Health Organization

Muslim Muslimov:

Muslim Muslimov is with you in the Medical Management program. Our topic is “Public-private partnership in healthcare in practice.” My guest is Japaridze Roman Mirabovich,

My first question is traditional: what healthcare trends do you see in the development of your business, perhaps internationally? What will we ultimately arrive at in the next 3-5 years?

Roman Japaridze:

First of all, thank you for the invitation and for the topic you touched on. Indeed, very relevant and timely. Currently, among the trends in the healthcare sector, the fundamental one is probably public-private partnership - this is the topic for which we have gathered here today. This is very promising and hot topic for the social sphere, and, in particular, for healthcare. Indeed, public-private partnership mechanisms are now actively developing in all areas - in social and transport infrastructure, in IT technologies and, probably, in all spheres of social life. But in healthcare, indeed, PPP (that’s what it’s called for short) has long been included in this area. Today, these mechanisms are being implemented quite widely in many projects, both in the regions and in Moscow and St. Petersburg.

What does it mean? When the state does not have enough resources either to equip healthcare facilities, or to bring them into proper condition, or simply does not have enough funds to launch a particular area of ​​medical activity, it resorts to the help of a private partner. The private partner invests his money, reconstructs, creates this medical infrastructure, or then provides medical services himself, or transfers a ready-made facility to the state, but under certain conditions. In principle, this trend is inherent, as I already said, not only in healthcare, but also in other areas. Nevertheless, this trend is actively, very actively developing; there are now a lot of projects at the federal level, and at the regional, and even at the municipal level. In particular, our company is engaged in the implementation of investment projects.

Muslim Muslimov:

How do you see this market? How will it develop in the next 5 years, or where is your company headed?

Roman Japaridze:

We are developing in the field of free medical care (free for patients). It is clear that for us, for the state, it is not free, it is financed from compulsory medical insurance funds. However, we provide all our medical services that we provide in our medical centers free of charge to the population. The fundamental trend, second only to compulsory medical insurance services, is telemedicine technologies. We have modern IT systems into which all our medical centers are integrated; we develop them ourselves. With their help, we are introducing remote telemedicine consultations into our practice. This is not only a doctor-doctor or doctor-patient consultation, something like Skype or an analogue, no, it is a special technology that allows the doctor to make a certain decision on the treatment of the patient. This is a decision support system. That is, the machine itself tells the doctor what decision to make now, in accordance with the procedures and standards of medical care. Naturally, the doctor himself chooses, taking into account the indications. That is, we are aimed at the global, let’s say, expansion of private medicine in the healthcare sector with the goal, probably, of both developing competition and helping government systems.

Muslim Muslimov:

Please tell us in more detail about your project. I know that you have more than 30 clinics and, as I understand, in addition to hemodialysis, there is also a desire to grow and expand services to the outpatient profile. Is this true?

Roman Japaridze:

Yes, we started implementing our first projects in 2012. Today we have more than 30 medical centers in 10 regions Russian Federation. These are the Kostroma, Kirov, Voronezh, Leningrad, Omsk, Tyumen, Kemerovo regions, Khanty-Mansi Autonomous Okrug, Ivanovo region, as well as the Republic of Tyva. We are present in these subjects.

It all started with hemodialysis centers. Indeed, we equipped government institutions with modern equipment, made repairs there and took them over for management. Over time, we realized that, let’s say, it is necessary to move to a broader format of interaction with the patient, to carry out a full cycle medical services. Do not pull out a service that is expensive from the point of view of compulsory medical insurance financing, but take exactly the entire cycle of the patient’s movement, starting from the primary level of outpatient care, ending with intensive care, laboratory diagnostics, 24-hour hospital, and so on. It is this approach that allows you to fully control the patient’s movement at all levels of medical care. This is exactly what we are moving towards now, this is why we are moving away from hemodialysis and, among other things, creating clinics. We want to develop the outpatient department; it is the most relevant and most in demand. You yourself know the state in which our clinics are often, especially in the regions. This is a very socially significant topic. Therefore, we now propose to implement PPP projects specifically at the outpatient level.

Muslim Muslimov:

Roman Mirabovich, to what extent is the compulsory medical insurance tariff sufficient to develop in the outpatient direction? As I understand it, private medical centers are developing high-tech medical diagnostics (CT, MRI), because the tariff is higher there. I think you know this too. How promising will this be for you, do you think? Is the financial model calculated?

Roman Japaridze:

It's no secret that tariffs, especially for ordinary, let's say, medical services, are often not competitive in the sense that they do not recoup the investments we make. But through the use of telemedicine technologies, which I mentioned, and through competent management of the facility, competent administration of all business processes, medical processes, we are able to save more. By reducing the wage fund, through the use of IT systems and IT functions that replace the usual person who previously performed this function in a regular clinic. Somewhere we are reducing the area. For example, we entered a region, they handed us 3,000 square meters and said that there used to be a clinic here that served 50 thousand of the assigned population. We said that 1000 square meters would be enough for us to serve exactly the same number of attached population. They were surprised: “How is this possible? Previously, we had a watchman, we had an elevator operator, a person who measures pressure, who fills out documentation, who issues...” We have all these processes replaced by modern equipment, which allows us to reduce our costs, use a minimum amount of space, and a minimum number of workers . Due to this, naturally, we manage to save and somehow get by, survive and even recoup our costs over time.

Muslim Muslimov:

How many patients do you pass through per year? And how much hemodialysis do you do?

Roman Japaridze:

According to statistics, now, so as not to lie to you, I won’t tell you, but we definitely have more than 2,000 hemodialysis patients. There is a small clinic in Kostroma, where we have about 5,000 attached population. This is not a lot considering the work of the clinic, but this was our first experience, a pilot project that we implemented. Over the past 3 years, we have seen how we manage to live competently with the compulsory medical insurance tariff, we understand how it works, and are now ready to replicate our experience. We are currently negotiating with many entities on organizing an outpatient clinic. This does not mean that we have abandoned hemodialysis centers; there is a need for them. In any case, there is a lack of quality equipment and quality service among nephrology patients. We are also inclined to make up for it, so that everything is fine with us, so that people receive medical care within walking distance. This is important.

Muslim Muslimov:

You are a member of the Expert Council of the non-profit partnership of the PPP Development Center, you know all the inner workings. What are the development priorities in the field of healthcare under PPP?

Roman Japaridze:

Currently, as I have already said, outpatient services and high-tech medical care are in great demand. Starting next year, it is planned that private medical organizations will be able to be included in medical services and provide medical care in the same way as is now done in the compulsory medical insurance system. If until now this medical care could only be provided by federal healthcare institutions or regional hospitals and so on (state), now this is the trend for next year. Therefore, we will also try to meet all the necessary criteria in order to participate. That is, for myself I highlight: clinics and telemedicine technologies. From my point of view, this is the most socially significant, most in demand and relevant topic.

Muslim Muslimov:

Can you give examples of large PPP projects within healthcare that Russia can boast of?

Roman Japaridze:

In the classical public-private partnership scheme, the fundamental law is the law on concession agreements and the law on public-private partnership, which was adopted quite recently. There are many examples of concession agreements being concluded at the municipal, regional, and even federal levels.

As for structured projects in accordance with the new federal law on public-private partnerships, they are now most likely at the implementation stage, because this is a very long and difficult process: to start a project, you need to prepare an application, you need to coordinate all the points with government agencies. And medicine is a very complexly structured area where it is necessary to describe a lot of issues, and all these issues, one way or another, come into contact with many government regulatory bodies. For example, if we take a subject, then the project needs to be agreed upon with the territorial compulsory medical insurance fund, with the Ministry of Health, with the Ministry of Finance, with the Ministry of Property, because, as a rule, property is transferred (either a land plot or an object), and with the ministry investment policy. While the project goes through all rounds of approval, a lot of time and effort is lost. Unfortunately, not all projects reach their logical conclusion. Therefore, of course, I would like this period to be as short as possible, as quickly as possible, and for the project to be implemented more easily than it is now. Therefore, it is difficult to say which mechanism has priority. Both are workers.

But we realized for ourselves that it is more effective to be guided by what we have. Federal legislation allows private medical organizations to organize medical care, find patients who are ready to come to you for this medical care, and begin to function with the subsequent declaration of themselves as a medical organization operating in a system, for example, compulsory medical insurance. The mechanisms currently provided for by current legislation will in no way prevent us from doing this. Therefore, today we work according to the following principle. We are creating a facility and positioning ourselves as a company ready to provide medical services in within the compulsory medical insurance. People have the right to choose who to go to, which doctor - in the public health care system, in the private one, or in another private one, ours or another. Further, the necessary volumes of medical care with payment through compulsory medical insurance, accordingly, follow the patient, because this right is enshrined in Federal Law 323 on the protection of citizens' health. Then we slowly begin to work. Yes, there are no such guarantees as in PPP, namely the minimum guaranteed tariff, routing, volume, and so on, but at least this makes it possible to provide medical care now, without waiting for endless approval.

Muslim Muslimov:

In your opinion, what is the time period for return on investment and what are the guarantees for the return of this investment?

Roman Japaridze:

It’s difficult to say because there are so many areas of overlap in medical services. It is clear that, for example, in hemodialysis or MRI, computed tomography, and so on, the payback period will be noticeably shorter than in a clinic. You can’t put everything under the same brush and say that this is the payback period here, and this is the payback period here. Much also depends on how you provide medical services, on who comes to you, how many people. The more competitive you are, the more you look head and shoulders above your colleagues in the industry, both private and public, the faster the payback period comes that everyone talks and waits for so much about. Therefore, the most important thing is to work efficiently, to work correctly, that is, for the benefit of patients, and the result will not be long in coming.

Muslim Muslimov:

Now the amount of investment, which means attention to the healthcare market, is quite large. Network clinics are now opening in many regions, for example, “Mother and Child”, or network diagnostic clinics are rapidly developing across Russia. Doesn't this mean that now is really the time to invest in healthcare?

Roman Japaridze:

Of course, always, if there is competition, if there is no monopolization of some service, then it is always good. We are only for competition to develop. This is primarily beneficial for patients - the end consumers of medical services. Therefore, here, on the contrary, we should be happy that clinics are coming to the regions. Yes, maybe not everyone works for free at the expense of compulsory medical insurance funds, like we do. Yes, these can also be paid services, not always cheap, not always accessible to all segments of the population. But, nevertheless, it’s good to have a choice. The most important thing is the qualifications of doctors. Unfortunately, this is a problem everywhere. Many centers are opening, and often the same people work there, half a day in one center, half a day in another. Therefore, it is important to approach it from this point of view.

Our holding has an educational organization, and we raise the level of our doctors, conduct specialized seminars, issue certificates and diplomas so that their level is always at the top and they are competitive. I will not hide that even in those regions where we previously had a monopoly in hemodialysis, new centers are already beginning to open, private companies are entering, offering a similar range of services with a similar set. But this is a benefit for patients, because if previously, for example, in a large city there was one medical center, and people from all the outskirts and from other areas went there, spending an hour and a half to two hours on the road, then when our competitor opens, - yes, for us this is, naturally, a minus, but for the patient it is a plus, because he has the opportunity, within a 10-minute walk from his home, to come and receive the same service for free. Therefore, we consider it normal, this is the development of the market, we only welcome it.

Muslim Muslimov:

How do you think the private healthcare market will develop? How will the state support it, and will it, in general?

Roman Japaridze:

It is very difficult to say how much the state will support, because we (I mean, we are private companies, especially those working in the compulsory medical insurance system) represent some kind of competition. It is clear that compulsory medical insurance funds are not so large that everyone now works there, but, nevertheless, this is a certain source of existence for a budgetary institution. Appearing in this or that entity and providing medical care, we are somewhere out there, far, far away, we can be perceived as competitors, if you look at it from a purely formal, financial side of the issue. It is this approach that is counterproductive.

Muslim Muslimov:

You say: a formality of a financial approach. What's the formality?

Roman Japaridze:

Let's take the head physician of a hospital; he has a flow of money, compulsory medical insurance funds to exist and conduct his financial and economic activities. A participant opens nearby that provides exactly the same range of services and works in the same way in the compulsory medical insurance system.

Muslim Muslimov:

Are there any such examples in your projects?

Roman Japaridze:

You see, they are implicit, but probably somewhere deep down everyone understands this. But, since this is, after all, for the benefit of the patients, they try, let’s say, to keep it on a subconscious level.

Muslim Muslimov:

You provide better quality, essentially, for the same money?

Roman Japaridze:

Yes, but we are slightly redirecting the flow of compulsory medical insurance funds that used to go to the hospital to ourselves and, accordingly, the hospital no longer receives the volume of medical care that it received previously. The patient who went to them now comes to us, and the money that followed him now comes to us. Somewhere, maybe on the level territorial funds Compulsory medical insurance, chief doctors of budgetary institutions, they understand this, but, nevertheless, they cannot do anything, because this is the law.

Muslim Muslimov:

State clinics are now able to provide commercial services to patients. In fact, at their base they are opening up a stream for competition with private clinics. Private clinics have the opportunity to provide compulsory medical insurance services. Do you think competition is healthy in this structure? Do you have any negative experience within the framework of general interaction under the PPP system?

Roman Japaridze:

Why not? If it is possible to provide paid services, why not provide them? The patient has the right to choose whether to pay him for the service or go for free. We all know that if it is free, how long it takes, how dreary and very bureaucratic it is. Therefore, it is easier for people to pay and resolve their issue. The most important thing here is not to overdo this scale, so that free medicine does not arouse hostility among consumers, so that the scale does not tip to the paid side. That is why we work in the compulsory medical insurance system, that is why we show that you can work in the compulsory medical insurance system with high quality, quickly and efficiently. This is what government clinics do, why not?

Unfortunately, there are negative experiences. Again, it exists because at one time we did not apply all the nuances of public-private partnership that needed to be applied to implement the project. I'll explain what's going on. In Kirov, we were once given a facility with an area of ​​about 4,500 square meters for use. The building, one might say, was in a ruined state; no renovations had been done, probably, since the 1970s. Can you imagine what condition it was in? They handed over the facility, signed a 20-year contract, and said: “Dear partners, make repairs there, organize medical profiles on the basis of this center, such as endocrinology, urology, cardiology, cardiovascular surgery and nephrology.” We signed the contract, shook hands, everything was fine, and started making repairs. 2 years pass, renovations are done, the facility is about to be commissioned. Here the leadership of the region is completely changing, including those who stood at the origins of the project, and their attitude towards us is being revised. Currently, we have been suing in arbitration court for a year and a half, because the contract with us is terminated with the following demands: terminate the contract with such and such a company and transfer, that is, return the object to us with all inseparable improvements, that is, with all repairs. To our question: if you want to take the object for yourself, you changed your mind after 2 years, then return the money for repairs to us, more than 300 million rubles that we invested - naturally, the answer was negative. Now we won the first station, despite the fact that probably all the administrative resources were connected there in terms of inspections by the prosecutor’s office, the Department of Economic Crimes, the Ministry of Health came more than once, Rosstroynadzor came and checked us. That is, everyone who could came and checked. However, despite the pressure, we were able to win the trial at first instance; the appeal is now being considered. Unfortunately, the appeal was also filed in the city of Kirov, and I don’t know what the decision will be, but we still hope that justice will prevail, and this building will remain ours, and we will be able to provide medical care. While the object is standing, hemodialysis is only performed there. 3000 square meters that could be used for the needs of residents Kirov region, for the needs of ordinary people, one might say, are idle.

Muslim Muslimov:

You mentioned that your projects have a social load. How would you voice it? What is your social burden?

Roman Japaridze:

The social burden in our projects is expressed in the fact that we provide all services free of charge, at the expense of compulsory medical insurance funds. This is a long payback period for the project. It is clear that it may be easier for us to provide these medical services for private money, for patients’ money. The policy of our leadership is that if a person has already paid taxes to the state once, he has the right to receive medical care at the expense of compulsory medical insurance funds, which are reimbursed to him by the same compulsory medical insurance fund that pays us for it. Therefore, there is a social burden that we take upon ourselves. Yes, this is longer than the usual projects of a commercial plan, a medical plan, but, nevertheless, we are ready to work.

Muslim Muslimov:

You have more than 30 clinics in 10 regions of Russia. In 10 districts, you said. What is your management style and how many people do you employ?

Roman Japaridze:

In each region, of course, we have a head of a branch, a staff of medical personnel, an administrative staff, and a medical staff. The main leadership comes from the center, from Moscow. With the help of those same telemedicine technologies, with the help of IT systems, we are able to sufficiently optimize all management processes. We are always aware of what is going on in the subjects, we see from the cameras, we read reports, that is, reports, literally, about every patient who comes for an appointment. We see his chart, medical history, what the doctor prescribed, what he forgot to prescribe, why he didn’t prescribe, how quickly he admitted the person, whether he delayed him, if he delayed him, then why. Accordingly, such a clear control system has been established, in the good sense of control. There are no supervisors who stand and say why you are 5 minutes late, why you have a line in front of the office - no, the curator of the entity in which this medical center is organized sees all this and begins, simply, to get to the bottom of the reason with the goal elimination so that it does not arise in the future.

Muslim Muslimov:

What information system do you work in?

Roman Japaridze:

We have our own development, Maximus, an information and analytical system. We can say, probably, a unique product, because those information technologies that are now being implemented by the Ministry of Health in the regions, that electronic patient record, that system for accumulating diagnoses and, in principle, all medical indicators that contribute to the treatment of the patient, have already been implemented here more than 3-4 years. It works and people appreciate it this system. The IT department of the Ministry of Health contacted us, we were happy to share our experience, tell us what nuances could be optimized in a modern system already being implemented at the state level. Therefore, the system is very helpful.

Muslim Muslimov:

Is it integrated into the state information system? For example, in EMIAS?

Roman Japaridze:

Now, this is exactly what we are doing.

Muslim Muslimov:

Second question: why? What is the purpose of integration? What further mechanisms and algorithms of interaction will there be with links that are not included in your pool of medical services?

Roman Japaridze:

Here, in any case, it would probably be wrong not to get involved, because I also don’t want to position myself separately, in a small-town way. Moreover, through this integration we can actually improve those aspects that are currently still unfinished. Unfortunately, there are many such shortcomings. Due to the fact that we have already passed this path, the path of formation, the path of developing those, let’s say, bonuses that telemedicine provides, we are ready to help the state. Such interaction will also help us, because it will be a kind of globalization of the entire process. For now, we work only within our medical centers. Yes, our program is being tested in government institutions, that is, doctors and staff are looking at how this system works, how effective it is, how much it optimizes all internal processes. We hope that the system will move from our inner circle to the outer one.

Muslim Muslimov:

Regarding telemedicine, do you work on some kind of telemedicine platform, or do you also have your own development? This is the first question. Second point: are you connected with large federal centers for redirecting complex patients for diagnosis and treatment?

Roman Japaridze:

Unfortunately, this is not yet the case. This is a very long process. You yourself know how bureaucratic everything is. We cannot simply enter this system. This is probably a matter of time, and we plan to do this in the very near future.

Muslim Muslimov:

But why? Now there are solutions on the market that already provide an opportunity. For example, the Almazov Center in St. Petersburg, they work on a single telemedicine platform, by connecting to which, patients can be redirected directly to the center for treatment.

You are an expert in the field of public-private partnerships, and I know that you are the co-author of a book on public-private partnerships. How did the idea for writing come about, and what was the goal?

Roman Japaridze:

It was 2010, when this trend was just beginning. The book became a kind of collection of those practices that existed at that time, a collection of the normative and theoretical framework that existed at that time. But nothing has changed much since then; conceptually everything remains the same. The only thing that appeared new law about PPP, new practices, new projects have appeared, something has been modernized, but the basic postulates remain the same as they were in 2010. This book was a kind of attempt to position ourselves even then in a new field for our country. But public-private partnerships have been known abroad since ancient times; they existed back in the early 20s of the 20th century.

Muslim Muslimov:

What is your company's mission?

Roman Japaridze:

Our most important mission is to provide high-quality medical care to residents of the Russian Federation, to all citizens with a compulsory medical insurance policy, and to bring this medical care as close as possible to the people, to make it within walking distance so that the patient can come and quickly and efficiently receive high-quality medical care for free. This is probably the most important thing.

Muslim Muslimov:

What goals and objectives do you see for the next 3-5 years for the company, in addition to the development of the outpatient department and telemedicine?

Roman Japaridze:

The main ones are to develop the areas that you mentioned, improve the areas in which we are currently working, and take on new areas of activity. Not everything is focused on hemodialysis and the outpatient clinic; there are many other areas that require development. The main trend is the development of these areas, including through telemedicine technologies, this is the most effective and fastest way.

Muslim Muslimov:

You are talking about telemedicine technologies, but the law allows only a repeat consultation, or a doctor-to-doctor consultation. How do you set this up?

Roman Japaridze:

Yes, indeed, it is impossible to make a diagnosis using a remote consultation, however, this is a very good opportunity for an ordinary person who lives in a small town, who does not have the opportunity to come to Moscow, and there is not always a reason to come, because many diagnoses, you yourself As a doctor, you can say that it can be delivered remotely. It is not necessary to touch a person, look into his eyes, and so on.

Muslim Muslimov:

Although, the old school would probably hardly agree with you.

Roman Japaridze:

However, there are a number of areas where treatment can be adjusted, when the patient can get a second opinion, the so-called, and he does not need to travel far beyond the borders of his city, his home village, region, and so on. He may well receive medical care remotely. Yes, in any case, the final diagnosis will be made by the attending physician and the treatment tactics adopted, but we have the right to arm the patient with a set of additional information, and we do this.

Muslim Muslimov:

Are there clinics in the Moscow region - Moscow, Moscow region? Second question: which, in your opinion, is the easiest region, so to speak, for interaction and which is the most difficult?

Roman Japaridze:

I'll start with the last one. The heaviest, as you already understood, is Kirov. This is all connected with the experience that we now have; we have been suing for almost 2 years. But, again, this situation arose, probably, also through our fault: we signed the agreement based on the good partnership relations that had developed before the signing.

Muslim Muslimov:

That is, the problem is in the documentation, which was not prepared enough?

Roman Japaridze:

The problem is that we have not worked out all the nuances of this agreement. There are a lot of nuances in medicine, and it’s quite easy to pull up a problem from a very vague formulation.

Muslim Muslimov:

This is more, it seems to me, the sphere of jurisprudence.

Roman Japaridze:

Yes, but still. By the way, there is probably no such easy region, because in all our regions everything happened quite quickly. There was a need, we were ready to implement it, and everything was done quite easily, quickly, and is working quite effectively now.

We are now planning to develop in Moscow. We are planning to take 2 objects in which to organize medical care - we want to create a clinic and a hemodialysis center.

Muslim Muslimov:

How aware are you of similar projects like yours abroad, to what extent do they have the opportunity to be translated into our reality, and do you take the best practices from abroad and implement them in your own activities?

Roman Japaridze:

Our company actively participates in international exhibitions; twice a year we go to the largest event in the field of digital telemedicine and simply medicine, and exhibit our IT products there. It is of truly wide interest to foreign investors and players in the medical services market there. Are similar projects presented here? There are large German corporations that operate under a similar system in Russia, and we have to compete with them. These are global companies with a well-known name, so, let’s say, it’s not very easy for us, since they, after all, have financial side more accessible, and in general, when there is a big “locomotive” going around the world, of course, it is easier for them to enter the Russian Federation and implement projects. However, we are actively resisting in the good sense of the word and offering a worthy alternative to the people of our country. PPP, indeed, is actively developing abroad; their projects also take a long time to structure, and also not quickly, but, nevertheless, such a practice exists. We can say that the very first public-private partnership projects that were implemented in our country are a well-adapted copy of those projects that have already been implemented abroad.

Muslim Muslimov:

Tell me, are you developing independently, or are you considering attracting additional partners - investment partners, for example, or partners who have key competencies?

Roman Japaridze:

At the moment, our holding is engaged in a full cycle. We build ourselves, manage ourselves, modernize ourselves, and there is no need to attract funds from outside yet. Within our holding there is, as I already said, a construction company, an investor company, a non-profit organization - the Nefrosovet company, which acts as a medical operator, and an educational company that trains our staff, improves their qualifications, and a company engaged in IT development. These 5 main components work within our holding.

Muslim Muslimov:

We wish you success in development, in implementation and in playing a very important role! You called it a “socially active role,” when our patients have already paid the tax once and should have the right to receive high-quality free care in comfortable conditions. Good luck to you!

Roman Japaridze:

On April 11, 2017, within the framework of the forum of Russian regions “Healthcare”, a plenary session “Public-private partnership in the medical field” was held

Co-organizer of the session - Committee on Medical Services " Business Russia“, headed by a member of the general council of the organization, Muslim Muslimov.

Public-private partnership is one of the ways to develop public infrastructure, based on long-term interaction between the state and business, in which the private party (business) participates not only in the creation of an infrastructure facility, but also in its subsequent operation and / or maintenance in the interests of the public party .

Recently, the Russian Federation has been increasingly developing PPP in various fields, and more and more actively in the medical field.

Share of government social expenditures, by expert assessments market remains small, and in times of crisis does not cover the existing need for infrastructure development. In this regard, the issue of increasing the efficiency of using budget funds and stimulating the influx of private investment in the social sphere remains open, which we can clearly observe in the healthcare sector, where a course has been taken to attract private investors and develop PPP at the level public policy and programs.

It was the reduction in spending on social infrastructure due to the crisis and budget deficit that led to attempts to attract private investors in the healthcare sector. As a result, the development of public-private partnerships has become one of the important areas of work of the Russian Ministry of Health in recent years.

We can roughly identify two main ways of developing PPP in healthcare, aimed at achieving a common goal - improving the quality and accessibility of medical care for the population.

The first is to attract private investment in the development of healthcare infrastructure that is state and municipal property using “classic” PPP instruments.

The second is the involvement of private organizations in the compulsory medical insurance system and/or the transfer to private organizations of outsourcing certain functions (types of activities) of government institutions, primarily “technical” ones (for example, outsourcing activities for transport support, cleaning, food, etc. ).

The global trend of expanding the practice of partnership in the healthcare sector between government and business has led to the development of a number of replicable models for the implementation of PPP projects. The introduction of PPP mechanisms is impossible without taking into account the specifics of the country: organizational structure, legislation, investment climate.

In particular, a promising model can and is becoming the implementation by private partners of work on the reconstruction of public medical organizations, as well as obtaining the right to operate and maintain the infrastructure of these institutions for a period that pays off their financial investments. This model is beneficial for the state in the absence of sufficient resources for independent reconstruction of a medical facility. A variation of this model involves shared financing from the state and business, in which at the initial stage the private partner makes 100% of the investment, and after the facility is put into operation, the state reimburses part of the initial costs for several years. The construction of a new institution should solve the current problems of the region in healthcare due to the possibility of providing scarce medical services. Also applicable in Russian practice is a model in which the state builds a medical organization at its own expense and then transfers it to a private partner for trust management with the right to buy out. In addition, a model in which the construction of a medical organization is carried out by a private partner in accordance with the instructions of the state, and upon completion of construction, the infrastructure is transferred to the partner, who receives the right to provide medical services and manage the medical organization, has great potential. At the same time, the resulting profit covers costs and provides the required level of return on investment, taking into account risks. The advantage of this model is that the state pays for both the provision of paid medical services and the provision of services in the compulsory medical insurance system. Moreover, each of the above models requires the establishment of indicators for monitoring and control over the actions of the private partner.

At the end of 2016, more than 70 projects were being implemented in healthcare at various stages in the public-private partnership format, of which 61 projects were already at the construction and operation stages. As part of the ongoing PPP projects in healthcare, it is planned to attract investments of 61 billion rubles, while the total volume of private investments in PPP projects reaches 57 billion rubles, which is about 10% of the total investment in PPP projects in all industries. Among the leaders are Tatarstan and Novosibirsk, where 3 such projects are being implemented, and a medical center has already been built using the PPP mechanism.

As for compulsory medical insurance and the work of private clinics under this system, the situation is also far from ideal.

The outpatient department, including clinics and dental clinics, in private medical companies operating under compulsory health insurance accounts for 59% of the total number of private medical organizations of private ownership. Hospitals - 12%, centers of various organizational and structural forms - 15.1%, emergency medical stations and health resort organizations - 5%. Also, private companies account for about 3% of the state task in providing high-tech medical care.

IN in monetary terms The share of private medical organizations in the compulsory medical insurance market is still very small. Costs for inpatient medical care provided in private clinics amount to 1.8% of the funds allocated to public medical organizations, in outpatient settings, including dentistry - 4%, in day hospitals - 15%. Emergency medical care accounts for 0.4% of expenses.

The problems of developing PPP in the healthcare sector, as noted by the Session participants, include the lack of control over the effectiveness of projects and insufficient motivation of private investors. In addition, with deep forms of interaction, problems may arise with the return on investment of projects if they are not popular enough with consumers.

Based on an interesting and fruitful discussion based on the analysis of case studies, emotional speeches by economists and scientists, the following conclusions can be drawn so far:

Legislation requires changes

The initiative for PPP projects should come from both investors and the state (in the form of open proposals),

Still, the market is currently interested in PPP projects in volumes that are not so significant that they can attract large players.

Organizing an effective health care management and financing system is a pressing problem for most countries of the world. Within market model healthcare, which most developed countries are focusing on, one of the key areas for increasing the efficiency of the entire national healthcare system is the integration of the capabilities of the public and private sectors. In this regard, forms of interaction between the state and business in the healthcare sector are being widely developed as part of the implementation of public-private partnership projects.

The main goal of PPP in healthcare is to combine the capabilities, resources and qualifications of partners in order to achieve the best financial and material results with maximum mutual benefit as a result of such cooperation.

An analysis of foreign experience shows that the scope of application of PPP projects in healthcare can be quite wide. This may include the design, construction, operation and management of the infrastructure of medical institutions; and provision of health services; and the introduction of new medical technology, instruments and equipment.

Studying the world practice of implementing PPP projects allows us to draw a conclusion about the uniqueness of the process of their application, which is due to the peculiarities of constructing a financing model and organization of the healthcare system, trends economic development country, level of decentralization and autonomy in the management of medical institutions.

Nevertheless, the very fact of the possibility of implementing PPP in healthcare is already very indicative and can be used for development in Russia.

These issues are of particular relevance in modern economic conditions. A significant reduction is currently projected budget expenditures for healthcare.

Our country is developing under conditions of sectoral sanctions, which have caused a contraction of the capital market and a decrease in the investment attractiveness of the country, as well as a significant drop in oil prices, which has led to a fall in GDP and a reduction in budget revenues.

All these factors are already forcing the economy to contract, and the state and citizens to save on their expenses, incl. and healthcare.

In such conditions, the issues of PPP development in the healthcare industry become especially relevant. It should be noted that provisions on the development of PPP in healthcare are reflected in a number of strategic documents for this industry. Thus, the draft long-term strategy for the development of healthcare until 2030 plans to develop the federally owned healthcare infrastructure, attracting extra-budgetary sources of funding. In addition, the state wants to transfer economic functions to private business as much as possible, leaving behind only the control function. In return, investors will be ensured a return on their projects, subject to the preservation of the state’s social obligations in terms of providing medical care to citizens.

The Ministry of Health has already created a coordination council for PPP, which should develop a proposed package of orders for the business community, describe standard projects, help investors, when interacting with regional authorities, create favorable conditions for business participation.

As the main areas in which PPP in healthcare can develop in the future, the government considers primarily the primary level of medical care, as well as high-tech medical care. Primary care does not require large expenses, and it is expected that in the near future up to 15% of institutions providing medical care compulsory medical insurance program, will be private. In the regions, there is a shortage of many types of high-tech medical care, for example, hemodialysis centers, radiation therapy, oncology, and centralized laboratories for expensive research, so they want to entrust the development of these areas to private business.

The wider use of PPP in Russian healthcare will be facilitated by the fact that in 2015 the federal law “On public-private partnerships, municipal-private partnerships in the Russian Federation and amendments to certain legislative acts of the Russian Federation” No. 224-FZ was adopted dated July 13, 2015, which defines the basics legal regulation relations arising in connection with the preparation of a public-private partnership project.

Before the adoption of this law, within the framework of the legislation of our country there was not even a normative definition of the concept of public-private partnership, regulatory regulation Only some forms of PPP (concession) were subject to it.

Therefore, in conditions of improvement regulatory framework In this area, we can expect an intensification of the use of PPP mechanisms in healthcare practice.

According to the Center for the Development of Public-Private Partnerships in the Russian Federation, partnerships in the healthcare sector are represented, as a rule, only by investment agreements for the construction, reconstruction or modernization of targeted socially significant facilities. In terms of the forms, content, structure of contracts, mechanisms of guarantees from the state, methods of regulating public-private partnerships in healthcare, they differ little from similar contracts in other industries.

Appendix 1 presents data on PPP projects in healthcare in the Russian Federation according to data for 2015.

From the data in the table in the Appendix, it can be seen that the leader in the number of implemented PPP projects in healthcare and the volume of investments attracted for these purposes is the Republic of Tatarstan.

Let's consider one of the first PPP projects in the healthcare sector launched in Tatarstan - a concession for the Family Planning and Reproduction Center in Kazan. The main reasons for the development of this project was the sharp increase in the prevalence of infertility cases in the republic. To solve this problem, changes were made to the republican program of guarantees for the provision of medical care: decisions were made to include in vitro fertilization procedures (hereinafter referred to as IVF) in the state task for the provision of high-tech medical care and to compensate for the cost of IVF treatment.

Back in the 90s, a family planning and reproduction center was created on the basis of one of the clinical hospitals in Kazan, which began to provide in vitro fertilization services and participate in the implementation of the state task of providing high-tech medical care in the Republic of Tatarstan.

However, the implementation of IVF procedures required reconstruction and equipping the center with modern medical equipment, but the republic’s budget did not provide funds for these purposes. At the same time, the tasks performed by the family planning and reproduction center, in the context of negative trends in the demographic situation in the Republic of Tatarstan, were of great social importance. For the population, the problem of insufficient capacity of the center manifested itself in limited availability of medical care.

In this regard, the Republican Ministry of Health developed a PPP project within the framework of a concession agreement for a family planning and reproduction center.

The lengthy preparation of the project was due to the fact that this PPP project became the first concession agreement in Russia for an existing healthcare facility. The decision to transfer the center into a concession was made back in 2009, and the concession agreement was concluded only in 2011. The current Federal Law of July 21, 2005 N 115-FZ “On Concession Agreements” obliges the concessionaire not only to build or reconstruct the facility, but also to provide relevant services, determined the form and mechanisms for implementing the project by A.I. Titov. Implementation of PPP projects in Russia [Electronic resource] // Science: electronic journal [Official website]. 2015. No. 4. URL: http://nauka-rastudent.ru/16/2539/.

In accordance with this condition, the tender documentation contained requirements both for the reconstruction of the center and for the future activities of the company (preservation of free medical care in a volume no less than until the facility is transferred to the concession, timing of reaching the planned volumes of medical care, etc.)

During the competition, a single application was submitted from Ava-Peter LLC, and this company was declared the winner. It should be noted that Ava-Peter LLC has been present in the medical services market of the Republic of Tatarstan for some time as the main participant in the project to create a modern multidisciplinary medical center (Ava-Kazan LLC).

The grantor under the PPP project was the Ministry of Land and Property Relations of the Republic of Tatarstan, the customer of the services was the Ministry of Health of the Republic of Tatarstan. The concession agreement established the requirements for the design and reconstruction of the object of the agreement, describing the full range of works and the necessary additional equipment of the center. The total investment amounted to about 49.4 million rubles, the income received by the concessionaire during the implementation of the agreement is its property.

The duration of the agreement is 10 years. The concession agreement also contained requirements for the annual volume of medical care, since when forming the state order for the center’s services, the main principle was to prevent a reduction in the volume of free medical care to the population.

The reconstruction of the center was carried out in full and included a major renovation of the premises (ventilation systems, hot water supply, reconstruction of the IVF laboratory and operating rooms taking into account the principle of “clean rooms”, computerization of offices, etc.) and complete re-equipment with medical equipment.

From a financial point of view, the success of the project is associated with a well-thought-out scheme for ensuring payback due to the size of the compulsory medical insurance tariff provided for by the agreement - the tariff was higher than the national average, but lower than the commercial price, as well as a significant volume of commercial services. Since Ava-Peter LLC is the only executor of the state order for IVF in the Republic of Tatarstan, after the inclusion of IVF in the program Compulsory medical insurance tariff This procedure is still individual in nature.

It was assumed that the investment of the private partner would pay off within seven years, but according to data for 2014, it is expected that the investment will pay off within 2-2.5 years, i.e. in just 5-5.5 years thanks to an increase in government orders Based on materials from the website of the Ava-Peter clinic. [Electronic resource] // http://www.avapeter.ru/offices/kazan/..

The reconstruction of the Center has significantly increased the availability of artificial insemination using the IVF method for the population of the republic; over the years of the commissioning of the family planning and reproduction center, it was possible to significantly increase the number of IVF procedures (for example, in 2014, 697 operations were performed, and during the period 2008-2011. - only 650). That is, in annual terms the number of operations increased 3 times Ibid..

In addition to this PPP project, such projects in the healthcare sector have been successfully implemented as the concession of a maternity hospital building in Novosibirsk, where, at the expense of a private partner, reconstruction and restoration of the facility was carried out, and it was possible to resume the provision of high-tech medical care to the population for artificial insemination using the IVF method; transfer to concession of the city clinical hospital No. 63 of Moscow (European Medical Center).

On modern stage A number of PPP projects are also being implemented, but for the most part these are projects for the design and construction of healthcare facilities, that is, there are not so many projects on the design + construction + provision of medical services model in Russian practice.

There is a possibility that the situation may change somewhat for the better with the entry into force of the federal law on PPP No. 224-FZ, since it legally establishes various forms of partnership, and not just concessions. Under the PPP, the state receives the right to determine the volume and quality of medical services, while retaining ownership of the facility. The private partner receives the right to income in the form of fees for the provision of services, as well as his share of the risks of project management. In addition, it will be possible to implement a scheme in which the investor will be able to lease and manage ready-made facilities with an obligation to retrofit and use them.

In foreign PPP practice, contracts under which private investors are involved in the provision of services are widespread. The private partner is entrusted, at the expense of its own resources - time, personnel, financial, to provide services for which the state is responsible, for this the private partner receives certain preferences that provide undoubted competitive advantages in the market. The contract form allows PPP to be formulated quite broadly and to involve business in performing socially significant functions.

Among the industry areas that are attractive in the healthcare sector for the implementation of PPP in our country, we can highlight the creation of mobile medical centers for remote settlements, medical examinations under contracts with government clinics, mass testing for oncology, laboratory services, etc.

Another important feature of the development of PPP in Russian healthcare, in our opinion, will be the process of clustering and consolidation of medical institutions. Such facilities will combine clinical research, diagnostics, outpatient care, rehabilitation treatment, prevention, medical logistics, education and advanced training for physicians. Assistance will be provided for a wide range of nosologies for all groups of patients.

PPP mechanisms in healthcare have proven themselves in many countries around the world. In Russia, for a long time, from the moment PPP appeared in Russian practice, one of the main obstacles to the development of PPP was the lack of regulatory forms of PPP other than concessions, which could not always be applicable in healthcare. In addition, there are certain difficulties in initiating and motivating private businesses to participate in projects, the payback of which may have problems.

To develop forms of PPP in healthcare, it is important to understand who can act as an investor. As a rule, financial and industrial groups that have an existing medical area that has proven itself in the market have great potential for participation in partnerships. Such potential partners have several advantages:

• - medical past and present and desire to develop in this direction;
• - financial institution and other assets that can both generate the financial basis of the project and obtain some synergistic effect from interaction;
• - reputation, which will primarily concern the public partner. It is the lack of reputation that will now be an obstacle for many potential investors in the implementation of public-private partnership projects Galastyan G.S. On a promising model of public-private partnership in the field of healthcare with the involvement of management companies // Problems of modern economics. 2014. No. 3. P. 45-52..

The option of PPP with the participation of foreign capital is quite possible, but in the current economic and political conditions such an option in our country is unlikely.

Theoretically, PPP provides advantages and benefits to all participants in the partnership: the state, business, and society - one of the main consumers of the partnership “product”:

• 1. The state gets rid of the burden of investment and operating costs, plus maintains the scope of the social contract with the population.
• 2. Business, reducing business risk, receives a guaranteed flow of clients for its services with the opportunity to develop and commercialize new capacities. Business can be understood not only as a medical operator, but also financial institutions, developers, suppliers of equipment and materials.
• 3. Society receives higher quality medical services while maintaining physical volumes.

These advantages are obvious, but for the development of PPP in healthcare in our country it is necessary to work out large number questions. Among the most important is assessing the effectiveness of these projects. When making a decision on the implementation of PPP, it is necessary to calculate the total expenses and revenues of the state for the entire period of the project’s life cycle, limit the maximum allowable amount of annual payments for PPP projects, and develop a procedure independent of the budget process for checking the feasibility of spending budget resources in PPP projects. For transparency in the functioning of projects, budget documents and reports will need to disclose information about future payments and government receipts related to the provision of services under PPP agreements; amounts and terms of financing and other PPP support; volumes of state guarantees for PPP projects, etc.

To summarize, it should be noted that public-private partnerships can become a critical component of the functioning of the healthcare system in our country and, in the near future, one of the mechanisms for reforming domestic healthcare. In view of the special relevance of this form of interaction between the state and business, it is necessary to form a full-fledged partnership between the state and business as an effective mechanism for integrating public and private resources and their sources.

At the present stage, PPP is the most important condition for the effective development and functioning of a market economy, which is confirmed by the experience of both developed and developing countries that actively use PPP mechanisms. PPP allows for the integration of business models into the public sphere, as well as offering solutions to the most pressing problems of public policy.

The interest in PPP observed in most countries of the world is largely due to the need to implement long-term investment projects in various socio-economic areas that require large expenditures of budget funds. One of these areas has traditionally been healthcare. There is quite an extensive practice of using PPP in healthcare in the world, which can be summarized into 3 main forms: PPP only within the framework of the construction of hospital infrastructure; PPP within the framework of construction and maintenance of the facility, as well as the provision of related services (for example, cleaning the territory and premises); PPP, which includes all the elements of the first two.

In our country, despite the less long experience of using PPPs as, for example, in the EU countries, the USA, etc., a certain PPP base has been formed, including in the healthcare sector. One of the most significant and successful projects PPP in our country is a concession in relation to the Center for Family Planning and Reproduction in Kazan. Also, at the present stage, other PPP projects in healthcare are being implemented, so it can be assumed that in the presence of more favorable conditions, such as the adoption of a special normative act in this area, PPP should be further developed.

Simply put, the state's capabilities are not keeping pace with the needs of citizens. In particular, the patient's need for medical care. Despite all the health care reforms, for some reason Russians are not getting healthier. The federal budget is not enough to cure them. The state turns to private capital. How significant will the budget savings be? What problems can a public-private partnership solve?

PRIVATE CLINICS ARE SHIFTING TO COMPLIANT MHI, PUBLIC CLINICS - TO PATIENTS’ MONEY

One of the striking examples of public-private partnership is the Moscow City Clinical Hospital No. 63, which was granted a 49-year concession to the European Medical Center. He committed himself to creating 4 high-tech medical centers on the site of the old hospital: endovascular surgery, positron emission tomography, as well as perinatal and rehabilitation. It is already known that after the transfer of hospital No. 63 to a private partner, 40% of medical care remained free for patients. You have to pay for the remaining 60%. According to the General Director of the European Medical Center, all questions about whether public-private partnerships will lead to damage to free medicine are incorrect. After all, “there is no free medicine in nature.” It is mistakenly considered to be funding for medical care from state budget.

Veronika Skvortsova reported on lesser-known (but, according to her, more successful) examples of public-private partnerships. The first of them is the increase in the number of private companies participating in the state guarantee program under compulsory medical insurance. Recently there have been almost 3 times more of them: changes in the basic financial program Compulsory health insurance has made participation in the state guarantee program profitable.

Another example is the construction of positron emission tomography centers. Such a center will appear on the territory of Hospital No. 63. The remaining private centers are being built on the territory of oncology centers operating in the compulsory medical insurance system.

Medical public-private partnerships are already operating in 40 of the 83 constituent entities of the Russian Federation. Basically, these are private medical and obstetric centers. The Ministry of Health assures that such cooperation is beneficial to both the state and commercial organizations. What is the benefit?

IS COMMERCIAL MEDICINE USEFUL FOR THE STATE BUDGET?

In the case of the state, the interest in private capital is quite understandable. At one of the press conferences, the Minister of Health said: “We have calculated the potential for savings - more than 150 billion rubles. We can save money per year thanks to fundamentally new methods of paying for medical care, similar to the best Western models.” Thus, public-private partnerships are another way to “optimize” medical costs. Moreover, the total need for healthcare investments is approximately 2 trillion 200 billion rubles. This is exactly what the federal budget lacks.

To save money through public-private partnerships, legislation will have to be rewritten. Amendments are planned to federal laws - “On compulsory health insurance”, “On concession agreements”, “On autonomous institutions” and to the Tax Code of the Russian Federation. Experts fear a wave of legislative acts: first on public-private partnerships in medicine, then in all other areas of professional activity.

One of the initiatives is the transfer of state and municipal medical institutions to a public-private partnership system. District clinics and city hospitals want to be allowed to rent out concessions.

Future private partners are promised various benefits. There is a proposal to exempt companies that invest in healthcare and companies that provide medical services from VAT and income tax. Those who finance medicine are going to be given land plots for the construction of medical centers and connect medical institutions to the infrastructure.

However, patients will not be exempt from taxes. They are only going to be given the opportunity to return or reduce personal income tax for the amounts spent on treating themselves and their loved ones. Tax refund and tax exemption are not the same thing. In the first case, you will have to pay tax, and then write an application for a refund. Some people would prefer not to deal with the bureaucratic procedure... If they are exempt from tax, they can immediately pay a smaller amount. Everything necessary will be deducted from it in advance. Let us recall that the patient will become the main sponsor of two partners - private (commercial company) and public (state). Neither of these partners wants to lose out on income.

In order to quickly transfer public medical institutions into the sphere of public-private partnership, they decided to organize special institutes. They will have to identify medical institutions that are ineffective or require reconstruction. In the future, such institutions will be transferred to private investors.

THE STATE BUDGET WIN, EVERYONE ELSE TAKES RISK

Public-private partnership is a tripartite contract. The third party is the people for whom the concessioned institution operates. In the case of medicine, patients. They are the main sponsors of public-private healthcare. If something doesn’t suit them (for example, the price of treatment), they simply won’t come for medical help. As they say, “in Russia, drug prices increase immunity.” Not only the patients themselves, who are left without the help of a doctor, will suffer, but also the private partner who has not received any income. The state will have to protect it. Thus, savings from the federal budget at the initial stage will result in large expenses in the future. True, events may develop according to a different scenario: the state simply will not pay a private company...

An unambiguous conclusion follows from the proposed amendments to the legislation: citizens of the Russian Federation will pay for medical care. However, supporters of the project argue that it is vital for the patient. One third of Russian medical institutions require overhaul. Half of the country's medical equipment is outdated. And all this - despite modernization. And if the state is not able to renovate hospitals and clinics and provide them with all the necessary equipment, private companies will have to be involved. Otherwise, the construction and “modernization” of medical institutions will take... 80-100 years. About 500 regional hospitals need to be built in the country. But it is unlikely that public-private partnerships are the only way to find funds for healthcare.

Another argument in favor of the patient: if the law on public-private partnership comes into force, you can rest assured about the quality of the constructed clinics and medical centers. In today’s system, a building is designed by one organization, built by another, and operated by a third. Public-private partnership will avoid this: design, construction, and operation will be carried out by the same company. Those who build for themselves will be more attentive to their work. The question arises again: perhaps it would be easier to make changes to the state order procedure?

The benefit of the private partner is as relative as the benefit of the patient. The state and the commercial company must share all risks. But in practice, most of the risks will fall on the investor. Problems may be associated with the construction of the building, its operation, and the financing of the institution.

There are also risks associated directly with the state. For example, the risk of nationalization of an enterprise. What is more profitable for the state budget: to pay off a private investor or to take away an already built medical center from him? A number of risks are caused by the financial situation of Russians: few are able to pay for treatment. Will a private company be able to pay for the hospital it built? Everything depends on the patients’ ability to pay.

Medicine itself is a low-return and very complex partnership. Let's give an example: in psychiatry and narcology, approximately 70% of the investment is returned to a private investor.

THE RESULT OF THE PARTNERSHIP COULD BE FREE MEDICINES

According to Director of the Institute of Health Economics of the National Research University Higher School of Economics Larisa Dmitrievna Popovich, public-private partnerships can be successfully implemented in Russia, but excessive optimism may prevent this. Today in the country there is neither a control system for public-private partnerships nor a motivation system for both partners. If a private investor is offered to build a first aid station, he will never recoup his costs. Especially if the FAP will work in the compulsory medical insurance system. The investor will not receive anything, and the state will have to pay him compensation for lost profits. Therefore, there is no need to chase quantity and hastily transfer medical institutions to private companies.

I agree with Larisa Popovich’s opinion and Advisor to the Minister of Health of the Republic of Tatarstan Rostislav Ivanovich Tuishev. According to him, the project is convenient for the state, but at the same time very expensive.

In the domestic understanding, the only form of public-private partnership is a concession. The institution is transferred to the management of a private company, and it uses it to make a profit. However, public-private partnerships in medicine take several forms.

In the UK, private partners are also building clinics. Thanks to public-private partnerships, more than 100 large hospitals have been built there. The investor builds a building, equips it and then maintains it for 30 years. All this time he receives a fixed payment from the state.

Moreover, all payments for medical services in English clinics are outside the framework of public-private partnerships. Medical care is provided only by government agencies. There are not many successful examples of transferring the treatment process itself into the hands of a private investor.

However, it is public-private partnerships in the field of medical services that are most interesting for Russian government agencies.

The head of the department of price regulation in the social sphere of the Federal Tariff Service, Ivan Mikhailovich Berezkin, draws attention to drug provision. Instead of limiting ourselves to the concession of medical institutions, it is more promising to create public-private partnerships with pharmaceutical manufacturers. Such contracts are common abroad. For example, in the United States, patients in the second year of treatment receive Avastin, a drug for the treatment of a number of cancers, free of charge. Pharmaceutical assistance is paid for by the manufacturer. In Russia, the medicine costs more than 20 thousand rubles. for one bottle.

In countries where the patient does not pay his last money for the drug, but receives it, the five-year survival rate of patients with colorectal and breast cancer is 95%. In Russia, where cancer patients experience enormous financial difficulties, it is 60%. Unlike a medical partnership, cooperation between the state and the pharmaceutical manufacturer would protect the patient from unnecessary expenses.

But, apparently, free provision of life-saving drugs does not fit well with the “optimization” of federal budget spending on health care. It is true that the concession of medical institutions saves public funds only at the first stage. In the future, patients may simply not come to the hospital. Why, if only those who are able to pay are treated? The state will reimburse the lost profit to the private partner. The “cost savings” will be obvious.

Labudin A.V., Galstyan G.S.

Public-private partnership in healthcare

Labudin Alexander Vasilievich

Northwestern Institute of Management - branch of RANEPA (St. Petersburg) Head of the Department of Accounting, Control and Financial Management Doctor of Economics, Professor [email protected]

Galstyan Gayane Smbatovna

LLC "Medius and K" (St. Petersburg) General manager

Applicant at the North-Western Institute of Management - branch of RANEPA [email protected]

The article is devoted to the organization of the system of providing medical services in the Russian Federation and the use of the public-private partnership mechanism in this area. The article examines government decisions in this area and proposes options for public-private partnerships in healthcare.

KEY WORDS

reform of the public sector of the economy, provision of medical services, public-private partnership

Labudin A. V., Galstyan G. S.

State-private Partnership in Healthcare

Labudin Alexander Vasilyevich

North-West Institute of Management - branch of the Russian Presidential Academy of National Economy and Public

Administration (Saint-Petersburg, Russian Federation)

Head of the Chair of the Account, Control and Financial Management

Doctor of Science (Economics), Professor

[email protected]

Galstyan Gayane Smbatovna

JSC "Medius & Co" (Saint-Petersburg, Russian Federation) Director General

Candidate for the degree in economics of the North-West Institute of Management - branch of the Russian Presidential Academy of National Economy and Public Administration (Saint-Petersburg) [email protected]

This article is devoted to a very important problem - the organizations of system of providing medical services in the Russian Federation and uses of the mechanism is public-private partnership in this sphere. In article the state decisions in this area are considered and options are offered is public-private partnership in health care.

reform of the budgetary sector of economy; providing medical services, public-private partnership

Over the past 20 years, since the collapse of the USSR, Russia has been searching for the most effective healthcare model. In recent years, one of the most promising forms of healthcare development is the use of

2 public-private partnerships (PPP). It is obvious that a modern market economy cannot function without effective interaction between the state and private business. The methods and forms of this interaction are determined by the level of development of the market economy, national characteristics and the state of public sector economy.

x Despite the fact that there is no federal law on PPP in Russia, most n-regions have long had their own laws regulating it. One of the first to be accepted< Закон Санкт-Петербурга от 25.12.2006 № 627-100 «Об участии Санкт-Петербурга т в государственно-частных партнерствах». Во исполнение закона принято постановление Правительства Санкт-Петербурга от 31.03.2009 № 347 «О мерах по реализации Закона Санкт-Петербурга „Об участии Санкт-Петербурга в государственно-частных партнерствах"».

In the Budget Message of the President of Russia on budget policy in 2012-2014 It is noted that it is necessary to expand the use of public-private partnership mechanisms. In turn, in his speech on March 16, 2012, the President of the Russian Federation V.V. Putin emphasized that it is necessary to carefully study the best domestic and foreign experience of PPP in the social sphere, including healthcare, and make this institution one of the most important mechanisms for implementation social policy in the Russian Federation. Round table meetings of the Committee are held annually State Duma on health protection on the topic “Organization of public-private partnerships in the field of healthcare.” The business community also constantly organizes seminars and conferences on this topic and offers possible options for cooperation.

It should be noted that in Russia in recent years there have been changes in legislation aimed at introducing elements of public-private partnership in healthcare. In accordance with clause 10, part 1, art. 14 of the Federal Law of November 21, 2011 No. 323-f3 “On the fundamentals of protecting the health of citizens in the Russian Federation”, to the powers federal bodies State authorities in the field of health care include establishing the procedure for carrying out medical activities on the principles of public-private partnership in the field of health care.

It would seem that the need to introduce PPP mechanisms is obvious to everyone, however, in Russia, public-private partnerships in the field of healthcare are represented only by regional dialysis centers created by manufacturers of such equipment, and single projects, such as the creation of the AVA-Kazan perinatal center. Why, despite the desire of both the state and business, the model, recognized by everyone as promising and effective, is not widely used? In our opinion, the main reason for this is the problems and contradictions in the relationships between partners, which are caused by the following factors.

1. In the former socialist countries, in the process of transition from a centralized economy to a market economy, social conflicts were formed that are characteristic of a market economy as a whole. In Russia, in particular, this is acutely manifested due to the fact that the majority of the population was brought up on the ideal of free healthcare. The principle of free healthcare is enshrined in the Constitution of the Russian Federation. However, already in the early 1990s, during the economic crisis, the possibility of financing health care from the state budget sharply decreased. For this reason, decisions were made, enshrined in a number of sectoral federal laws and regulations, which allowed budgetary institutions health care to independently “survive” by earning money through entrepreneurial activity and the use of property assigned to

go after them on the right operational management. Income from these activities 2 went to so-called off-budget accounts. |

Since then, the share of paid medical services has been growing steadily. It was expected that with an increase in healthcare funding and significant investments within the framework of the healthcare modernization program, taking into account the requirements of budget legislation, the volume of paid medical services in public institutions would be reduced, and they would even be prohibited at the legislative level. n However, in 2012, Government Resolution No. 1006 dated October 6, 2012 “On approval of the rules for the provision of paid medical services by medical organizations” was issued, which at the legislative level established the right of state institutions to provide paid medical services.

Thus, the current situation in the medical services market is as follows: on the one hand, there is a huge network of state medical institutions that have received free land, buildings, structures, and receive subsidies as part of the state assignment (including for the maintenance of institutions) and funding for providing high-tech medical care. They freely provide paid medical services.

On the other hand, there are private medical organizations that are forced to rent or purchase buildings, structures and equipment at market prices, that do not have any benefits when lending, that through incredible efforts obtain additional capacity for connecting electricity, etc. It is precisely because of these difficulties that the majority of private clinics provide limited range of services. In such conditions, the creation and maintenance of a more or less large private medical organization is extremely complicated.

It should be noted that the only completed project"Ava-Kazan" is associated with the provision of a unique medical service - IVF: expensive and in demand. In 2012 and 2013 In St. Petersburg, another project implemented within the framework of public-private partnership in healthcare was widely covered. The clinic has established offices for general practitioners in gardening and the Primorsky district of St. Petersburg. It is stated that within the framework of the project, medical services are provided to citizens free of charge - only at the expense of the compulsory medical insurance fund. It is indicated that the private partner has invested significant funds in the creation of offices. Analyzing the tariffs established in this project, it is difficult to imagine how the interests of the private partner are taken into account.

Thus, private medical clinics forced to compete with government agencies within the framework of not only official paid services, but also “shadow” medicine.

2. Successful foreign public-private partnership projects require long-term agreements for up to 30 years. In this case, different schemes are used: as a public-private partnership, when a business invests funds in government projects, and public-private - when a significant part of the investments belongs to the state, but is managed by business.

Governments of many countries are beginning to use PPP to solve problems of improving the quality of medical services provided and increasing access to them, while transferring financial risk to a private partner. However, the current budget legislation of the Russian Federation does not allow guaranteeing long-term interaction between the state and the private partner within the framework of PPP agreements.

State and municipal guarantees provided for by the Budget Code of the Russian Federation are an important tool for structuring public-private partnerships, since they make it possible to ensure obligations

2 private partners for the return of debt financing. In accordance with the Code, state (municipal) guarantees are an integral part of the state (municipal) debt and can be provided for a period of up to 30 years from the federal or regional budget and for a period of up to 10 years from the budget of a municipal entity ( Art. 98-100 of the Code). Allocations for the possible implementation of issued guarantees are enshrined in the law (decision) on the budget for the next financial year (fiscal year and planning period) (clause 4 of article 115.2< Кодекса).

t The Budget Code of the Russian Federation establishes (Federal Law No. 145-FZ dated July 31, 1998, as amended on May 7, 2013), in accordance with Art. 179.2 that “an investment fund is a part of budget funds to be used for the implementation of investment projects carried out on the principles of public-private partnership.” Obviously, a specific amount budget allocations will always depend on the main parameters of the Federal and regional budgets for the next financial year.

Projects that involve large-scale investments in design, construction, financing and technical operation large medical institutions, in our opinion, cannot be implemented within the framework of existing budget legislation, taking into account the following problems: division of property rights between partners; the right to receive a state assignment for the provision of medical services; the right to receive funding for high-tech medical care (including until 2015); obtaining the necessary amounts of funding as part of the implementation of the territorial program of state guarantees for compulsory medical insurance; right to income; right to manage; right to use assets; the right to receive a contract for the provision of non-medical services, taking into account the legislation on placing government orders, etc.

At the same time, in Russia there is a constant search for the most effective mechanisms for managing public financial resources and optimal models for organizing the provision of essential public services. As we can see, so far PPP is associated either with infrastructure projects or with the supply of goods, works and services. In our opinion, it is wrong to limit public-private partnerships to just this framework. There is a form of public-private partnership that is very relevant for Russia, namely: the transfer, under certain conditions, for a certain period of time, of ineffective public institutions to the management of private companies, the creation of a kind of management company, which, by more efficiently using the funds allocated from the budget, achieves something different the final result.

Today, when the state has invested significant funds in strengthening the material and technical base and in informatization of healthcare as part of modernization programs, it is no secret that the main problem in Russian healthcare remains the lack of qualified personnel. Moreover, we are talking not only about the shortage of medical specialists, but, to a greater extent, about the lack of qualified managers, economists, accountants, lawyers, and especially technical specialists.

Traditionally low salary in the public sector does not allow government agencies to compete in the labor market. But for the effective functioning of institutions today, all these specialists are extremely necessary. In addition, the main postulates of 83-FZ are aimed specifically at increasing the efficiency of management of government institutions. In our opinion, it is in solving this problem that the mechanism of public-private partnership can be most effective.