Mandatory Medical Insurance Research Articles

PND32 Out-of-Pocket Payments and Healthcare Resource Utilization in Patients with Episodic and Chronic Migraine in Moscow, Russia

According to an epidemiological study (Ayzenberg I. et al., 2012), the prevalence of migraine in Russia is over 20%. Generally, diagnostic procedures and hospital treatment of migraine patients are covered by the Mandatory Medical Insurance system, but out-patient medicines are not included into the insurance, and access to medical services is sometimes limited. Meanwhile, little data are available on the out-of-pocket payments of migraineurs in Russia. The aim of the study was the assessment of annual out-of-pocket payments and resource utilization in relation to the migraine severity in patients treated at a neurology clinic in Moscow.

ОБЗОР НАУЧНОЙ ЛИТЕРАТУРЫ И НОРМАТИВНОЙ ПРАВОВОЙ ДОКУМЕНТАЦИИ ПО ОРГАНИЗАЦИИ И ОПЛАТЕ СТОМАТОЛОГИЧЕСКОЙ ПОМОЩИ

The article presents a review of scientific domestic and foreign literature and regulatory legal documentation, which allowed to identify problems in the organization of and payment for dental care and to determine possible directions of scientific research on the stated topic. Dependence of availability of specialized dental care on the income level, limited availability and late medical assistance in the rural regions, measures to increase availability through use of the programs of preferential prosthetics are shown. The problems of low coverage of dental services by mandatory medical insurance programs are considered. The levels of provision of population of RF with medical care, methods and difficulties of payments to specialists, of use of conventional units of labor inputs, of correction factors for children and adults, the issues of standardization of primary dental care, ambiguous attitude to the classifier of basic medical dental procedures and technologies that changed the established principle of remuneration in dental practice, are described. The method of payment for primary dental care provided on an outpatient basis for a completed case of treatment in terms of cost of clinic-statistical groups, as well as the per capita principle of payment for outpatient dental care and the difficulties with its implementation within compulsory health insurance in most regions are considered. An important role of automation of the working place for filling the medical documents, of improvement of organizational and medical technologies with use of new materials and equipment, is indicated. Analysis of the scope of medical care demanded by the population within the programs of the state guarantees is given. An emphasis is placed on the priority of the development of the modern dentistry as governmental-private partnership in terms of high adaptation to the market conditions. A complex character of issues of prophylaxis, screening, improvement of organization of and payment for dental care is emphasized, salvation of which will permit to considerably improve the quality of medical care and to guarantee its availability.

The comparative analysis of mandatory and voluntary medical insurance in national and international practice

Nowadays, the formation and development of medical insurance system of citizens attracts attention of experts in the medical field and the insurance market. The possibilities of using foreign practice in the formation and organization of medical insurance, including improving of models of financing health care system in foreign countries and implementation of mechanisms of resource support of health care industry tested in world practice, deserve interest of researchers in order to enhance financial institutions of national system of mandatory and voluntary medical insurance. In Russia and foreign countries, the mandatory medical insurance policy allows citizens insured in mandatory medical insurance system, to undergo examination and receive treatment in medical organizations in amount established at the state level. In Russia, popularity of the voluntary medical insurance policy depends on medical care quality in the mandatory medical insurance system and volume of services guaranteed within the framework of mandatory medical insurance.

The pharmacological economic analysis of application of magnetic resonance contrast mediums containing gadolinium in case of multiple sclerosis

The MS Excel calculator was applied to estimate costs and analyze impact on the budget under treatment of multiple sclerosis exacerbations, that were diagnosed using various gadolinium-containing contrast mediums. The direct medical costs for diagnostics with gadolinium-containing contrast medium and hospitalization due to exacerbation in accordance with mandatory medical insurance system were taken into account. At the expense of reducing number of multiple sclerosis exacerbations due to the use of single-molar gadolinium-containing contrast medium (gadobutrol) as compared with semi-polar gadolinium-containing contrast medium (gadodiamide, gadoteric acid and gadoteridol) in 1000 patients it is possible to reduce financial expenses from 1,968,642 to 7,175,520 RUB. The cost of magnetic resonance imaging diagnostics with contrast enhancement and treatment of multiple sclerosis exacerbations increases in the series: gadobutrol < gadodiamide (Jodas Expoim) < gadodiamide (GE Health Care) < gadoteridol < gadoteric acid.

ИЗУЧЕНИЕ ЗАТРАТ МЕДИЦИНСКОГО СТРАХОВАНИЯ В СРАВНЕНИЕ ДОХОДОВ И РАСХОДОВ СТОМАТОЛОГИЧЕСКОЙ ПРАКТИКИ ПО ВИДАМ ЛЕЧЕНИЯ

Currently, the number of private dental clinics is growing. However, there is also mandatory medical insurance for free dental care. The purpose of this study is to study the costs of health insurance in comparison of income and expenses of dental practice by type of treatment. The study examined all medical expenses for dental care, purchase of dental materials, depending on the type of dental treatment. The economic significance of expenses and revenues for dental materials was calculated depending on the type of treatment, as well as the optimal amount of remuneration for employees. In our study, regular dental examinations are covered by insurance, since patients who visit dental clinics for regular dental examinations carry out preventive measures at the expense of mandatory medical insurance. In the course of the study, we calculated the economic significance of preventive measures and the cost-effectiveness of dental care. Thus, early diagnostics of dental pathology and high-quality provision of dental services at the early stages under the mandatory medical insurance policy are effective for improving the entire management balance of dental clinics.

Features of the competitive environment in the compulsory health insurance market

In the context of increasing concentration in the medical services market, one of the key areas of the industry's development is expanding the opportunities for private medical organizations to participate in the MHI and developing competition between medical organizations participating in the MHI system. In the work the analysis of the competitive environment in the market of mandatory medical insurance for 2015-20018 years, the reasons to reduce insurance companies on the market of OMS over the years, as well as the consequences of this event, considered leaders by revenues and shares in the market during 2016-2018, the identified indicators of the level of concentration in these regions, the analysis of market OMS of the SFD identified the problematic aspects and ways of increasing the effectiveness of competition between health insurance organizations, the built Matrix porter services OMS, identified obstacles (obstructions), faced by entities when entering into the market of medical services in the MHI system.

Profit of medical organization from conducting medical activity: axiom or a reason for discussion?

This article examines such mandatory element and special purpose of entrepreneurial activity as gaining profit applicable to medical activity. The author analyzes medical activity in terms of gaining profit based on the legislatively consolidated sources of funding in the sphere of health promotion, which are united into three groups: funds from budgets of all levels, funds from mandatory medical insurance and funds from organizations and citizens, funds received from private and legal entities, including voluntary donations, and other sources that are not prohibited by the legislation of the Russian Federation. The article employs the general and private scientific methods, such as formal legal, analytical, systemic, statistical, and economic analysis. The scientific novelty of this research consists in the following conclusions: that profit from conducting medical activity can be acquired within the framework of rendering paid medical services; the prices (tariffs) for medical services provided within the framework of compulsory health insurance and budget funding do not imply profit. The author advances an opinion that the model of funding in the sphere of protection of public health is substantiated by the social orientation of the activity of the state towards maintenance and promotion of health of its citizens.

РЫНОК МЕДИЦИНСКИХ УСЛУГ РЕСПУБЛИКИ КРЫМ: ТРЕНДЫ И ПЕРСПЕКТИВЫ РАЗВИТИЯ

The article examines the trends in the development of the medical services market in the Republic of Crimea for the period 2015–2020. The analysis of the number of medical organizations by form of ownership, size and types of activity, capacity and technical equipment, provision of medical personnel, the volume of medical services in the context of public and commercial segments was carried out. In the period under study, there was an increase in the medical services market, due to an increase in the number of private medical organizations, the volume of mandatory medical insurance funds under the basic program. The expansion of the base and capacity of the sanatorium-resort complex, the growth of domestic medical tourism, laboratory services and telemedicine were identified as promising areas of market development.

Clinical and economic comparison of utilization of reslizumab, mepolizumab and benralizumab in the treatment of severe eosinophilic asthma

The aim of this study was to compare the clinical and economic consequences of the use of biological agents that antagonize IL-5 in the treatment of severe eosinophilic asthma in adults. Two methods of clinical and economic research were used: assessment of the cost-effectiveness ratio and analysis of the budget impact. The effectiveness of the drugs was assessed using indirect comparison; special attention was paid to comparability of the patient groups in the studies chosen for such an assessment. Two approaches were used for calculation of the cost of therapy for severe asthma: using DRGs (applicable to most regions of Russia), and without the use of DRGs, which is relevant only for few Russian regions. Basing on the data obtained from a budget impact study without the use of DRG, it was shown that reslizumab was dominating for patients with body mass of up to 70 kg, while for the patients with body mass of 70 to 110 kg, mepolizumab was dominating, while utilization of reslizumab appeared to be somewhat more expensive. In the group of patients with body mass over 110 kg, mepolizumab also was dominating. The calculation of the cost-effectiveness ratio (CER) showed that reslizumab appeared to be dominating over two other MABs, The results of the study using the DRG demonstrated that the cost of an annual course of benralizumab in most cases in Russia would exceed the amount that can be compensated by Territorial Funds for Mandatory Medical Insurance to a healthcare institution for therapy of bronchial asthma in one adult patient with genetically engineered drugs. Therefore, further comparisons were made for reslizumab and mepolizumab only. Analysis of the impact on the budget demonstrated that treatment with reslizumab and mepolizumab would represent a similar burden for the budget. When applying cost-effectiveness analysis, reslizumab was more cost-effective than mepolizumab (regardless of patient body mass). Thus, the results of the clinical and economic study suggested that, basing on the cost-effectiveness analysis, reslizumab appeared to be the dominant IL-5 antagonist (regardless of body mass if DRG approach was used and in patients with body mass up to 110 kg, if such an approach was not used). Basing on budget impact analysis, calculations without use of DRG approach showed superiority of reslizumab over mepolizumab and benralizumab for the patients with body mass up to 70 kg and the DRG-based approach showed equal burden for the budget for reslizumab and mepolizumab for the patients with any body mass.

PIN126 Russian Mandatory Medical Insurance System Response to COVID-19 Pandemic

All over the world, the governments must adjust their healthcare systems to COVID-19 pandemic. Among other problems paying for large number of additional sometimes severe cases is a challenge. The objective of our study was to analyze the response of the Russian mandatory medical insurance (MMI) system to COVID-19 pandemic.

Clinical and economic analysis of caries prevention programs by mathematic modeling

Relevance. Underestimating the importance of economic analysis is the barrier to the implementation of cariesprevention programs.The aim is to study with use of mathematic modeling method the clinical and economic effectiveness of dental caries prevention programs provided for schoolchildren.Materials and methods. The method of mathematic modeling was used to evaluate the clinical and economic efficiency of the caries prevention programs (educational, fissure sealing, fluoride varnish). The cost of prevention program implementation and the expenses for caries treatment without prevention were calculated according to the rate of Volgograd territorial mandatory medical insurance Fund for 2018 year. The differences between the caries prevention program’s cost and the expenses needed for the treatment of “prevented caries” were considered as saving.Results. It was revealed that the Educational Dental Program for the first grade schoolchildren has short duration (2 years) of clinical-economic efficiency. The Continuous Educational Dental Program applied for 6 years by dental hygienists or dentists led to saving (per 100 children) of 99.5-115.0 or 84.0-99.6 thousand roubles respectively. The economic effect of The First Permanent Molar Fissure Sealing Program was revealed after 2 years only when The Program was implemented by dental hygienists. After 6 years of working with this Program the saving were 181.3 or 146.2 thousand roubles per 100 children depending on who implemented the Program, dental hygienists or dentists. The cost of Fluoride Varnish Program implementation was higher than the treatment of “prevented caries”. However, the number of “prevented caries” after fluoride varnish application is higher than after the implementation of the Educational Dental Programs. Moreover, fluoride varnish, in contrast to fissure sealing, prevents caries of smooth surfaces of permanent teeth. Conclusions. The method of mathematic modeling can be used for the development of the caries prevention programs in various regions considering the availability of personnel and financial resources, and for evaluation of the clinical and economic effectiveness of preventive programs implementation.

The lean polyclinic: aspects of optimization of medical processes

The article considers main issues of implementing the lean polyclinic project in practice of Russian polyclinic institutions. The main problems that can be solved by implementing the principles of economical production, optimizing operations and eliminating losses, including financial ones, are identified. It is concluded that saved funds can be distributed to motivate employees in the form of higher salaries and bonuses, as well as to provide training opportunities, to attend conferences by specialists. This approach results in reasonable use of the Federal funds, the mandatory medical insurance Fund, and regional budgets.

Problems of legislation and law enforcement in the field of children’s health care

Introduction. The protection of children’s health is considered to be the most important among the state priorities. The aim of the study was to study the problems of legislation and legal enforcement in the field of children’s health protection to develop proposals for further improvement of its management. Materials and methods. Analysis of information in abstract databases of scientific publications and assessment of existing legislative framework related to children’s health protection in the Russian Federation. Results. The following issues were identified: lack of mechanisms for implementing the principle of priority of children’s health protection; violation of children’s rights when providing them with medical and preventive care within the framework of mandatory medical insurance and when providing paid medical services; insufficient quality of preventive medical examinations and preventive work in outpatient clinics and educational institutions. Existing standards of time for a patient to visit a pediatrician have been shown to have a negative impact on the quality of medical (including preventive) care for children. The need to create a regulatory framework for the legitimate introduction of the “early assistance” technologies and to establish a system of medical and social support for children in difficult situations had been justified. Issues of school medicine and regulation of juvenile labor require a legislative solution. Conclusion. The enhancement of existing legislation in the field of children’s health should consist not only in new legal mechanisms development and new laws adoption but also in improving the effectiveness of existing legal norms, i.e. improving law enforcement practices.

The public-private partnership in Russian health care: the regional aspect

The health care problems are considered in detail both in the program and non-program activities of the sector state regulatory bodies. The public-private partnership, in particular, participation of private clinics in the system of mandatory health insurance can become one of the effective tools to cope with many problems. The article analyzes participation of private clinics in implementing territorial program of mandatory health insurance as exemplified by the Krasnodar Krai. This is to provide guaranteed free medical care by private clinics of municipalities in the Krai. The regional features of public-private partnership in health care are considered in fairly prosperous Russian region that allow to develop positive scenario. Out of the total number of medical organizations, potential participants of the mandatory health insurance system the private clinics were identified. The analysis of participation of private medical organizations in the mandatory medical insurance system was carried out in context of two main classification criteria: geographical location and the type of medical services. According to the study results, the structure of private clinics of the Krasnodar Krai participating in mandatory health insurance program on a territorial basis is determined. The types of medical care that are not carried out by the selected companies, as well as the types of medical services that are in demand by private clinics are established. The list of private clinics participating in territorial mandatory health insurance program with the widest range of services is determined. The matrix of participation of private clinics in mandatory health insurance system was developed on the example of the Krasnodar Krai.

Estimation of the influence of the effectiveness of the planning process on the quality of medical care on the example of the mandatory medical insurance fund

Estimation of the influence of the effectiveness of the planning process on the quality of medical care on the example of the mandatory medical insurance fund

The system of mandatory medical insurance as evaluated by patients

The population awareness about merits of mandatory medical insurance (MMI) continues to be inadequate. The study purpose was to investigate opinion of Moscow Oblast residents about MMI system. The sociological survey was carried out according standard technique using specially developed genuine questionnaire. The public opinion was studied in 2013 (584 respondents) and 2017 (709 respondents) on the basis of sampling of visitors of medical organizations. The survey established that percentage of positive responses of respondents concerning their awareness about which medical insurance company they belong slightly increased in 2017. However, every thirteenth still was unaware of it. Only every sixth respondent addresses to insurance company when occur problems related to medical care support. The right to choose insurance company, medical organization and physician was used by 17-22% of respondents in both surveys. In 2013 20% of respondents addressed nowhere due to absence of problems with health services support. In 2017, number of addresses to administrations of medical institutions increased up to 35%. The number of addresses to insurance companies and MMI foundations increased up to 13% and 27% correspondingly. The percentage of respondents with positive answers about being constrained to pay for medical services unofficially decreased up to 18% in 4 years and reached 12,6% in all sampling. Thus, activities concerning population information about changes occurring in health care system, including development of citizen rights is inadequate still. The citizens in number of cases are not interested to obtain necessary information and ignore it down to name of insurance company mentioned on their insurance policy.

НАЛОГООБЛОЖЕНИЕ САМОЗАНЯТЫХ ЛИЦ: ОСОБЕННОСТИ И ПЕРСПЕКТИВЫ ВНЕДРЕНИЯ

The article discusses the features of taxation of self-employed persons in the Russian Federation in connection with the adoption in 2018 of new legislation that allows individuals who are not registered as individual entrepreneurs to work in the legal field, but who receive income from the sale of goods, services and work. In addition, this type of tax can also be applied by individual entrepreneurs in compliance with all legal norms. It has been studied that the tax on professional income has its own features related to restrictions on application in terms of the volume of annual income received, the existence of labor relations, the types of activities carried out, and the combination with other special tax regimes. The advantages of the application related to a low tax burden, non-payment of mandatory fixed payments for mandatory pension provision and mandatory medical insurance are considered. Statistical studies of the quantitative characteristics of the application of the professional tax on the territory of Moscow and the Moscow region, as well as qualitative characteristics in the form of the formation of the revenue part of the budget of these subjects were conducted. It is revealed that citizens are actively included in the legal field, but the share of this tax in the total amount of tax revenues in the budgets of the subject is insignificant.

The Russian characteristics of organization of motivational and stimulating systems of labor remuneration in non-state health care institutions

The article considers topical aspects of formation of motivational and stimulating component of remuneration in non-state health care institutions. This organizational legal type of medical organization presupposes specific characteristics of financial economic functioning and processes of organization of remuneration fund. In Russia, state and municipal medical organizations provide own sources of motivational component, that much more depend on implementation of mandatory medical insurance territorial programs. In case of non-state clinics quite different sources of employees' incentives of improving quality and productivity of labor exist. The non-state health care institutions occupy in-between position with their financial opportunities between state (municipal) and private structures. Most non-state health care institutions are of departmental subordination. The article deals with issues of development of motivational and incentive mechanisms as exemplified by JSC "Russian Railways". The empirical research permitted to specify in detail algorithm of process of organization of remuneration fund with designation of system of indicators for bonuses distribution. The specific characteristics of development of motivational and incentive systems of remuneration fund in non-state health care institutions are identified.

Государственно-частное партнерство в системе обязательного медицинского страхования в Российской Федерации

The article provides an analysis of the reform of the structure of national health care for the period from 2010 to 2020 and an assessment of the development of public-private partnership in the system of mandatory medical insurance. The analysis was conducted before the beginning of the pandemic on the date of 15.01.2020.

Cost-effectiveness of vaccination against pneumococcal infection of adults at risk within the federal and regional programs

The aim. of the work was to evaluate the cost-effectiveness of vaccination with the 13-vaIent pneumococcal conjugate vaccine (PCV13) and its combination with the 23-valent pneumococcal polysaccharide vaccine (PPV23) of immunocompetent adult patients with different levels of risk of pneumococcal infection. Material and methods . Cost-effectiveness analysis was carried out by a modeling method, with a horizon of 15 years from the position of the healthcare system, and. taking into account the social perspective. The analysis was performed, for 20, 40, and 60 year oId patients with 1, 2, and 3 risk factors. In accordance with national recommendations, the vaccination. regimen included, the introduction, of PC 1 dose of PPV23 one year later. In addition, the analysis was performed, for vaccination, with 1 dose of PCV13. The efficacy of PCV13 and PPV23 in different age groups corresponded, to the results of foreign studies, taking into account the data of a Russian study of the serotypic landscape of pneumococci with community-acquired, pneumonia, which required, hospitalization. The cost of treating pneumococcal infections was calculated. on the basis of the mandatory medical insurance rates in St. Petersburg for 2019. The cost of vaccination, for federal programs was calculated, on the basis of the PCV13 price of 1199 rubles per dose, and. for regional programs — 1518.63 rubles per dose. The cost of PPV23 in both, cases corresponded. to the weighted average price of auctions for 2019 (1639 rubles per dose). Indirect costs were calculated, on the basis of data on average wages in the Russian Federation, and. employment of citizens of various age groups. Costs and. life expectancy were discounted, at 3.5% per year. Results. The number of cases of infection prevented, and. the amount of costs averted, increase with increasing risk level. Moreover, with age, the number of deaths caused, by these diseases increases significantly. The volume of prevented, direct medical and. general costs per 1 vaccinated, patient varies from 0.41-2.95 thousand, rubles and. 1.00-6.82 thousand, rubles, respectively. Vaccination, of patients with 3 risk factors is most cost-effective. Conclusion. When analyzed, from the perspective of the healthcare system., vaccination, against pneumococcal infection with PCV13+PPV23 in 60-year-old. patients with at least 1 risk factor and. patients of any age with at least 2 risk factors can be considered as cost-effective. Vaccination with 1 dose of PCV13 of patients of any age with at least 1 risk factor in the analysis from the perspective of the healthcare system, can be considered, as a cost-effective intervention.