uniform requirements for quality and availability of medical care, qualifications of medical personnel, etc.), as well as uniform state, expert and public control. In this regard the study of prospects of using in health care of various organizational and legal forms of noncommercial organizations that contribute to formation of competitive environment in the industry, is of particular relevance, which should also affect quality of medical care provided. The article considers prospects for development of those organizational and legal forms of noncommercial organizations that are already functioning in health care system: state budgetary health care institutions, state autonomous health care institutions, autonomous noncommercial organizations, private institutions. According to the Federal Foundation of Mandatory Medical Insurance Register of medical organizations, on June 2021 about half of medical organizations in the Russian Federation are registered as budgetary organizations. Accordingly, predominant organizational and legal form is budgetary institution, which makes up to 55% of all medical organizations of various organizational and legal forms involved into mandatory medical insurance system. The percentage of state autonomous institutions comes to 8%, private healthcare institutions - 2%. The percentage of autonomous noncommercial organizations comes to 0.4%. The perspectives of development of each of these organizational and legal forms in health care system are analyzed in the article.

The analysis of attitude of patients to rendering of paid medical services in municipal polyclinic.

In modern society conditions, particular importance is attached to implementation of concept of relationship marketing in organization of provision of medical services. At that, implementation of marketing approaches in interaction between physician and patient, as well as between patient and administrators of department of paid medical services as primary link of contact "patient - medical institution" is of great importance. Purpose of the study is to develop portrait of consumer of paid medical services in state budgetary medical institution. The method of continuous questioning was implemented in study during 2015-2018. The sampling included 343 respondents. The survey demonstrated that main consumers of paid medical services in Moscow budgetary medical institutions are individuals of able-bodied age, married and with income per family member from 10 to 30 thousand rubles per month. Most of respondents are satisfied with quality of paid medical services. According to survey results concerning patients preferences of various forms of participation in paying for medical services, official payment to cashier was the most preferable form (45% of respondents), 73% of respondents noted their positive attitude towards paid medical services in municipal polyclinics and 61% noted that availability of paid medical services in state budgetary medical institutions helps to more fully implement right of citizen to medical care, provided that they are not included in mandatory medical insurance program. The high level of patient satisfaction with provision of paid medical services was revealed for following aspects: competence and courtesy of physician, convenient location of medical institution. There is positive attitude of patients to availability of paid medical services that are not included in state program in territorial polyclinic, related to increasing of territorial accessibility when receiving them at relatively low cost.

The activity of noncommercial organizations providing medical social care to migrants in conditions of COVID-19.

The article considers actual topic concerning acquisition by migrant associations of certain importance in the public sphere of different countries. The analysis demonstrated that these public structures begin to act as actors of intersectorial cooperation within the framework of state policy in the fields of migration and health care. It is substantiated that various institutions of civil society remained in shadow of state and commercial structures for a long time. Only recently, Russian socially oriented noncommercial organizations acquired status of suppliers of social services, including medical social care of population. At that, they became a subject of cooperation in order to provide medical social care to population, which is provided not only to Russian citizens within the framework of mandatory medical insurance, but also to migrants. It is proved that during the pandemic, many noncommercial organizations expanded scope of cooperation with government, business and public structures of medical and social profile. Some noncommercial organizations that were originally organized as associations of migrants and had character of diasporas are now legitimate NGOs. Such organizational and functional changes can be interpreted as a result of development in the field of care of migrants and their integration into the Russian noncommercial sector. As a consequence of transnational commitment of migrants themselves and their interest in development of their native countries. Also, as a result of institutional integration, and consequence of spreading of COVID-19 and intensification of need in medical and social care to countrymen and their families. It is concluded that institutional changes allow NGOs to establish more open relations with associations of migrants of various origins, as well as to attract additional resources for planning, financing and implementing projects that are strategically important both for survival of organizations themselves and for helping migrants in pandemic conditions.

The development of mechanism of participation of private clinics in the mandatory medical insurance system

The article considers actual aspects of participation of private clinics in implementation of territorial program of mandatory medical insurance from position of development of mechanism of interaction at micro-level. The principles of public-private partnership are gaining more popularity in social sphere, especially in health care. In Russia, private clinics developed their own motives to participate in implementation of territorial program of mandatory medical insurance, but mechanism itself is not always elaborated considering regional characteristics. Therefore, medical organizations encounter problems concerning implementation of mechanism of public-private partnership: application deadline, normative legal base, positioning of executive and regulatory authorities, etc. The situation is aggravated by lacking of municipal health care departments in region that could inform private business about its corresponding rights and obligations. The problems of implementing public-private partnership are analyzed and mechanism of participation of private clinics in implementation of program of mandatory medical insurance (as exemplified by the Krasnodar Kray). The study permitted to determine detailed algorithm of participation of private medical organizations in program of mandatory medical insurance. The study results permitted to scope regional features of development of interaction between state and business.

Priority areas for improving the efficiency of the functioning of mandatory medical insurance funds in Russia

Priority areas for improving the efficiency of the functioning of mandatory medical insurance funds in Russia

Медико-экономическое обоснование применения микроперкутанной нефролитотрипсии в клинической практике

Introduction. Percutaneous nephrolithotripsy (PNL) is traditionally used in the surgical treatment of patients with kidney stones. The use of retrograde intrarenal surgery using a flexible endoscope (RIRS) and micropercutaneous nephrolithotripsy (micro PNL) in the treatment of kidney stones with a diameter of 10-15 mm allows minimizin renal bleeding and reducing the period of hospitalization of the patient. Despite the development of urolithiasis treatment methods, the results of a comparative study of the medical and economic aspects of various surgical options for kidney stones treatment were not described. Materials and methods. We carried out a retrospective analysis of 654 cases of PNL and RIRS for the period of 2015-2019. We analyzed the results of surgical and medical material costs in 15 patients whom micro PNL was done according to the standard protocol. All patients underwent an assessment of the blood hemoglobin level and the frequency of complications according to Clavien-Dindo classification, as well as a control examination to exclude residual stones was done. Results. According to the data of the planning and economic service of healthcare institutions, the costs under the mandatory medical insurance tariff for RIRS and PNL amounted to 47,743.10 rubles and 71,300.00 rubles, respectively, without differences in hardware. The cost of endoscopes used for RIRS and PNL differed significantly (1,045,185. 00 rubles and 886,203. 00 rubles, respectively). Taking into account labor costs and general anesthesia, the cost of surgical treatment of kidney stone in PNL increased by 7,429. 78 rubles (74.9%). For fragmentation of the stone with micro PNL, a thulium or YAG laser was used, without nephrostomic drainage. The duration of the PNL was longer-on average 113 minutes (62-186 minutes), than with micro PNL – on average 83 minutes (42-122 minutes,). After micro PNL, there was a slight decrease in the level of hemoglobin and a minimal degree of complications (I-II Grade Clavien-Dindo), compared with PNL. The transition to the RIRS was required in three cases: during the mobilization of the migration of the stone into the middle calyx and during the removal of residual fragments of the upper and lower calyx. The duration of hospitalization of patients decreased after micro PNL to 2 days. Conclusions. Micro PNL for small (up to 2 cm) kidney stones treatment is more advantageous compared to traditional PNL in a number of positions: less the duration of the operation, reduced blood loss, lack of drainage, reduced costs for hospital observation of the patient. From a medical and economic point of view, the RIRS is the most preferable, but it requires initially large costs for the purchase of flexible endoscopes with a small working resource and a relatively high cost. The development of surgical equipment and production capacities, as well as the accumulation of clinical experience of micro PNL will allow us fairly assess the feasibility of this technique with a personalized approach.

The economic analysis of provision of medical services via medical insurance in Russia

The article demonstrates that the restrictions introduced during the coronavirus pandemic affected the dynamics of mutual settlements between the territorial funds of the mandatory medical insurance (MMI, TFMMI). According to the results of the first nine months of 2020, medical institutions of a number of subjects were not able to earn even a half of the amount of sum that was presented for payment in 2019 on medical care support of patients from other regions. It was established that besides such relevant features of the Russian health care system as large territory, fragmentation of population, necessity to maintain a number of state medical institutions, there is also a number of factors that during the pandemic were most aggravated in those "weak" places in the MMI system that have been stagnating for a long time. Among them, insufficiently large listing of medical services covered by MMI, inability to provide medical services to all those in need due to shortage of equipment, working areas, qualified care, etc. It is noted that among the general trends of MMI, the Russian medical insurance system (not only that it is not a classical one), especially during the pandemic, is broken out of social insurance: two funds, structures, costs of informatization, etc. However, in Russia, even in such conditions, health care is funded through the MMI system up to 50%. The pandemic demonstrated that no private sector, no paid services, no commercial insurance companies can cover the whole spectrum of health care complicities during the pandemic crisis. Namely, the MMI system bore the brunt of the survival of medicine during the pandemic. It is concluded that namely the need in medical institutions with sufficient reserve of bed fund with MMI services can input into development of necessary stable basis for survival in difficult conditions of pandemic crisis. The proposal of the Audit Chamber of the Russian Federation of further reforming of the mandatory medical insurance system is considered reasonable and logical especially in difficult situation of struggle against COVID-19. The article also presents data concerning the state of MMI in 2020, at the height of the pandemic crisis in the regions of the Russian Federation.

ОБЕСПЕЧЕННОСТЬ РЕАБИЛИТАЦИОННЫМИ МЕРОПРИЯТИЯМИ ПАЦИЕНТОВ, ПЕРЕНЕСШИХ СЕРДЕЧНО-СОСУДИСТЫЕ КАТАСТРОФЫ, В АСТРАХАНСКОЙ ОБЛАСТИ

The relevance of the study is explained by the need to increase attention to the situation with acute cardiovascular diseases and the creation of an accessible system of medical rehabilitation for patients with cardiovascular diseases in the region. The aim of the study is to analyze the provision of rehabilitation measures for patients who have suffered cardiovascular accidents in the Astrakhan region. Materials and methods - based on the data of the annual reporting statistical forms No. 12 "Information on the number of diseases registered in patients living in the service area of the medical institution" and No. 14 "Information on the activities of the hospital", the calculation and analysis of indicators of general and primary morbidity was carried out ( on appeal), hospitalized morbidity, hospital mortality, the need for rehabilitation measures and their provision of adult patients aged 18 years and older with diseases of the circulatory system, including cardiovascular accidents in the Astrakhan region. Results and discussion - the article shows the general situation with the incidence of diseases of the circulatory system of the adult population, including acute coronary syndrome and acute cerebrovascular accident in dynamics from 2014 to 2020, discloses the organizational and structural aspects of the existing system of organizing rehabilitation care in the region. The results of assessing the satisfaction of the needs of the adult population of the region in neuro- and cardiac rehabilitation by medical organizations licensed for medical activities with an indication of the work (services) for medical rehabilitation and participating in the federal and territorial program of state guarantees of free provision of medical care to citizens in the region are presented. It was revealed that less than half of those in need receive medical rehabilitation assistance at the expense of the mandatory medical insurance fund. Proposals have been formulated to increase the availability of rehabilitation care for patients who have undergone cardiovascular accidents. Conclusion. The obtained research data can be used for further organizational, methodological and coordination work to provide modern medical and rehabilitation care to patients with acute cardiovascular accidents at the regional level.