The formation of the system of compulsory medical insurance (CMI) in Russia took place in difficult conditions of a system-wide crisis. The transition of the country's economy to market relations, accompanied by a significant decrease in the level of social protection of the population, put domestic medicine in conditions where its further functioning in new relations became impossible.

Adoption in the context of a constant deficit of budgetary financing of health care and the legalization of paid medical services in 1991, the law on the introduction of compulsory and voluntary forms of health insurance made it possible to mitigate the social consequences of economic reform and ensure the inflow of additional funds into the industry. All provisions of the Law of the Russian Federation of June 28, 1991 No. 1499-1 "On medical insurance of citizens in Russian Federation"(hereinafter referred to as the Law on Health Insurance) regarding compulsory medical insurance were put into effect starting only from 1993.

During the implementation of the norms of this law in CHI system many problems have been identified that do not allow for the effective functioning of the industry. Transformations in the healthcare system continued with the adoption in 2010 of a new law regulating relations arising in connection with the implementation of compulsory medical insurance (Federal Law of November 29, 2010 No. 326-FE "On Compulsory Medical Insurance in the Russian Federation").

Background

The development of the hospital insurance system is associated with the appearance in the second half of the 19th century. in many European countries, health insurance funds. They were formed at the expense of contributions from employers and employees and guaranteed their members: benefits that partially compensate for the earned income lost during illness; lump sum payments and pensions to the family in the event of the death of an employee; compensation for women in childbirth; provision of medical and pharmaceutical care.

In Russia, before the revolution, health insurance was not widespread. In 1912 State Duma a law was passed introducing compulsory insurance workers in case of illness, obliging employers to provide employees with medical care at their own expense.

Employers mainly organized and paid for the treatment of the insured through the system of hospital insurance funds, the principles of operation of which were similar to those in Western Europe. In Soviet times, there was no health insurance, since the healthcare sector was completely supported by the funds state budget, government departments and ministries, as well as social funds enterprises.

At present, a multi-subject health care financing system has developed in Russia (Fig. 7.10).

The main share of funds for medical care of the population comes from the state budget and through the CHI system.

The domestic compulsory medical insurance system as a branch of state social insurance has certain features, namely:

A polysubject management structure, in which, on the territory of the Russian Federation as a whole, the management of CHI funds is carried out by federal fund Compulsory medical insurance, and in the territories of the subjects of the Russian Federation - territorial funds of compulsory medical insurance;

CHI system- an interconnected set of CHI subjects and relations between them regarding the formation of funds for this type of insurance and the use of these funds to compensate for the costs associated with providing the insured medical care.

Rice. 7.10.

• - within the framework of compulsory medical insurance, no cash payments to the population are made. Financial resources are used to pay for medical services provided to citizens free of charge, and are sent to the system of medical institutions;
• - Limited reimbursement for medical expenses only, not including coverage for loss of income during temporary disability;
• - individual CHI principle, when insurance premiums are paid individually for each insured, as opposed to the family principle of insurance operating abroad;
• - payment of insurance premiums is carried out by employers and the state, where the state is equated to the insurer, obliged to make contributions for the non-working population. Employees do not participate in the financing of the CHI system;
• - the universality of compulsory medical insurance, which consists in providing all citizens with equal guaranteed opportunities to receive medical care in accordance with government programs OMS. Foreign practice shows that compulsory medical insurance is established by the law of the respective country not for everyone, but only for certain categories of the population.

The financial and organizational mechanism of compulsory medical insurance is shown in fig. 7.11.

Subjects of compulsory health insurance are: insured persons; policyholders; Federal Fund (FFOMS).

Participants of compulsory medical insurance include: territorial funds (TFOMS); insurance medical organizations (SMOs); medical organizations.

Insured persons are citizens of the Russian Federation permanently or temporarily residing in the Russian Federation Foreign citizens, stateless persons. Insured persons in the CHI system have the right to:

• - for free provision of medical care to them by medical organizations in the scope of the basic CHI program - throughout the territory of the Russian Federation; in the scope of the territorial CHI program - on the territory of the subject of the Russian Federation in which the CHI policy was issued;
• - selection of an insurance medical organization and its replacement once during a calendar year;
• - choice of medical organization;
• - choice of doctor;
• - obtaining reliable information about the types, quality and conditions of medical care;
• - protection of personal data necessary for maintaining personalized records in compulsory medical insurance;
• - compensation for damage caused in connection with non-fulfillment or improper fulfillment of the duties of the CMO and medical institutions;
• - protection of rights and legitimate interests in the field of CHI.

Rice. 7.11

The insurers of the working population in the CHI system are persons making payments and other remuneration individuals, and individual entrepreneurs notaries, lawyers engaged in private practice. For the non-working population (children, students, non-working pensioners, the unemployed, etc.), the executive authorities of the constituent entities of the Russian Federation are required to pay contributions. Insurers must be registered with the territorial offices of the PFR, since the PFR is the administrator of contributions to CHI.

The insurer in the compulsory medical insurance system is the Federal Fund, a non-profit organization established to implement the state policy in the field of compulsory medical insurance. The Fund provides subventions to budgets territorial funds for financial support of expenditure obligations of the constituent entities of the Russian Federation. As part of the fund's budget, a normalized safety stock is formed.

To implement the compulsory medical insurance system in the territories of the constituent entities of the Russian Federation, territorial funds (TFOMS) are being created - non-profit organizations exercising certain powers of the insurer (in terms of the implementation of territorial CHI programs within the basic CHI program; in terms of the additional volumes of insurance coverage established by the territorial CHI programs for insured events established by the basic CHI program, as well as additional grounds, lists of insured events, types and conditions for providing medical care in addition to those established by the basic CHI program). To exercise their powers, territorial funds may create branches and representative offices.

TFOMS revenues are generated from: subventions from the FFOMS budget; intergovernmental transfers transferred from the budget of the Federal Compulsory Medical Insurance Fund, payments of constituent entities of the Russian Federation for additional financial support for the implementation of the territorial CHI program within the framework of the basic CHI program; payments of constituent entities of the Russian Federation for financial support of additional types and conditions for the provision of medical care not established by the basic CHI program; income from the placement of temporarily free funds; interbudgetary transfers transferred from the budget of a constituent entity of the Russian Federation; accrued penalties and fines.

The total amount of subventions provided to the TFOMS budgets is determined based on the number of insured persons, the standard for financial support of the basic compulsory medical insurance program and others. set targets. Subventions are targeted and provided subject to compliance in the region of volume budget appropriations for compulsory medical insurance of the non-working population to the approved amount of the insurance premium, and subject to transfer to FFOMS budget monthly 1/12 of the annual volume of budgetary appropriations for compulsory medical insurance of the non-working population, approved by the law on the budget of the constituent entity of the Russian Federation, no later than the 25th day of each month.

TFOMS provides insurance medical organization (SMO) target funds in accordance with the application, based on the number of insured persons and per capita funding standards. In the event that the amount of funds established for HMOs for paying for medical care is exceeded due to increased morbidity, an increase in tariffs for paying for medical care, the number of insured persons and (or) a change in their structure by sex and age, the TFOMS may provide the funds missing for payment from the normalized safety stock TFOMS.

An insurance medical organization is a licensed insurance organization exercising certain powers of the insurer in the territory of the subject of the Russian Federation. HMOs must be included in the register of companies operating in the MHI system. Since 2012 the minimum authorized capital CMO should be 60 million rubles.

So, HMOs are not entitled to carry out other activities, with the exception of CHI and VHI activities, and keep separate records for operations with CHI funds and VHI funds.

Companies carry out their activities in the CHI system on the basis of:

• - an agreement on the financial support of compulsory medical insurance, concluded between the CMO and the territorial fund of compulsory medical insurance;
• - an agreement for the provision and payment of medical care under compulsory medical insurance, concluded between the HMO and the medical organization.

Under the agreement on financial support, the HMO undertakes to pay for medical care provided to insured persons in accordance with the territorial CHI program at the expense of earmarked funds. In order to implement this function, the CMO performs:

• - registration and issuance of CHI policies;
• - maintaining a personalized record of insured persons and the medical care provided to them;
• - submission to the TFOMS of an application for targeted funds;
• - conclusion of contracts with medical institutions;
• - monitoring the volume, timing, quality and conditions of medical care in medical organizations;
• - implementation of activities to protect the rights and interests of the insured persons;
• - other functions that do not contradict the law.

HMOs send funds to medical organizations in accordance with the contract for the provision and payment of medical care under compulsory medical insurance and the conditions provided for by the territorial programs of compulsory medical insurance.

Under the contract for the provision and payment of medical care under CHI, the medical organization undertakes to provide medical care to the insured person within the framework of the territorial CHI program, and the HMO undertakes to pay for the provided medical care in accordance with the approved tariffs. At the same time, the CMO performs the following duties:

• - obtaining from medical organizations the information necessary to monitor compliance with the requirements for the provision of medical care; as well as verifying their validity;
• - monitoring the volume, timing, quality and conditions of medical care in medical organizations;
• - organizing the provision of medical care to the insured person in another medical organization in case the medical organization loses the right to carry out medical activities.

The responsibilities of a medical organization include:

• - providing information about the insured person and the medical care provided to him,
• - submission of invoices for medical care rendered;
• - submission of reports on the use of compulsory medical insurance funds, on the medical care provided to the insured person and other reporting in the manner established by the Federal Compulsory Medical Insurance Fund.

The funds received by HMOs and intended to pay for medical care are targeted financing funds. HMOs keep separate records of their own funds and MHI funds intended to pay for medical care.

The target funds of the CMO are formed due to:

• 1) funds received from the territorial fund under the agreement on the financial support of compulsory health insurance (the annual amount of funds for HMOs is determined based on the number of insured persons in a given company and differentiated per capita standards);
• 2) funds received from medical organizations as a result of the application of sanctions to them for violations identified during the control of the volume, timing, quality and conditions of the provision of medical care;
• 3) funds received from persons who caused harm to the health of the insured persons, in terms of the amounts spent on paying for medical care.

TO own funds CMOs in the field of CHI include:

• 1) funds intended for the costs of conducting a case under compulsory medical insurance and received from the TFOMS within the established standard;
• 2) the established part of the amounts unreasonably presented for payment by medical organizations, identified as a result of an examination of the quality of medical care and a medical and economic examination;
• 3) the established part of the amounts received as a result of the payment of fines by the medical organization for failure to provide, untimely provision or provision of medical care of inadequate quality;
• 4) the established part of the funds generated as a result of saving the annual amount of funds calculated for the medical insurance organization;
• 5) funds received from persons who caused harm to the health of insured persons, in excess of the amounts spent on paying for medical care.

Medical organizations in the field of CHI include organizations of any organizational and legal form that have the right to carry out medical activities and are included in the register of medical organizations operating in the field of CHI, as well as individual entrepreneurs engaged in private medical practice.

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“The amount of funding for medical organizations is increasing every year”

Today, almost all medical and preventive institutions of the republic work in the system of compulsory medical insurance. public policy in the field of compulsory medical insurance on the territory of our republic, it is implemented by the Territorial Fund of Compulsory Medical Insurance of the Chechen Republic, to the head of which, Denilbek Abdulazizov, we turned with questions of interest to our readers.

- Denilbek Shervanievich, please tell us how the compulsory medical insurance funds are formed to finance medical care?

- Compulsory health insurance has two main sources of income - receipts for the working population and contributions for non-working citizens, who make up about 60% of the total population of Russia. With regard to working citizens at the federal level, a decision was made to increase the rate of contributions for compulsory health insurance by 2% (from 3.1 to 5.1%). In 2011 and 2012 these additional funds purposefully directed to finance regional programs for the modernization of health care. From 2013, this increase will be an addition to the tariffs for compulsory health insurance.

- How is the financing of medical institutions operating in the CHI system carried out?

Financing of medical institutions operating in the system of compulsory medical insurance is carried out on the basis of an agreement on the financial support of compulsory medical insurance concluded by the Territorial Fund and an insurance medical organization and contracts for payment of medical care concluded by an insurance medical organization and medical organizations. On a monthly basis, in accordance with the agreement on the financial support of compulsory medical insurance, from the budget of the Territorial Fund for Compulsory Medical Insurance, targeted funds are sent to the medical insurance organization according to the differentiated per capita standards approved in the established manner. Financing is carried out at the request of the insurance company in the order of advance payment for the current month and settlement for the reporting month. The insurance medical organization, on the basis of contracts for the payment of medical care, directs the funds received from the Territorial Compulsory Medical Insurance Fund to medical organizations in payment for the register invoices submitted by them for the volume of medical services provided under the above agreement. Cash are sent to medical organizations in the order of "advance payment - final payment".

- Has the volume of funding for healthcare facilities increased in recent years, or is there a shortage?

- The amount of funding for medical organizations is noticeably increasing every year. If in 2011 4,754.7 million rubles were allocated for the implementation of the basic program, which is 13% more than in 2010, then in 2012 it is planned to allocate funds in the amount of 5,134.6 million rubles for the implementation of the basic territorial program, which is higher than in 2011. But, nevertheless, the funding gap for the implementation of the approved compulsory medical insurance program remains, which for 2012 is 751.0 million rubles (12.7%), against 899.7 million rubles (17.8%) in 2010, although annually it decreases. The lack of funding is clearly visible per person, the approved cost of medical care in 2012 per person is 4026.5 rubles, while the estimated cost is 4615.4 rubles. And this is mainly due to the low volume of income from taxes on compulsory medical insurance of the working population.

-This is a very good indicator. Is there arrears in the payment of wages in medical institutions in the region?

- As noted earlier, medical institutions are financed according to differentiated per capita standards through insurance company. Funds to pay for medical care provided to insured persons are transferred strictly according to the financial security agreement, which makes it possible for medical institutions to receive wages on time and in the required amount. At present, the fund has no accounts payable By wages in front of medical institutions. I want to note that the Fund fulfills all financial obligations in a timely manner and in full. For example, during the entire past year, there was not a single case of delay in financing health care facilities for the volume of medical services that were accepted for payment by an insurance medical organization.

The next question concerns single-channel financing. Our readers do not quite understand what it is. Tell us more about it.

In accordance with the Concept for the Development of Health Care until 2020, the strategic goal of the health care reform is the transition to single-channel financing and the introduction of the per capita principle of payment for medical care. At present, a budget-insurance financing model is functioning in Russia state system healthcare. This model is based on attracting funds from the budget system of the Russian Federation at all levels and funds from compulsory medical insurance. Multi-channel healthcare financing reduces the industry's manageability and creates difficulties in exercising control over the rational and targeted spending of funds and the quality of medical care. The transition to a predominantly single-channel form of healthcare financing assumes that the bulk of the funds will be directed from the CMI system. At the same time, it is planned that payment for medical care will be carried out according to the final result on the basis of complex indicators of the volume and quality of services provided.

- What exactly will the transition to single-channel financing give?

Single-channel financing has a number of advantages. First, it will provide financing for all medical care in full, taking into account real costs. Will explain. At present, tariffs in the compulsory medical insurance system are formed on the basis of the planned volumes of medical care and allocated funding. Single-channel financing will replace this approach with the calculation of the cost of treatment on a completed case according to the standards of medical care. The transition to payment for the work done will lead to a change in the structure and quality of medical care itself.

Secondly, single-channel financing is aimed at ensuring the principle of accessibility of medical services for all citizens of the country, regardless of place of residence. Thirdly, the transition to single-channel financing will improve the efficiency of spending budget funds in the healthcare system. As early as 2013, the country is planning to make the transition to single-channel financing, in which funding from compulsory medical insurance funds for healthcare institutions in the region will be about 80%.

- Denilbek Shervanevich, we thank you for your interesting and very detailed answers. We wish you success in your future work.

- Thank you too.

FINANCING OF THE RUSSIAN HEALTH CARE THROUGH THE SYSTEM OF MANDATORY HEALTH INSURANCE: MAIN DIRECTIONS AND PROSPECTS Tsareva Olga Vladimirovna Head of the Department for the Modernization of the CHI System Candidate of Medical Sciences All-Russian Forum of Heads of Health Care Institutions Moscow, October 2010

…introduce predominantly single-channel financing of healthcare organizations and carry out a phased transition to paying for medical care at the full rate at the expense of compulsory medical insurance… …introduce predominantly single-channel financing of healthcare organizations and make a phased transition to paying for medical care at the full rate at the expense of compulsory medical insurance… Prime Minister of the Russian Federation V. PUTIN 2

Scheme of organizational and financial interaction in the MHI system MHIF Financing agreement MHI Insurance premiums for MHI of the non-working population Agreement with health care facilities Financing according to the estimate + targeted programs Subsidies Payment of bills since 2011 - 3.1% since 2011 - 2.0% TFOMS S M O Medical organizations Insurers of the working population Executive authorities of the constituent entity of the Russian Federation Local self-government bodies Medical service Existing links Single-channel financing Existing links Single-channel financing Support for activities 3

REGULATORY LEGAL ACTS OF THE RUSSIAN FEDERATION FIXING THE TRANSITION TO SINGLE-CHANNEL FINANCING Decree of the Government of the Russian Federation dated p “The main activities of the Government of the Russian Federation for the period up to 2012” Decree of the Government of the Russian Federation dated “On the program of state guarantees for the provision of free medical care to citizens of the Russian Federation for 2011 " Project federal law"On Compulsory Medical Insurance in the Russian Federation" 4

REGULATORY LEGAL ACTS ADOPTED AT THE LEVEL OF THE RUSSIAN FEDERATION REGIONS AND FIXING THE TRANSITION TO SINGLE-CHANNEL FINANCING The law of the constituent entity of the Russian Federation "On the budget of the constituent entity of the Russian Federation" The law of the constituent entity of the Russian Federation "On the budget of the territorial fund of compulsory medical insurance of the constituent entity of the Russian Federation" Territorial programs of state guarantees for the provision of citizens of the Russian Federation with free medical care General Tariff Agreement approving an expanded tariff for paying for medical services in the compulsory medical insurance system and additional types medical care paid through the CHI system, previously financed from the budgets of all levels The procedure for transferring health care institutions to single-channel financing, including their preparation for the specified transfer healthcare of subjects of the Russian Federation 5

ANALYSIS OF THE CURRENT SITUATION ON THE TRANSITION TO SINGLE-CHANNEL FINANCING IN THE SUBJECTS OF THE RUSSIAN FEDERATION IN THE FIRST HALF OF 2010 (25 constituent entities of the Russian Federation)

Expansion of the tariff for compulsory medical insurance in the constituent entities of the Russian Federation (Syktyvkar, Leningrad, Penza, Tomsk and Tyumen regions, Chukotka Autonomous District); Maykop Kazan Kostroma Penza Tomsk Tyumen Perm Vladimir All items of expenditure, except for the cost of rent for the use of property (Kamchatsky Krai, Kursk Region); Kursk All items of expenditure, except utilities (Republic of Altai, Krasnodar Territory, Nizhny Novgorod and Tambov Regions); Gorno-Altaisk Krasnodar Tambov All items of expenditure, except for the acquisition of fixed assets (Krasnoyarsk Territory); Krasnoyarsk All items of expenditure were paid (Republics of Adygea, Komi, Tatarstan, Perm Territory, Vladimir, Kaliningrad, Kostroma, All items of expenditure, with the exception of utilities, expenses for rent for the use of property (Republic of Mari El, Kaluga and Orenburg regions); Yoshkar -Ola Kaluga Orenburg All items of expenditure, except for the cost of rent for the use of property, costs for the acquisition of fixed assets (Kemerovo Region); All items of expenditure, except for utility costs, for the acquisition of fixed assets ( Kirov region) Kemerovo Kirov 9

10

11

Syktyvkar Kazan Penza Tyumen Medical care for socially significant diseases: Inclusion in the territorial program CHI medical care for socially significant diseases in the constituent entities of the Russian Federation Sexually transmitted infections (Republics of Komi and Tatarstan, Kaliningrad, Leningrad, Penza and Tyumen regions, Chukotka Autonomous Okrug) district) Acquired immunodeficiency syndrome (Republics of Komi and Tatarstan, Kaliningrad, Leningrad, Penza and Tyumen regions, Chukotka Autonomous District) Mental and behavioral disorders, drug addiction (Republics of Komi and Tatarstan, Kaliningrad, Leningrad, Penza and Tyumen regions, Chukotka Autonomous District) ) 13

Activities that provide effective management system resources CHI Implementation effective ways payment for medical care Transition to federal standards provision of medical care Transition to the wage system medical workers result-oriented implementation of outsourcing mechanisms 14

(letter of the Ministry of Health and Social Development of the Russian Federation dated June 29, 2009 20-0/10/2-5067) Implementation of effective methods of payment for medical care for a completed case of medical care based on per capita financial support for outpatient medical care, taking into account the sex and age structure of the attached of the population by the average cost of inpatient treatment of a patient in the profile department of a hospital institution by clinical and statistical group of diseases by unit of volume of medical care provided 15

1. Strengthening the material and technical base of medical institutions 2. Implementation of modern information systems in healthcare 3. Implementation of medical care standards regional program for modernization of healthcare for the years the goal is to improve the quality and ensure the availability of medical care of the subject of the Russian Federation Tasks of the program sources of financing the Federal Fund for the Compulsory medical insurance Territorial fund of obligatory medical insurance Consolidated budget of the constituent entity of the Russian Federation 16

Financial support for modernization of healthcare of the constituent entities of the Russian Federation at the expense of compulsory medical insurance 1. Strengthening the material and technical base of healthcare institutions 2. Implementation of modern information systems in healthcare 3. Implementation of medical care standards 17 inter-budget transfers Treaty on financial support of the Russian Federation TFOMS HCIs operating in the CHI system Subsidies for the implementation of the program in terms of the basic CHI program Funds from the budget of the TFOMS Funds from the MHIF

REGIONAL PROGRAM OF HEALTH CARE MODERNIZATION FOR YEARS Preparation for the transition to single-channel financing in 2013 is one of the directions for the modernization of healthcare in the constituent entities of the Russian Federation in 2011-2012 communication services, transport services, utilities, works and services for the maintenance of property, expenses for rent for the use of property, payment for software and other services, purchase of equipment worth up to 100 thousand rubles per unit. 2. Financing of medical institutions based on effective methods of payment for medical care, focused on the results of their activities (completed case of treatment in stationary conditions, per capita financing of outpatient care). 18

FINANCING THE EXPENSES OF MEDICAL INSTITUTIONS OUT OF THE FUNDS OF MANDATORY HEALTH INSURANCE Expenditure items of health facilities paid at the expense of compulsory medical insurance: wages (210), medicines, dressings, food, soft inventory, medical instruments, reagents, chemicals, chemical dishes and others inventories(340), payment for services for the placement of non-medical services (outsourcing) (226). 1. Expansion of the tariff for compulsory medical insurance: – communication services; – transport services; - public utilities; - rent for the use of property; – purchase of software; – purchase of equipment worth up to 100 thousand rubles per unit. 2. Expansion of the types of medical care paid for at the expense of compulsory medical insurance. According to the base CHI program 19 With single-channel financing

20 Regional financial standard 2013 Federal financial standard 2013 A necessary condition for the implementation of measures for the transition to single-channel financing is the gradual bringing of financial standards for TPOMS in line with federal standards (cost per unit of medical care by type, per capita funding standard).

Many citizens of the Russian Federation know that they have every right to be treated completely free of charge in state and municipal hospitals and clinics, subject to presentation compulsory medical insurance policy. However, not everyone understands where the money for the financial support of health insurance comes from. And if everything is clear with the working population - the main source of providing them with gratuitous medical services is the insurance premiums paid by their employers, then what about the non-working citizens? The answers to all questions are further in our material.

Legislative consolidation

The main regulatory legal act that regulates the financing of compulsory medical insurance is 326-FZ of November 29, 2010 “On Mandatory ...” (hereinafter - Federal Law No. 326), namely Chapter 5.

Particular provisions are contained in the following legal acts:

• Chapter 34 of the Tax Code of the Russian Federation (on the procedure, terms of payment, amounts of transfers to compulsory medical insurance for working citizens, including at reduced rates for certain categories of payers);
• Federal Law No. 354 dated November 30, 2011 “On the amount ...” (on how the tariff is calculated insurance payment for medical insurance for non-working citizens);
• Order of the Ministry of Health No. 182n dated April 30, 2013 “On approval ...” (on the form of a certificate provided by policyholders on a quarterly basis on accrued and paid insurance premiums for non-working citizens);
• FFOMS Order No. 229 dated 1. 12. 2010 “On approval ...” (on a unified form of an act that is drawn up by officials of the FFOMS or territorial funds in violation of the legislation of the Russian Federation in terms of financial support for compulsory medical insurance);
• Appendix to the Order of the Ministry of Health and Social Development No. 1229n dated December 30, 2010 “On Approval ...” (on the procedure for spending the normalized insurance reserve provided for in the FFOMS budget);
• other federal and regional regulatory legal acts on the financial support of CHI.

Sources of financing