Target. Study the main historical stages of the formation and development of health insurance.

• understand the main stages of the origin and development of health insurance abroad and in Russia, their social preconditions;
• to find out the socio-economic prerequisites and main tasks of introducing insurance medicine in Russia in the early 90s. XX century

Questions. The emergence of health insurance as a social phenomenon among artisans. The procedure for generating funds from health insurance funds for hired workers. Adopted in Germany at the end of the 19th century. laws on social insurance as a prototype of the modern compulsory medical insurance system. Otto Bismarck's insurance medicine system and its further development. Formation in Russia in the 19th century. factory medicine systems. Development in Russia of a public insurance system for artisans and hired workers. Creation of the first health insurance fund. Adoption of insurance laws by the III State Duma. Insurance program of the Soviet government. Revival of health insurance during the NEP period. Introduction of health insurance in post-Soviet Russia. Socio-economic prerequisites and main tasks of introducing insurance medicine in Russia in the early 90s. XX century

Basic concepts and terms. Insurance (sickness) funds for artisans and hired workers. Voluntary public insurance. Social Security Laws. Bismarck Health System. City and zemstvo medicine. Factory medicine. Work insurance medicine. Soviet medicine. Health insurance model.

Health insurance as a model for providing social guarantees from the state to citizens within the framework of the healthcare system in its modern form arose relatively recently. The development of the health insurance system has occurred over the past several centuries and was based on long-standing traditions of providing social assistance to citizens in the event of the onset of any disease. Modern principles of social insurance come from ancient Greek and Roman rules that ensured the functioning of the so-called mutual aid organizations, which were formed within the framework of professional colleges and were engaged in collecting funds and paying them in the event of an accident, injury, disability as a result of illness or injury.

In Europe, the emergence of health insurance as a social phenomenon is largely due to the development of craft production, the increase in the number of residents involved in it, and subsequently, the increase in the number of hired workers in factories and factories. They were unable to pay for expensive medical services provided by private doctors, but also did not have the right to government support and charitable assistance, since they did not belong to the poorest segments of the population.

Health insurance in the form of hospital insurance originated in Germany and Great Britain in the 17th-19th centuries. Currently, the stages of development of hospital insurance in Germany can be considered as a model for the development of health insurance in Europe, since it was German legislation that for the first time in history defined the principles of social insurance for citizens, including in case of illness.

In the 17th century in Germany, artisans organized the first insurance (sickness) funds, which, in addition to medical (hospital) insurance, providing payment for medical services to artisans and members of their families, carried out their protection on a public collective basis in other cases related to the social insurance system today. Similar insurance organizations received in the 19th century. distribution in most European countries.

With the development of capitalism, the funds of craftsmen were replaced by insurance (sickness) funds of hired workers, the funds of which were formed on the basis of an agreement from contributions from insured workers and entrepreneurial employers. The management of such sickness funds was carried out by meetings of sickness fund members and boards, which included representatives of workers and employers. A number of laws of the Prussian state provided for the functioning of both voluntary and compulsory mutual aid funds, as well as competition between them. At the same time, the procedure for interaction between the association of industrialists and compulsory insurance offices was determined.

The prototype of the modern compulsory medical insurance system is considered to be compulsory social insurance, which was first introduced in Germany at the end of the 19th century. During this period, in Germany, on the initiative of the government of Reich Chancellor Otto von Bismarck, three laws on social insurance were adopted:

• 1) June 15, 1883 - Law on workers' sickness insurance;
• 2) July 6, 1884 - Accident Insurance Law;
• 3) June 22, 1889 - Disability and Old Age Insurance Act.

With the introduction of these laws, the entire health insurance system in Germany underwent a significant reorganization. The Health Insurance Law provided for the introduction of the principles of compulsory insurance. Health insurance funds became the subjects of the insurance system. The law determined that insurance funds in the new system can guarantee assistance to family members of the insured. Individual funds could ensure appropriate equalization of differences in insurance premiums. Contributions for 2/3 were paid by the insured himself and for 3 - by his employer. The guaranteed minimum volume of medical care, which was covered by compulsory insurance, consisted of free medical care, free medicines, sickness benefits from the third day from the onset of the disease and up to a maximum of 6 weeks, money paid to family members in the event of death in the amount of 20 times wages. The minimum amounts of payments could be expanded within certain limits in accordance with the charters of individual cash desks.

Social insurance laws adopted in Germany under the Bismarck government laid the foundation for a health care system called “insurance medicine.” Their historical significance was that the introduction of elements of national compulsory insurance served as the basis for the inclusion in the health insurance system of a large number of the working population of Germany, which had previously been among the socially disadvantaged groups. The healthcare organization system began to be based on three sources of financing: the state budget, mandatory contributions from employees and employers.

Most European countries passed similar laws between 1883 and 1912.

At the beginning of the 20th century. In Germany, objective preconditions for introducing amendments to the laws on social insurance had developed, since many segments of the population were not covered by health insurance. With the introduction of the State Insurance Rules in 1911, which were included in the consolidated law on social insurance, significant changes occurred in the field of health insurance: community insurance was abolished and the minimum number of members in one health insurance fund was limited; The number of workers subject to compulsory insurance was expanded, in particular, they included workers in agriculture, consumer services, as well as people doing work at home.

In modern Germany, social protection of the population is one of the most effective state social systems in the world. This is ensured to the greatest extent through social, including medical, insurance of citizens. More than 90% of German citizens participate in the social insurance system and are insured. Such high results are ensured, among other things, through the consistent development of the system of compulsory state social insurance.

Currently, two basic models for the provision of medical services have historically developed in Europe.

• 1. State universal health care (Beveridge model) (Fig. 1), characterized by the following features:
  • based on state budget funding;
  • introduces universal coverage of medical expenses for the population due to the obligation imposed on the state to pay for basic types of medical care using tax payments to the budget;
  • is based on the principles of solidarity and state responsibility for protecting the health of citizens.

Rice. 1.

Denmark, Spain, Finland, Great Britain, Greece, Italy, Ireland, Portugal, and Sweden have a unified public health care system in Europe. However, in four of them - Spain, Great Britain, Greece and Italy - a portion of health insurance premiums is used to finance health care.

• 2. Insurance medicine within the framework of social insurance (Bismarck model) (Fig. 2), which has the following features:
  • financed from social insurance contributions;
  • introduces universal coverage of medical expenses for the population by imposing an obligation on the population and employers to pay insurance premiums;
  • based on the principles of self-sufficiency and state responsibility for its organization and financial stability;
  • health insurance includes two main types of coverage: replacement of earnings lost during a period of disability, and compensation for expenses associated with receiving medical care.

Rice. 2.

This system is typical for six European countries: Austria, Belgium, France, Luxembourg, the Netherlands, and Germany.

In Russia, the emergence of elements of social insurance and insurance medicine began at the end of the 18th - beginning of the 19th centuries, when the first mutual aid funds appeared at the first capitalist enterprises that emerged. In 1861, the Law “On the compulsory establishment of auxiliary partnerships at state-owned mining plants” was adopted, which for the first time introduced elements of compulsory insurance in Russia. Due to mandatory deductions from workers' wages (2-3%) and contributions from plant management, equal to the contributions of workers, special insurance funds were formed, from which sickness benefits and pensions were paid to the disabled, widows and orphans.

Along with city and zemstvo medicine, in Russia already in the second half of the 19th century. a system of factory medicine is being formed. In 1866, in connection with the cholera epidemic, the “Highest Command” ordered the owners of factories and factories to allocate and equip premises for the provision of medical care or to build hospitals at the rate of 1 bed per 100 workers with free treatment. Factory medicine was completely dependent on the owners of the enterprises and was not popular in the working environment. Medical care was extremely unsatisfactory.

Gradually, in Russia, as in Western Europe, a public insurance system for artisans and hired workers is becoming widespread, with insurance (sickness) funds becoming the main insurance institution. The first health insurance fund in Russia was organized in Riga in 1859 at the P.H. Rosencrantz and Co.

In 1903, Russia adopted the “Law on the remuneration of citizens who suffered as a result of an accident, workers and employees, as well as members of their families at enterprises of the factory, mining and mining industries,” in accordance with which the obligation to make payments to victims or members of their families in the form of benefits and pensions at the expense of the employer and the treasury.

In 1912, the III State Duma adopted a number of insurance laws, including the “Law on Insurance of Workers in Case of Sickness and Accidents,” which provides for compulsory medical insurance for workers, which covers about 20% of employees. The insurance body was the health insurance fund, established in every enterprise with at least 200 employees. Small enterprises could organize general health insurance funds. The health insurance fund was governed by the general meeting, which was the supreme body, and the board, which was the executive body. The general meeting and the board included representatives of workers and entrepreneurs. The health insurance funds consisted of contributions from workers and entrepreneurs. The main function of the health insurance fund was to provide benefits in cases of illness, injury, childbirth and death. The funds entered into contracts with hospitals and could create their own hospital institutions.

The first cash hospital was created in Russia in 1914 at the Tula copper rolling and cartridge factories. Health insurance funds were subordinate to provincial insurance offices, which were headed by the governor or mayor. Insurance presences were subordinate to the Russian Insurance Council.

After the February Revolution in 1917, the Provisional Government came to power, under which the “Regulations on changing the rules on providing workers in case of illness” were developed, and on July 25, 1917, a new Law on Health Insurance was adopted, providing for an expansion of the circle of compulsory insured persons. insurance. However, the reforms of the Provisional Government remained unrealized.

With the advent of Soviet power on October 30, 1917, the People's Commissariat of Labor announced the insurance program of the Soviet government, declaring “full social insurance” on the basis of complete centralization. A number of decrees are adopted: “On the transfer of medical institutions to health insurance funds” (November 14, 1917); “On insurance presences and insurance council” (November 29, 1917); “On Insurance in Case of Unemployment” (December 11, 1917); “On health insurance” (December 22, 1917). In accordance with the decrees, the creation of the so-called workers' insurance medicine began, controlled by the People's Commissariat of Labor. In a short time, a system of medical institutions (outpatient clinics and hospitals) was created at health insurance funds, where the insured received qualified medical care.

The creation of the People's Commissariat of Health in July 1918 led to the existence of two parallel health care systems: “workers' insurance medicine,” subordinate to the People's Commissariat of Labor, and “Soviet medicine,” created on the basis of zemstvo and city medicine and subordinate to the People's Commissariat of Health.

On February 18, 1919, the Council of People's Commissars adopted a resolution "On the transfer of the entire medical part of the former sickness funds to the People's Commissariat of Health." Since that time, “worker insurance medicine” was eliminated, and a unified national “Soviet medicine” was created. At the same time, the entire social insurance system was reformed and replaced by a state social security system.

Some revival of the social insurance system occurred during the period of the New Economic Policy (NEP) due to the emergence of various forms of ownership of the means of production, which also required new approaches to social insurance. Resolutions of the Council of People's Commissars in 1921 - 1923. insurance contributions of employers were determined for various forms of ownership for certain types of social insurance. In particular, contributions were established for temporary disability and other related types of support: for disability, widowhood and orphanhood, for unemployment and for medical care. At the same time, the size of the insurance premium for all types of insurance, except unemployment, depended on the danger and harmfulness of production. The statutory contributions for medical care were transferred directly to health authorities: 10% to the People's Commissariat of Health and 90% to provincial and local health authorities to improve medical care for the insured.

Thus, social insurance introduced in Soviet Russia during the NEP period was mandatory and was a real additional source of healthcare financing while maintaining state funding as the main one and using other forms of payment for medical services.

After the liquidation of the NEP, health insurance as such was abolished and only certain elements of it continued to exist in the Soviet social insurance system under the auspices of trade unions in the form of sanatorium-resort treatment, as well as certain types of preventive and health-improving work at industrial enterprises.

Until the beginning of the 90s. XX century In Soviet Russia there was a unified national health care system, which was financed from the state budget.

With the beginning (in the late 80s - early 90s) of economic reforms associated with changes in forms of ownership and the emergence of entrepreneurial employers using hired labor, a need arose to reform the social insurance system and revive the institution of health insurance. The collapse of the socialist system, the growing crisis in the economic and political life of the country, the growing inability of the state to provide payment for medical care to the population at its own expense were the socio-economic prerequisites for the introduction of health insurance.

Medical insurance in post-Soviet Russia was introduced on January 1, 1993 in accordance with the Law of the RSFSR “On Medical Insurance of Citizens in the RSFSR” adopted on June 28, 1991 by the Supreme Council of the RSFSR, which provided for a new budgetary and insurance model for financing domestic healthcare.

The main objectives pursued by the introduction of compulsory medical insurance in Russia were:

Attracting additional financial resources to healthcare

• increasing the sustainability of the healthcare system;
• providing all citizens of the Russian Federation with equal opportunities to receive treatment and preventive care provided through insurance premiums and payments, in the amount and on conditions corresponding to compulsory insurance programs.

As a result of studying the chapter, the student will:

• know history of development, basic concepts, structure and legal basis of the health insurance system, the role of health insurance in financing health care;
• be able to formulate the purpose, objectives and conditions of compulsory and voluntary health insurance;
• own methods for drawing up voluntary health insurance programs.

Key terms: medical care, medical support, public health, social charity, medical and medical-social insurance, compulsory and voluntary medical insurance, program of state guarantees of free medical care to citizens, compulsory and voluntary medical insurance programs, availability of medical care, insurance tariff.

Historical overview of the development of health insurance in Russia

The development of health insurance, as one of the ways to finance medical care, is inseparable from the development of healthcare. Several stages in the development of public medical care (health care) can be distinguished, i.e. organizing the provision of medical care to the entire or significant part of the country's population and corresponding to these stages of the formation and development of medical insurance in Russia. On first stage public medical care was provided in the form of charity and social charity for the sick. Insurance mechanisms for financing public health care were not used at this stage. Funds for assistance were allocated by rich people, the church, and later by the state.

Second stage the development of public medical care is associated with the abolition of serfdom and the development of zemstvo self-government. At this stage, the principles of mutual insurance are applied to finance medical care.

Third stage development of public health in the last third of the 19th century. in Russia is associated with the emergence and development, as in most developed European countries, of compulsory medical and social insurance, initially in the form of mutual insurance.

Medical and social insurance– a form of public organization and financing of medical care for part or all of society.

The first state legislative acts introduced elements of compulsory medical and social insurance in Russia for workers in the mining industry and railway transport, where the most dangerous working conditions were observed. On March 6, 1861, the Law “On the compulsory establishment of auxiliary partnerships at state-owned mining plants” was adopted. This law recommended the establishment of health insurance funds in partnerships to provide benefits to members of mining partnerships, as well as one-time benefits to members of their families. The management of such a cash register was carried out by a council, whose members were elected from among the members of the cash register, and the chairman was appointed by the mining chief from among engineers or officials. All employees of this plant were members of the partnership. Due to one-time government donations, mandatory deductions from wages (2–3%) of workers and equal contributions from plant managements (employers), special insurance funds were formed in sickness funds, from which sickness benefits, pensions for the disabled, widows and orphans were paid. In total, 14 such partnerships were established at state-owned mining plants. On January 1, 1886, they had 6,659 members and a capital of 613,612 rubles.

Along with zemstvo medicine, factory medicine begins to develop, which is an element of compulsory medical and social insurance for the working population. In 1866, a law was passed obliging owners to create hospitals (hospital premises) at the rate of 1 bed per 100 workers at large factories and factories with 1000 or more workers and maintain them at their own expense to provide free medical care to workers.

The law was not fully implemented. Opened in 1870–1880 hospitals in large factories were underpowered and could not provide medical care to all workers in a factory or factory in need. Medical care provided to factory workers was unsatisfactory and covered only 20–30% of all industrial workers. By 1907, medical care was organized in only 38% of all factories in the country. The rest of the workers, like the rest of the population, used city and zemstvo medical institutions on a general basis, and they were charged a hospital fee.

The introduction of medical and social insurance in Russia on the basis of sickness funds was prepared by the previous development of social mutual insurance. The law of June 23, 1912 consisted of four separate provisions, the effects of which were interrelated:

• 1. Law and Regulations on presence in cases of workers' insurance.
• 2. Law and Regulations of the Workers' Insurance Council.
• 3. Law and Regulations on provision of workers in case of illness.
• 4. Law and Regulations on workers' accident insurance.

The laws came into force on January 1, 1913 and served as the basis for the introduction of two types of compulsory insurance: in case of illness and against industrial accidents. The compulsory nature of insurance extended to a wide range of industrial enterprises that had machines and engines, with a number of workers and employees of at least 20 people; as well as industrial enterprises that did not have machines and engines - with a number of workers and employees of at least 30 people. Construction workers, agricultural workers, commercial employees, artisans and servants were not subject to compulsory insurance on the basis of the above laws.

Health insurance was supposed to be carried out through hospital (insurance) funds. Initially, cash desks were created only:

• a) to provide benefits to its participants in connection with their illness;
• b) funeral benefits in the event of the death of a member of the fund;
• c) benefits to a member of the fund in the event of injury, but only for the duration of treatment and until the outcome of the injury is determined;
• d) benefits for mothers in labor.

The number of members of a separate health insurance fund should not be less than 200 people. With a smaller number, a common (united) cash desk should have been created for several enterprises. All workers and employees of the enterprise (or several enterprises) at which the cash desk was established were required to become its members from the day the cash desk was opened. Those who entered the workforce later became members of the cash register from the day they were admitted to work.

The cash desks were established on the basis of the Charter and were governed by a general meeting of authorized representatives, which was the decision-making body and resolved fundamental issues. The number of authorized representatives included persons elected by the workers who were members of the cash register, as well as representatives of the owner of the enterprise, who, regardless of their number, had 2/3 of the votes of the workers present at the meeting. The meeting was always chaired by the owner of the enterprise himself or his representative.

The general meeting of the health insurance fund elected members of the board, the audit commission, heard and approved the annual report of the board, elected, and considered complaints from fund members about the actions of the board. In addition, the law gave the assembly the authority to resolve the following important issues directly related to the conditions of insurance:

• – establishing the exact amount of insurance payments in the event of illness of a member of the fund and benefits for mothers in labor;
• – granting the right to pay for treatment to family members of a participant (member) of the cash fund and establishing the maximum amount that the cash fund can spend in each case;
• – approval, within the limits established by law, of the specific amount of insurance premiums to be paid by members of the cash fund, etc.

The board of directors was the executive body of the health insurance fund. It consisted of workers' representatives, who were elected by the general meeting from among those present at the meeting, and employer representatives, appointed by the owner of the enterprise. The number of selected persons should always be 1 person. more than the number of appointed persons1. The board was elected for the period established by the Charter of the cash fund. The chairman of the board and his deputies were elected by the board from among those elected to the board. But the Charter of the cash fund could determine that the chairman of the board is the owner of the enterprise. In this case, elections for the chairman were not held.

The funds of the cash desk consisted of contributions from employees and employers. Workers paid from 1 to 2% of earnings (3% was allowed in small cash registers); the employer paid from 0.7 to 1.3% of the workers' wages. The amount of contributions to each health insurance fund was established by the general meeting of commissioners. In accordance with the law, insurance premiums were not deducted from members of the fund during illness.

The higher the employee's income, the higher the percentage of his mandatory contributions to the health insurance fund. Contributions were accrued from earnings not exceeding 5 rubles. per day or 1500 rub. per year. The amounts of insurance payments were limited to the maximum amount calculated from earnings of 1,500 rubles, no matter how great the actual earnings of a member of the cash register. Consequently, the insurance principle of the financial relationship between the health insurance fund and its member was applied here: the amount of insurance payment was limited, but determined in accordance with the insurance premiums paid.

The cash desks also had other sources of financial resources: income from cash desk property, donations, monetary penalties imposed by the board, penalties and other random income.

In accordance with the law, cash desk funds were divided into working capital and reserve capital. The current expenses of the fund were made from working capital, which was formed from regular contributions, surcharges and income from the property of the health insurance fund, as well as voluntary donations.

Reserve capital served as a reserve of working capital and, in case of shortage, was used for current expenses. Its sources were the amounts of contributions and additional payments in the amount provided for by the charter of the cash desk. By law, this amount had to be in the range from 5 to 10% of the amount of receipts at the cash desk. In addition, the balance of the cash register based on the results of work for the year and some other income were transferred to the reserve capital. If the size of the reserve capital reached an amount equal to the amount of cash expenses for the last two years, then contributions to it stopped. If its amount fell below the amount of two-year expenses, then the contributions had to be resumed. The law also established that when the reserve capital reached the amount of two years' expenses, the general meeting of the treasury could reduce the amount of contributions of participants below the lower limit, i.e. below 1% of earnings.

If there were insufficient funds for operating expenses, the board of the health insurance fund had to either increase contributions or reduce expenses. In addition, the law gave the cash registers the right to receive loans and benefits from public funds in certain circumstances, for which the management of the cash fund had to send a request to the Minister of Trade and Industry. Loans were to be repaid using reserve capital.

Temporarily available funds from sickness funds were to be placed in government and government-guaranteed securities and securities of other government agencies, as well as in deposits and current accounts of a state bank or state savings bank. The placement of such funds into the current accounts of private credit institutions was permitted only on the instructions of the Minister of Industry and Trade, agreed with the Ministry of Finance.

The funds paid benefits in the event of illness, injury, childbirth and death. They also provided assistance to family members of the insured, but the amount of expenses for providing this assistance should not exceed 1/3 of the cash receipts budget.

The law established the minimum and maximum amount of the benefit and the timing of its issuance. The specific amount of the benefit was determined by the health insurance funds themselves, which had to proceed from their financial capabilities.

The principles of operation of the health insurance fund had a certain similarity with the principles of departmental mutual insurance. The financial sustainability of sickness funds was supported to a certain extent by the state, since they were eligible to receive loans and benefits from public funds. In addition, the state's concern for the financial stability of sickness funds was manifested in the establishment of rules on the formation of reserve capital, as well as in the precise indication of how temporarily free funds of sickness funds should be allocated.

In accordance with the Law of June 23, 1912, sickness funds were subject to triple supervision. Their activities were controlled by the following organizations:

• 1. Factory inspectorates, which approved the charters of sickness funds, had the right to audit cash funds, monitor the correct receipt of contributions, and collect payments from entrepreneurs that were not made on time. Inspections also carried out inspections of the records management and reporting of health insurance funds.
• 2. Presence for workers’ insurance matters (insurance presence). They included officials and owners of industrial enterprises in the amount of 13 people, and 2 representatives from workers. These presences operated in every province and region, as well as in cities (St. Petersburg, Moscow, Odessa, Warsaw). The chairman of the presence was the governor, mayor or chief of police, respectively. The workers' insurance offices were subordinate to the workers' insurance council.
• 3. Workers' Insurance Council. In accordance with the law of June 23, 1912, it was the central body for workers' insurance, established under the Ministry of Trade and Industry. It consisted of 26 members, including the Deputy Minister of Trade and Industry, 2 members each from the Ministry of Trade and Industry and the Ministry of Internal Affairs, 1 member each from the Ministries of Justice, Finance and Transport, the General Directorate of Land Management and Agriculture, and the Medical Council or the Main Directorate of Medical Inspector, St. Petersburg Provincial Zemstvo, St. Petersburg City Duma, and 5 representatives of enterprise owners and participants in health insurance funds. The Workers' Insurance Council issued

Regulatory documents on compulsory insurance of workers and employees against illnesses and accidents. In particular, on his initiative, a standard (“normal”) charter for general health insurance funds was developed and approved on March 6, 1913. The Council also considered complaints about the activities of insurance companies.

The presences for workers' insurance matters (insurance presences) were assigned the following functions in terms of interaction with health insurance funds:

• 1) organizational and control function, which consisted of issuing permits for the opening of health insurance funds and monitoring their activities. The presence had to approve the charter of the cash desk in the event of a significant deviation from the standard charter; issue permission to merge several health insurance funds into one, conduct audits of the funds of the health insurance fund, its records management, board reporting, etc.;
• 2) maintaining a register of health insurance funds;
• 3) protection of the interests of members of health insurance funds, including consideration of complaints against factory inspectors, entrepreneurs, and board members;
• 4) participation in establishing relations between health insurance funds and medical institutions, in particular, determining the daily cost of maintenance and treatment of persons insured by health insurance funds in hospitals belonging to city or zemstvo self-governments.

In accordance with the law, sickness funds were intended primarily for insurance against illnesses and accidents, which meant only the issuance of benefits. Health insurance funds had the right to provide assistance to family members of the insured, but the costs of this assistance should not exceed 1/3 of the income budget of the health insurance fund.

The law of June 23, 1912 does not prohibit sickness funds from organizing medical care, namely: setting up and maintaining their own outpatient clinics, emergency rooms and hospitals; enter into agreements with city and zemstvo public administrations, as well as with private medical institutions. The employer decided independently or in agreement with the management bodies of the sickness funds the issue of the application of payment mechanisms and methods of providing medical care in factory, zemstvo and city hospitals or in the medical institutions of the sickness fund. This served as the basis for the creation of sickness funds of their own medical institutions.

And health insurance funds began to work in this direction. For example, the sick fund of the Nasal plant in 1914, along with issuing benefits to members of the fund, began to provide medical care to members of their families, for which it entered into agreements with 19 doctors, 26 midwives, as well as paramedics, dentists and massage therapists. They received patients at home or at their main place of work on the basis of coupons issued at the office of the health insurance fund. The provision of medical care was organized in a similar way in other cash offices, for example, those operating in the Smolensk province and Kazan.

Along with this, some health insurance funds have taken the path of creating their own outpatient clinics, hospitals, and pharmacies. The organization of medical care for members of sickness funds on the basis of insurance principles was an important point for the organization of their medical care. The funds tended to select doctors from whom their members could be treated. But at the same time, the cash desks had the opportunity to monitor the quality of medical care, as well as the ratio of price and quality of medical services provided. If necessary, the cash register could refuse the services of one doctor and enter into an agreement with another.

Important, in our opinion, is the fact that the state made no effort to centralize the collection of financial resources in the system of compulsory medical and social insurance in the Russian Empire. The insurance principles underlying the organization of sickness funds determined their desire for unification. After all, the more policyholders in a mutual insurance company, the more stable its financial position. By concentrating large financial resources in its hands, the mutual insurance organization had the opportunity to organize the provision of higher-quality medical services on their basis. In this regard, work has intensified in the Russian Empire to create united health insurance funds in St. Petersburg, Moscow, Riga, Kharkov and other cities.

The State, through the Workers' Insurance Council and the Workers' Insurance Presence, supervised the activities of the sickness funds. But these bodies had mainly control functions; they did not exercise centralized management of insurance organizations. The cash desks themselves decided such fundamental issues as establishing the amounts of insurance premiums and insurance payments, and determining the circle of insured.

A distinctive feature of sickness funds was that the owners of enterprises, who could act themselves or through representatives, took a direct part in their work, both material and organizational. Another important feature of the activities of sickness funds was the fact that members of its board performed their duties for free. The number of health insurance funds has grown steadily (Table 2.1).

Table 2.1

Organization of sickness funds for compulsory medical and social insurance in the Russian Empire in 1914–1916.

With the establishment of Soviet power, in connection with the beginning of radical reform of the system of compulsory medical and social insurance, we can talk about fourth stage development of public health care and medical insurance in Russia on the basis of its centralization and ensuring universal coverage of the population.

In 1919, V.I. Lenin signed the Decree of February 19 “On the transfer of the entire medical part of the former sickness funds to the People’s Commissariat of Health,” as a result of which all medical work was transferred to the People’s Commissariat of Health and one hundred local departments. The decree abolished insurance medicine. The results of such reform in the fight against infectious diseases were quite convincing at first. The incidence of social diseases (tuberculosis, syphilis, etc.), infant mortality, etc. have significantly decreased.

Medical and social insurance during the NEP period was characterized by an extremely large volume of insurance coverage, wide coverage and a differentiated approach to organizing insurance for various groups of workers, which created difficulties in the implementation of legislative and regulatory acts.

Medical and social insurance applied to all employees employed in state, public, cooperative, concession, mixed or private enterprises, institutions, farms or individuals, regardless of the nature and duration of work and methods of remuneration. Persons employed in seasonal and temporary work, farm laborers and farm laborers working at home, in the service and freely employed in military and naval departments, artel workers, apprentices working in enterprises, small handicraft and handicraft industries were also subject to insurance. students studying in factory schools, students undergoing practical training, elected officials, literary workers. It should be especially noted that medical and social insurance applied only to hired workers and practically did not affect the unemployed urban population and the overwhelming majority of rural residents, both self-employed and those united in collective farms.

The scope of coverage for medical and social insurance included:

• – provision of medical care;
• – payment of benefits for temporary disability due to illness, injury, quarantine, pregnancy, childbirth, caring for a sick family member;
• – payment of benefits for feeding the child and for child care items;
• – payment of disability benefits;
• – payment of benefits to family members in the event of death or unknown absence of the breadwinner;
• – payment of funeral benefits;
• – payment of unemployment benefits.

In 1924, only 956 health insurance funds operated in the USSR, which is 2.5 times less than in 1916 in the Russian Empire. But the volume of insured persons increased 3 times. At the same time, the average number of participants in health insurance funds increased by 7.2 times (Table 2.2).

Table 2.2

Dynamics of development of compulsory medical and social insurance in the USSR in the period 1916–1924.

By 1928, medical and social insurance covered more than 9 million people, i.e. There was a positive trend in increasing the coverage of medical and social insurance among the country's hired population.

It should be separately noted that the activities of hospital insurance funds were based on actuarial calculations, i.e. calculations of insurance risks and upcoming payments to insured persons for their obligations were used. To determine the parameters of insurance risks (the level and frequency of morbidity, injury, temporary and permanent disability, mortality and other insured events), employees of insurance offices used reporting data on the results of activities for previous years.

On March 4, 1924, the “Regulations on the procedure for organizing medical care for the insured and members of their families and spending funds intended for these purposes” was adopted. This document served as the financial basis for completing the formation of the compulsory medical insurance system in its modern sense and creating an organizational structure of medical care for insured citizens. Medical assistance to the population was provided by the state health care system, medical institutions of insurance funds and private doctors and clinics. Insured persons were served in state medical institutions and medical institutions of hospital insurance funds at the expense of insurance funds.

There were not enough insurance funds for medical care. Insurance premiums, according to calculations, should have amounted to 25% of the amount of expenses required for medical care, but in fact covered no more than 13% of the necessary expenses. At the same time, in rural areas there was a particularly difficult situation with the financing of medical care, since due to the low size of the wage fund, the volume of insurance premiums itself was insignificant. Therefore, it was decided to allocate a fund for curative (medical) assistance from the system of social insurance funds.

Since February 1925, management of the fund for curative (medical) assistance to insured persons was transferred to the People's Commissariat of Health of the RSFSR and its divisions (People's Commissariat of Health of the Autonomous Republics and Gubernia Health) through the departments of medical assistance to insured persons created under them. Management of the pension fund and other benefits was placed under the direct control of the social insurance authorities of the People's Commissariat of Labor. The costs of operating the department of medical assistance to insured persons amounted to up to 3% of the amount of insurance premiums collected by insurance authorities.

Medical assistance departments solved problems not only in organizing the provision of medical care to insured persons, but also in preserving the health and improvement of workers, as well as in coordinating the work of other structures to solve medical, health-improving and preventive problems. The management of the department, by decision of the social insurance authorities, was allowed to additionally use funds from local operating funds of pensions and other benefits for measures to prevent illness and occupational injuries, including the organization of rest homes, local sanatoriums, dispensaries, etc.

In accordance with the Resolutions of the Central Executive Committee and the Council of People's Commissars of the USSR dated August 15, 1926 and the Central Executive Committee and the Council of People's Commissars of the RSFSR dated March 7, 1927 No. 25-1, the following fundamental changes were made in the system of organizing and financing medical care within the framework of medical and social insurance:

• a) all departments, subdivisions and departments of funds for medical assistance to insured persons that existed at that time in the apparatus of the People's Commissariat of Health of the RSFSR, the People's Commissariat of Health of the Autonomous Republics and local health authorities were liquidated;
• b) funds for medical assistance to insured persons have been transferred to the full management and disposal of health authorities;
• c) the organization of medical care for insured persons is entirely entrusted to the health care apparatus;
• d) it was established that the funds of the medical care fund for the insured are not subject to inclusion in the budget and for their use separate plans and estimates are drawn up, while the funds could be used for all types of medical and preventive care for the insured;
• e) it was determined that health insurance funds are an addition to the local and state budgets and should not lead to a decrease in budgetary allocations for health care; the need to take them into account outside the balance sheet according to special income and expense estimates attached to the report on the use of budget funds was indicated;
• f) it is determined that the funds of the medical fund are transferred: in the amount of at least 10% of the total amount to the republican and 3% to the all-Union funds.

Important!

These changes led to the merger of medical and social insurance in the form of mutual insurance based on sickness funds and state medicine (for civil servants) into budgetary insurance medicine.

Budgetary funds were also used to pay for medical care of insured persons, for which special amounts were reserved from the state and local budgets. The insurance funds of the medical care fund were in addition to the budget funds; in addition, the Main Directorate of Social Insurance took a certain part in this area of ​​financing in the form of subsidies through the consolidation of all medical and social insurance funds.

The difficulties experienced by healthcare, including in organizing and providing medical services to insured persons, were primarily due to the low level of budget funding. For 38 administrative territories of the country in 1926–1927. Budget funds accounted for only 30.9% of the volume of funds used to pay for medical care of insured persons, and compulsory medical insurance funds, respectively, 69.1%. The costs of medical care for insured transport workers were covered by 82.4% of health insurance funds. A situation arose when public health care was financed mainly through compulsory health insurance funds.

The introduction of budgetary insurance medicine became a natural means of centralizing economic management during the construction of socialism. In the 1920s–1930s. The social insurance system of the USSR reached its peak and was practically at the level of developed European countries, ahead of

The USA and Japan, where social insurance did not yet exist at that time. In 1927, social insurance funds accounted for the national income: in the USSR - 4.5%, in Germany - 7.5%, in Great Britain - 3.75%. But later, starting in 1929, as a result of the adopted political course towards the complete centralization of management of the entire national economy of the country, medical and social insurance as an independent social insurance system, restored during the NEP period, was essentially abolished again, as a result of which health care lost an important , a significant and additional, and sometimes the main source of financing.

Important!

From this period we can talk about the beginning of the fifth stage of public health development - budgetary medicine, in which insurance principles were not applied.

These transformations of Soviet healthcare are associated with the name of N. Semashko. He based the proposed healthcare system on several ideas: unified principles of organization and centralization of the healthcare system; equal access to healthcare for all citizens; priority attention to childhood and motherhood; unity of prevention and treatment; eliminating the social basis of diseases; involving the public in health care. All these ideas have been developed by many leading doctors in Russia and the world since the end of the 19th century. However, they were first used as the basis of state policy in Soviet Russia.

Historical excursion

It should be noted that the ideas of centralizing healthcare were considered long before the October Revolution. Back at the end of the 19th century. In the bowels of the Ministry of Internal Affairs of Russia, a commission was created under the chairmanship of Professor S. Botkin, as it was said, to “find measures for the widespread improvement of Russia.” The commission, changing its chairmen, continued to work almost until the very beginning of the First World War. Its last chairman was Professor G. Rein, who finally formulated the idea of ​​​​the need for a centralized health care management system, which was developed by the commission from the very beginning of its activity. To organize such a system, the commission, for the first time in the world, developed standards for providing the population with medical care (or, in modern terms, programs of state guarantees for providing citizens with medical care).

Characterizing the approach of contemporary healthcare to the problems of the health of the nation, G. Rein wrote that until now “medical work has been reduced mainly to providing care to the sick and to stopping outbreaks of epidemics, and the task of eliminating the conditions conducive to the emergence and development of diseases, and the expedient formulation of public hygiene and sanitation were, by force of things, relegated to the background." It was public hygiene and sanitation that the planned ministry was supposed to primarily deal with.

However, the medical community condemned this idea. The majority of famous doctors, as well as the most authoritative association of Russian doctors, the Pirogov Society, also opposed it. All of them were afraid that the ministry would become a bureaucratic superstructure that would interfere with the free development of zemstvo and city medicine. Representatives of departmental medicine, which was already widespread in Russia at that time, also did not approve of the plan. By the way, left parties, including the Bolsheviks, also did not support the idea, advocating the development of compulsory health insurance following the example of Germany. Nevertheless, Nicholas II established the Main Directorate of State Health Care, which, under pressure from the State Duma, which reflected the sentiments of the majority of the then public on this issue, was liquidated in 1916.

However, the devastation that reigned after the revolution convinced most doctors that in such conditions concentration of resources, public administration and planning of the medical industry are necessary. And in June 1918, at the proposal of the All-Russian Congress of Medical and Sanitary Departments of the Soviets, the People's Commissariat of Health was created. After heated debates, this decision was eventually supported by the Pirogov Society. And then, through the efforts of N. Semashko and his followers, the budgetary healthcare system began to be built in a planned manner.

For the first time in the world, a special organization was created for the centralized management of healthcare throughout the country - the People's Commissariat of Health, under whose jurisdiction all departmental, zemstvo and insurance medical institutions were transferred. Private medicine was eventually eliminated, although public paid clinics remained. The concentration of resources in the hands of one department made it possible, even in conditions of limited funds (and this problem haunted Soviet medicine all the years of its existence), to achieve quite serious results, at least in overcoming traditional infectious diseases, reducing maternal and child mortality, in the prevention of social diseases and sanitary educating the population. The idea of ​​a comprehensive solution to social, scientific and technical problems of great national importance through the concentration of resources and planned economic management, no matter how banal it may sound now, was an amazing social innovation at that time, which attracted the attention of the whole world to the experience of the Soviet Union.

A coherent system of medical institutions was built, which made it possible to ensure uniform principles of organizing healthcare for the entire population, from distant villages to capital cities: paramedic and midwife station - local clinic - district hospital - regional hospital - specialized medical institutes.

However, despite all the efforts of N. Semashko, it was not possible to include all medicine into a single system. The army, railway workers, miners and many other departments, as well as the nomenklatura, retained their medical institutions. Access to healthcare was ensured by the fact that medical care was free, all citizens were assigned to local clinics at their place of residence and, depending on the complexity of the disease, could be sent for treatment higher and higher up the steps of the healthcare pyramid.

A specialized system of medical institutions for children was organized, replicating the system for adults, from a local clinic to specialized scientific institutes. To support motherhood and infancy, the same vertical system was organized - from antenatal clinics and district maternity hospitals to specialized institutes.

To combat occupational diseases in enterprises with hazardous working conditions, medical units were created that were supposed to monitor the working conditions and health of workers. Dispensaries, unique sanatoriums in the workplace, were also created there.

Subsequently, medical units appeared at almost all large enterprises.

Prevention was understood by N. Semashko in both a narrow and a broad sense. In a narrow sense - as sanitary measures, in a broad sense - as health improvement, prevention and prevention of diseases. The task of each doctor and the entire system of medical institutions, as N. Semashko believed, was not only to cure, but to prevent the disease, which was considered as a consequence of unfavorable social conditions and an incorrect lifestyle. In this regard, special attention was paid to such social diseases as venereal diseases, tuberculosis and alcoholism. For this purpose, a system of appropriate dispensaries was created. They had to not only treat, but also monitor the living conditions of the sick, informing the authorities about the non-compliance of these conditions with sanitary standards and the potential threat that the sick could pose to others.

An important preventive measure, according to N. Semashko, was vaccination, which for the first time took on a nationwide character and served to eradicate many infectious diseases, and sanitary and hygienic propaganda, which received great attention as one of the means of preventing epidemics and promoting a healthy lifestyle. Many outstanding poets and artists, as well as broad sections of the public, were involved in propaganda. Rest homes and sanatoriums were naturally included in the coherent system of health improvement, prevention and healthcare. Sanatoriums, where stay was part of the treatment process, were subordinated to the People's Commissariat of Health, and rest homes - to trade unions, i.e. the public, or, in modern terms, civil society, which was supposed to monitor the health of workers. But N. Semashko understood the policy of health improvement much more broadly, including in it the improvement of places of residence, and the creation of appropriate housing and communal conditions, and ultimately the solution of the housing issue, declaring the ultimate goal of the state’s sanitary policy to combat housing needs of the poorest people.

Important!

In the early 1990s, with the collapse of the USSR and the ensuing economic crisis, the authorities of the new Russia abandoned budgetary financing of healthcare and restored compulsory medical insurance to finance medical care, initially for working citizens, and then for the entire population. From this time it began and continues sixth period development of public health – the transition to primary financing of health care through compulsory medical insurance, which we will consider in detail in subsequent paragraphs of this chapter.

Today, taking into account rationally understood foreign experience, many experts believe that, despite all the problems, the healthcare system in Soviet Russia was exemplary and was in need of polishing rather than radical reform.

Nevertheless, the system built by N. Semashko and developed by his followers, for all its harmony, which aroused interest all over the world and generated a lot of followers, also had a number of shortcomings, which, along with the shortage of high-quality medical and service services, ultimately turned it into a subject of intense dissatisfaction.

The idea of ​​the social conditioning of diseases and the fight against social ills at the first stage of the development of Soviet health care greatly helped in overcoming infectious diseases, but later they did a disservice to both health care and biological science. True for diseases such as tuberculosis, the spread of which was largely determined by living conditions, it was transferred to other diseases - cardiovascular, oncological and many others, the causes of which, as is now clear, can only be partially explained by living conditions. Hence, there are too high hopes for the prevention of these diseases by social measures (although much has been achieved by social measures).

The slenderness of the system turned into rigidity: patients were assigned to a specific doctor, to a specific hospital. They could not choose a doctor or a medical institution, which made competition between the latter impossible. This, in turn, created stagnation and inattention to the needs of patients. Although the experience of Great Britain, where budgetary financing of healthcare was also used, shows that such rigidity is not inherent in the system as such.

But the main problem of Soviet healthcare, as well as modern Russian healthcare, was its chronic underfunding, which became more and more noticeable as medicine became more complex and more expensive. Because of this, many modern treatments and drugs were not developed in the Soviet Union and were simply not available to Soviet citizens. As a result, the USSR, which initially caught up with the advanced Western countries in terms of life expectancy and reduction in infant mortality, began to lag further and further behind since the 1970s.

Health care deficiencies caused by underfunding were perceived as shortcomings of the system itself. In conditions of a shortage of quality services and medicines, as with any shortage, groups of people arose, either involved in government or possessing appropriate material resources, who began to illegally purchase scarce services. The de facto shortage has given rise to payment for the best services. And in the conditions of the crisis of the entire system, it has become impossible to eliminate underfunding.

World experience has shown that the application of market criteria to medical services turned out to be not only unfair, but also irrational due to the special specifics of medical services, which many economists characterize as follows:

• – the patient lacks complete information necessary for a rational choice;
• – uncertainty of the onset of the disease: patients do not know when and how much medical services they will need, what is the likelihood of success of various types of treatment;
• – asymmetry of information, when doctors have a clear advantage in the medical services market, both on the demand side and on the supply side;
• – inelasticity of demand for medical services: their consumers usually react poorly to price changes.

And in this sense, N. Semashko’s system turned out to be more effective than all others, since it focused the doctor on fulfilling his medical duty, and not on making a profit, the origins of which in medicine can often contradict public morality.

These problems are recognized by the modern Ministry of Health of the Russian Federation (Ministry of Health) and the medical community, and the health care reforms being carried out today are ultimately aimed at solving them.

The appearance of the first elements of insurance in Rus' is associated with the monument of ancient Russian law - “Russian Truth” (X-XI centuries). It, in particular, set out standards for material compensation for harm by the community in the event of murder. Thus, for the murder of a member of the princely family and even if the killer was not caught, the community in whose territory the crime was committed had to pay 80 hryvnia, and in the case of the murder of a commoner - 40 hryvnia.

The emergence of elements of social insurance and insurance medicine in Russia began in the 18th - early 19th centuries, when the first mutual aid funds appeared at the first capitalist enterprises that emerged. The workers themselves began to create, at their own expense (without the participation of employers), mutual aid societies - the predecessors of health insurance funds. The first insurance partnership in Russia, which dealt with accident and life insurance, appeared in 1827 in St. Petersburg.

According to Koshkin I.V. The development and formation of the compulsory health insurance system in Russia took place in several stages.

In 1861, the first legislative act was adopted, introducing elements of compulsory insurance in Russia. In accordance with this law, partnerships were established at state-owned mining plants, and at partnerships - auxiliary cash offices, the tasks of which included: issuing benefits for temporary disability, as well as pensions to participants of the partnership and their families, accepting deposits and issuing loans. Participants in the auxiliary cash fund at mining plants were workers who paid established contributions to the cash fund (within 2-3 percent of wages). In 1866, a law was passed providing for the creation of hospitals in factories. According to this Law, employers, owners of factories and factories were required to have hospitals, the number of beds in which was calculated according to the number of workers in the enterprise: 1 bed per 100 workers.

Opened in the 70-80s of the 19th century. In large factories, hospitals were few in number and could not provide for everyone in need of medical care. In general, medical care for factory workers was extremely unsatisfactory.

Stage 2-from June 1903 to June 1912.

Of particular importance in the establishment of compulsory health insurance in Russia was the Law “On remuneration of citizens who suffered as a result of an accident, workers and employees, as well as members of their families at enterprises of the factory, mining and mining industries,” adopted in 1903. According to this Law, the employer was responsible for damage caused to health in industrial accidents, and the obligation of the entrepreneur and the treasury to pay compensation to victims or members of their families in the form of benefits and pensions was provided.

In 1912, the III State Duma did a lot for the social renewal of the country, including on June 23, 1912, the Law on Insurance of Workers in Case of Sickness and Accidents was adopted. In December 1912, the Insurance Council was established. In January 1913, Insurance Presences opened in Moscow and St. Petersburg. From June-July 1913, sickness funds were created in many territories of the Russian Empire. In January 1914, insurance partnerships began to appear to provide workers with accidents.

According to the Law of 1912, medical care at the expense of the entrepreneur was provided to the participant of the health insurance fund in four types:

a) initial assistance in case of sudden illnesses and accidents;

b) outpatient treatment;

c) obstetrics;

d) hospital (bed) treatment with full care of the patient.

After the February Revolution of 1917, the Provisional Government came to power, which, from the first steps of its activities, began reforms in the field of compulsory health insurance (Novella dated July 25, 1917), including the following basic conceptual provisions:

a) expanding the circle of insured, but not to all categories of workers (since it was technically impossible to do this at once, categories of insured were separated);

b) granting the right to health insurance funds to merge, if necessary, into general funds without the consent of entrepreneurs and the Insurance Presence (district, citywide health insurance funds);

c) the requirements for independent health insurance funds in terms of the number of participants have been increased: they had to have at least 500 people;

d) complete self-government of sickness funds by employees, without the participation of entrepreneurs;

e) the provisional government adopted four legislative acts on social insurance, which seriously revised and corrected many of the shortcomings of the Law adopted by the Third State Duma in 1912.

The Soviet government began its activities to reform social

insurance with the Declaration of the People's Commissar of Labor of October 30 (November 12), 1917 on the introduction of “full social insurance” in Russia. The main provisions of the Declaration were the following: the extension of insurance to all wage workers without exception, as well as to the urban and rural poor; extending insurance to all types of disability (in case of illness, injury, disability, old age, maternity, widowhood, orphanhood, unemployment); placing all insurance costs on entrepreneurs and the state; compensation of full earnings in case of disability and unemployment;

The reforms carried out by the Soviet government contributed to the implementation of full social insurance on the basis of complete centralization.

A logical continuation of the initiated policy of merging the People's Commissar of Health and insurance medicine was the adoption of the Decree of October 31, 1918, which approved the “Regulations on Social Security of Workers.” In the new Regulations, the term “insurance” was replaced by the term “security”. This was consistent with the Soviet government's concept that a year after the October Revolution, capitalism had already been abolished and Russia had become “socialist” and, therefore, the capitalist institution of social insurance had to give way to a socialist institution of social security. The content of the Decree of October 31, 1918 was fully consistent with this.

02/19/1919 V.I. Lenin signed the Decree “On the transfer of the entire medical part of the former sickness funds to the People’s Commissariat of Health,” as a result of which all medical work was transferred to the People’s Commissariat of Health and its local departments.

Thus, this Decree abolished cash medicine. The results of such a reform at first in the fight against infectious diseases were quite convincing. The incidence of social diseases (tuberculosis, syphilis, etc.), infant mortality, etc. have significantly decreased.

Stage 6 - from November 1921 to 1929.

Since 1921, a new economic policy (NEP) was proclaimed in the country, and the Government again turned to elements of insurance medicine, as evidenced by the resolutions of the Council of People's Commissars and the All-Russian Central Executive Committee for the period from 1921 to 1929.

On November 15, 1921, the Decree “On Social Insurance of Persons Engaged in Hired Labor” was issued, according to which social insurance was reintroduced, covering all cases of temporary and permanent disability. To organize social insurance in case of illness, insurance contributions were established, the rates of which were determined by the Council of People's Commissars and differentiated depending on the number of persons employed at the enterprise and working conditions.

For the first time, this Decree established the procedure for collecting contributions, with the labor protection and social security commissions becoming the main collectors. According to the Resolution of the Council of People's Commissars No. 19, Art. 124 of March 23, 1926, the following operating funds were formed from all social insurance funds: Funds at the direct disposal of the social insurance authorities. Funds for medical assistance to the insured (FMF), at the disposal of health authorities.

This stage can be characterized as a period of public health care, during which, due to the objective political and economic situation, a residual principle of financing the health care system was formed.

Stage 8-from June 1991 to the present.

Only with the adoption of the RSFSR Law “On Health Insurance of Citizens in the RSFSR” on June 28, 1991, can we begin to talk about a new stage in the development and further promotion of the socially significant idea of ​​compulsory health insurance in our country. Let us analyze the current state of the health insurance system in the Russian Federation as one of the main socially oriented programs. The workers themselves began to create, at their own expense (without the participation of employers), mutual aid societies - the predecessors of health insurance funds. The first insurance partnership in Russia, which dealt with accident and life insurance, appeared in 1827 in St. Petersburg.

Voluntary health insurance (VHI), developing as part of personal commercial insurance, has a common history with it. In 1835, personal insurance began in Russia; the private joint-stock insurance company “Life” was created, which until 1847 had a monopoly on personal insurance. In modern VHI, differentiated insurance programs are becoming widespread, which, at the choice of policyholders, can include such elements as preventive insurance, insurance for the purpose of rehabilitation, permanent and temporary disability, and life insurance.

The reason for the emergence of health insurance in Russia was the rapid development of industry in its western regions. The more complex production became, the more highly trained personnel were valued. Spending money on staff has become profitable.

In 1858 in Riga at the factory “P.H. Rosenkranz" the first health insurance fund appeared, which was replenished from the funds of the owner and the workers themselves. The insurance paid out in case of illness or death. Later, similar cash registers appeared in many factories of the empire.

In 1912, the Russian Duma adopted the first law on social and health insurance for workers and members of their families. At that time, the insurance system covered only 2% of the Russian population. The Provisional Government and then the Council of People's Commissars tried to extend the practice of sickness funds to the entire working class in 1917. At the same time, a new “Soviet medicine” was formed, subordinate to the People’s Commissariat of Health.

With the end of the NEP in 1929, insurance medicine was eliminated and a single one was approved - “universal and free”. Since the 60s, the system began to slip: the residual principle of financing health care was bearing fruit. In the early 90s, the situation became critical: there was a catastrophic lack of money from the budget, and no one could answer how much was needed and why doctors received the same salary for different work. Then in Russia they remembered about health insurance. The budget model of healthcare has given way to budget-insurance medicine.

Table 1.1. Stages of formation of the Russian insurance market

Insurance market	State regulation of the insurance market
		Stage of demonopolization of insurance in the USSR	Activities of the Ministry of Finance of the RSFSR.
		Stage of extensive growth of the insurance market of the Russian Federation	Creation of a national system of state regulation with the center - the Federal Service of Russia for Supervision of Insurance Activities.
		Stage of redistribution of insurance fields	Transformation of the state regulation system: development of insurance legislation, reorganization of supervisory authorities (transfer of functions to the Ministry of Finance of the Russian Federation), priority of regulation of insurers' access to the market.
	Sep. 1998 - present vr.	Stage of adaptation to new economic conditions	The beginning of a reorientation towards the primary regulation of the financial stability of insurers.
	(in the near future) - admission of foreign insurers and integration into the international regulatory system

The formation of the insurance market in its modern form began in 1988 with the adoption of the USSR Law “On Cooperation”. It is from this moment that the revival of commercial insurance in Russia begins. At the first stage - stage of demonopolization- the first insurance organizations were created practically in a legislative vacuum, without any adequate legal regulation, without work experience, qualified personnel and the necessary knowledge, in the complete absence of market infrastructure. The source of methodological and practical developments, insurance technologies and, to a large extent, personnel for new insurance companies was the old system of the USSR State Insurance. By that time, it itself had reached a critical state, especially complicated by the collapse of the unified insurance space of the USSR, repeated withdrawals of insurance reserves by the state to cover its financial needs, and the departure of many key personalities.

At this stage, the development of a compulsory health insurance system was launched. Then the Law “On Medical Insurance of Citizens in the RSFSR” dated June 28, 1991 No. 1499-1 was adopted, establishing the legal basis of the system. In accordance with it, the scope of compulsory and voluntary health insurance was differentiated. Thus, a system of medical support characteristic of many countries was established: a minimum of medical services are provided under the compulsory medical insurance system, the rest is voluntary.

The stage of demonopolization finally ended with the adoption of the Law “On Insurance” on November 27, 1992, which laid the foundations for the legal regulation of the insurance business for the next few years. A few months earlier, by Presidential Decree No. 133 dated February 10, 1992, in order to ensure the effective development of the insurance services market, as well as to protect the rights and interests of policyholders, insurers and the state, the Russian Federal Service for Supervision of Insurance Activities (Rosstrakhnadzor) was established. The second stage in the history of the modern system of state regulation of the Russian insurance market is associated with its functioning - extensive growth stage.

This second stage saw growth of the insurance market unprecedented in world history. The number of insurance companies as of January 1, 1996 reached 2,745, and the annual volume of insurance premiums for voluntary insurance increased from 86.99 billion rubles. for 1992 to 15,680.1 billion rubles. for 1995, payments - accordingly from 29.2 billion rubles. up to 10,261.3 billion rubles.

Rosstrakhnadzor has become the central link in the Russian system of state regulation of the insurance business. It was through him that the state policy in the field of insurance was mainly implemented.

By the end of the stage of extensive growth, an insurance market and a system of its regulation were generally created that met the needs of its time.

Third stage - redistribution stage - originates in the first half of 1996. Its beginning is associated with a sharp change in the regulatory framework of insurance (the introduction of the second part of the Civil Code, the adoption of the Law of the Russian Federation “On Joint-Stock Companies”, which regulates the activities of joint-stock insurance companies, etc.).

Fourth stage - adaptation stage - began after the crisis on August 17, 1998. Then a reorientation began to primarily regulate the financial stability of insurers.

Fifth stage - integration stage began on November 20, 1999, when the corresponding changes to the legislation regarding shares of foreign capital were approved.

Quantitative trends in the development of the Russian insurance market are formed as a result of various processes occurring in three key insurance sectors: life insurance, non-life insurance, and compulsory insurance.

Voluntary medical insurance is one of the new “non-traditional” types of insurance for Russia. The voluntary health insurance market in Russia is still young - it is about ten years old.

In our country, the health insurance system began to take shape in 1991, when the Law “On Health Insurance of Citizens in the Russian Federation” was adopted. It provided for the introduction of a compulsory health insurance system and allowed voluntary health insurance.

According to Part 5 of Article 1 of the Law of the Russian Federation “On Medical Insurance of Citizens of the Russian Federation” dated June 28, 1991 No. 1499-I, “voluntary medical insurance is carried out on the basis of voluntary medical insurance programs and provides citizens with additional medical and other services in addition to those established by mandatory programs health insurance." In fact, this rule of law is not observed: many medical insurance organizations offer VHI programs that cover medical services provided for in the basic compulsory medical insurance program.

The short history of the development of voluntary health insurance in Russia can be characterized by several stages.

The first stage is limited to 1991-1993. During this period, VHI was based on types and options that provided for the attachment of the insured contingent to a medical institution (or several medical institutions) chosen by them (or the insured), payment for services actually provided within the framework of the program provided for by the contract, and the return to the policyholder (insured) of unspent funds treatment of insurance premium. In these contracts, the concept of “sum insured” was essentially absent. The insurer's liability was limited to the amount of the premium paid, sometimes minus the costs of conducting insurance operations. Due to the specifics of taxation of legal entities in terms of the insurance premiums they pay and individuals in terms of the insurance payments they receive, VHI contracts began to be used by policyholders - legal entities not only and not so much to provide the insured with guarantees of receiving the paid medical care provided for in the contract, but to pay additional funds to their employees through the return of unspent contributions.

The second stage (1993-1994) is characterized by the appearance on the market (in addition to the previously existing ones) of types of voluntary medical insurance, which provide for a limit of the insurer's liability for payment for medical services provided to the insured in the amount of the insured amount corresponding to the cost of the VHI program and exceeding the amount of the insurance premium. These types of contracts appeared both due to the development of the insurance culture of insurance subjects, and due to the strengthening of requirements regarding compliance with the principles of insurance, reflected in the essential clauses of the insurance contract, on the part of state authorities regulating insurance activities, in particular, the Federal Service of Russia for Supervision of Insurance Activities . These types of insurance do not provide for the return of insurance premiums.

The third stage of development of voluntary health insurance began in 1995, when insurers were prohibited from carrying out VHI operations under contracts providing for the return to the policyholder of the portion of the insurance premium not spent on treatment at the end of the insurance period.

The legal basis for the implementation of returnable medical insurance at the first stage was Art. 6 and art. 15 of the Law of the Russian Federation “On Medical Insurance of Citizens in the Russian Federation”, which declared the right of citizens to receive and the obligation of an insurance medical organization to return part of the insurance premium for voluntary medical insurance, if this is provided for in the contract. However, the Law of the Russian Federation “On Insurance”, which appeared later, determined the conditions for the return of part of the insurance premium related only to the early termination of the insurance contract. The procedure for returning part of the insurance premium upon early termination of a VHI agreement, as well as the prohibition on returning unused insurance premiums upon expiration of the voluntary health insurance agreement, were determined by a number of orders of Rosstrakhnadzor, in particular letter No. 09/1-3 r/02 dated 02/07/95 G.

Thus, during this time, firstly, the foundations were laid for the formation of a system of state regulation of the insurance market similar to the Western ones; secondly, the prerequisites were created for the integration of the insurance market and its regulatory system into the global insurance industry; thirdly, negative aspects were admitted, including the weakness of the use of tax regulators, the lack of effective tools for protecting consumers of insurance services, etc. As a result, the need for further development and improvement of the system of state regulation of the insurance market in the Russian Federation emerged.

SAMARA STATE

ECONOMIC ACADEMY

Department of Finance and Credit

COURSE WORK

in the discipline "Finance"

on the topic: “Health insurance in Russia,

problems of its development"

V completed by: 4th year student

correspondence faculty

specialist. "Finance and Credit"

Isaeva Lyubov Alexandrovna

Scientific supervisor:

Candidate of Economic Sciences, Associate Professor, Sanginova L.D.

Defense date

Topic 48

Medical insurance in Russia.

problems of its development

p.
Introduction	3
Chapter 1.	Socio-economic nature of health insurance
1.1.	The need for a transition to insurance medicine. Importance of Health Insurance
1.2.	Principles of organizing health insurance	7
1.2.1. Compulsory and voluntary insurance 1.2.2. Objects and subjects of health insurance 1.2.3. Health insurance contract 1.2.4. Medical policy
1.3.	Health Insurance Financing	9
1.3.1. Health insurance funds 1.3.2. Health insurance rates
1.4.	Legislative support of health insurance in the Russian Federation	12
Chapter 2.	Organization of health insurance in Russia	15
2.1.	Medical insurance system in the Russian Federation	15
2.1.1. History of health insurance 2.1.2. Development of health insurance in Russia 2.1.3. Prospects for the development of the health insurance system
2.2.	Compulsory health insurance system (CHI)	21
2.2.1. The need to create 2.2.2. Central problems of compulsory medical insurance. News from Samara province 2.2.3. Participants of the compulsory medical insurance system 2.2.4. Models of implementation of compulsory medical insurance in the Russian Federation
2.3.	Voluntary health insurance (VHI)	33
2.3.1. Objects and subjects of VHI 2.3.2. Economic necessity of VHI 2.3.3. Development, current state and prospects of VHI in Russia
2.4.
2.5.	Prospects for a combination of compulsory and voluntary health insurance
Chapter 3.		43
3.1.	Foreign experience of health insurance	43
3.2.	Possibilities of using foreign experience of medical insurance in Russia
Conclusion	51
References	54
Applications

Medical insurance (Healthinsurance) in the Russian Federation is a form of social protection of the population’s interests in health care.

Health insurance is a set of types of insurance that provide for the insurer's obligations to make insurance payments (payments of insurance coverage) in the amount of partial or full compensation for additional expenses of the insured caused by the insured's application to medical institutions for medical services included in the health insurance program.

Legally, this type of insurance is based on the law that defines the legal, economic and organizational foundations of medical insurance for the population of Russia. The law ensures the constitutional right of Russian citizens to medical care. This will be discussed further in Chapter 1.

The purpose of health insurance is to guarantee that citizens of the Russian Federation, in the event of an insured event, will receive medical care from accumulated funds and finance preventive measures.

On the territory of the Russian Federation, stateless persons or foreign citizens permanently residing in Russia have the same rights and obligations in the health insurance system as citizens of the Russian Federation.

Medical insurance on the territory of the Russian Federation is carried out in two types: compulsory and voluntary. Compulsory insurance is carried out by force of law, and voluntary insurance is carried out on the basis of an agreement concluded between the policyholder and the insurer. Each of these forms of insurance has its own characteristics. The second chapter of this course work is devoted to studying the details of compulsory and voluntary insurance.

Medical insurance as a subject of specialization of an insurance organization is not compatible with other areas of insurance activity. This is evidenced by the high specificity of the subject of insurance - health, the need to deal with a massive contingent of insured, the everyday nature of relationships with clients regarding the occurrence of insured events, and finally, a significant volume of insurance compensation. Thus, the managers of health insurance funds should be, first of all, specialized insurance organizations and autonomous territorial insurance funds.

You should take care of your health, the sooner the better. In Rus', health is usually remembered - if remembered - with an irreparable delay. In countries with developed market economies, health insurance is one of the most important elements of the health maintenance system.

Medical insurance, or more precisely, insurance of medical expenses, along with pension insurance, represents an important component of the social infrastructure of any developed country. This type of insurance leads both in the number of insured and in monetary terms.

Currently, Russia has both a state system and private health insurance.

The state pays the costs of medical institutions through intermediaries - insurance companies. In essence, this is a distribution system with elements of insurance. As for private health insurance, in our country it is sold only by insurance companies and in a variety of forms. To understand the features of domestic health insurance, it is necessary, first of all, to consider the basic principles of insurance activities. This is what this course work is devoted to.

Socio-economic nature of health insurance

1.1. The need for a transition to insurance medicine. Importance of Health Insurance

In the complex of socio-economic reforms currently being carried out, the most important place is occupied by the development of insurance medicine, the transition to which is due to the specifics of market relations in healthcare and the development of the paid services sector. Health insurance allows each person to directly compare the necessary costs of health care with the state of their own health. The need for medical care and the possibility of receiving it should be weighed regardless of who incurred the costs: directly by the individual, an enterprise, an entrepreneur, a trade union or society as a whole.

In the world practice of organizing health care services, three main systems of economic functioning of health care have emerged - public, insurance and private:

- government system is based on the principle of direct financing of treatment and prevention institutions (HCI) and guarantees free medical care;

Fundamentally insurance system the principle of participation of citizens, enterprises or entrepreneurs in financing health care directly or through the mediation of medical insurance companies (organizations) is laid down;

- private medicine is currently represented by private practitioners, clinics and privately owned hospitals. They are financed through paid medical services for patients.

In economic and social terms, the transition to insurance medicine in Russia is an objective necessity, which is due to the social vulnerability of patients and workers in the industry, as well as its insufficient financial security and technical equipment. The low level of salaries of medical personnel, paid from budgetary funds, contributed to the social vulnerability of public health workers. The unsatisfactory provision of healthcare facilities with equipment and instruments, medicines, and the high degree of wear and tear of existing medical equipment indicated their low organizational and technical level.

The country's economic crisis led to a drop in the production of medical products, a severance of cooperation and foreign economic ties, and the closure of a number of unprofitable medical industry facilities. The severance of economic ties caused an unfavorable situation with the supply of state medical institutions with medicines and modern medical equipment.

The growing budget deficit led to a lack of financial resources, an aggravation of the situation in industries financed on a residual basis, and weak moral and material motivation for the work of medical personnel - a decrease in the quality of medical and preventive care, the “inflation” of the title of doctor and the Hippocratic Oath. This was also facilitated by rising prices and shortages of consumer goods, as well as the everyday instability of industry workers.

To radically overcome the crisis in the field of health care, it is necessary, first of all, to transform economic relations, denationalize and privatize property, as well as the transition of health care to the path of insurance medicine.

Basic principles of organizing insurance medicine:

A combination of compulsory and voluntary nature of health insurance, its collective and individual forms;

Universality of citizen participation in compulsory health insurance programs;

Division of functions and powers between republican (budgetary) and territorial (extrabudgetary) health insurance funds;

Ensuring equal rights of the insured;

Free provision of diagnostic and treatment services within the framework of compulsory insurance.

It is advisable to consider the health insurance system in two aspects. In a narrow sense, health insurance is the process of receiving financial resources and spending them on medical and preventive care. At the same time, medical insurance provides a guarantee of receiving this assistance, and its volume and nature are determined by the terms of the insurance contract.

Medical insurance, contributing to the accumulation of necessary funds, as well as the formation of a paid medicine system, acts as an effective source of healthcare financing. In the conditions of insurance medicine, the principle is implemented: “The healthy pays for the sick, and the rich pays for the poor.”

Public health care was based on the impersonal and addressless accumulation of funds in the general budget. The development of insurance medicine involves the targeted formation of health protection funds and their concentration primarily at the level of the district or regional level of the medical care system. The directions and forms of distribution of funds are largely determined by local health authorities. At the same time, the role of the population of the corresponding region in resolving issues related to the implementation of these funds is increasing. At the same time, the scope of local self-government is expanding and the mobility of healthcare management is increasing. The center of gravity in healthcare management is being transferred from the level of higher government bodies to the level of local government structures.

As part of the concept of financial and economic reform of healthcare and the organization of medical insurance for the population, insurance programs provide for the introduction of methods for assessing the quality of medical care that are new to domestic practice. Spot checks of the effectiveness of diagnosis and treatment based on records in medical histories, questionnaires and other forms of sociological examination of patients are used. For this purpose, expert commissions of various levels are created along the lines of:

Insurance organization systems;

Health care institutions or health care authorities;

Enterprises with which insurance contracts are concluded.

The transition to health insurance inevitably involves a certain degree of commercialization of healthcare. Therefore, the formation of tariffs for medical services and nosological standards (DRGs of diseases) will make it possible to control prices not only for services, but also for medical technology.

1.2. Principles of organizing health insurance

1.2.1. Compulsory and voluntary insurance.

Based on the nature of the assistance provided, medical insurance is divided into compulsory and voluntary.

Compulsory health insurance is an integral part of state social insurance and provides all Russian citizens with equal opportunities to receive medical care provided at the expense of compulsory medical insurance in the amount and on conditions corresponding to compulsory health insurance programs.

Compulsory health insurance, unlike voluntary health insurance, covers all insurance risks, regardless of their type.

Voluntary health insurance is an addition to compulsory insurance. It is carried out on the basis of VHI programs and provides citizens with additional medical and other services beyond those established by compulsory health insurance programs.

Compulsory health insurance is universal. Voluntary health insurance can be collective And individual .

In collective insurance, as a rule, the insurer is an enterprise, organization and institution that enters into an agreement with an insurance organization regarding the insurance of its employees or other individuals (family members of employees, pensioners, etc.).

In individual insurance, as a rule, the insured are enterprises, organizations, institutions that enter into an agreement with an insurance organization regarding the insurance of their employees or other individuals (family members of employees, pensioners, etc.).

In individual insurance, as a rule, the insured are citizens who enter into an agreement with an insurance organization to insure themselves or another person (relative, etc.) at their own expense.

1.2.2. Objects and subjects of health insurance

As in any subject of economic research, in insurance, incl. and in medicine, there are objects and subjects.

The subjects of health insurance are: citizen, policyholder, medical insurance organization (insurer), medical institution.

An insurer is a special organization (state or non-state) responsible for the creation and use of a monetary fund. In health insurance, these are medical insurance organizations - legal entities that provide health insurance and have the right to engage in health insurance.

The policyholder is a legal entity or individual who makes specified payments to the named fund. In voluntary and compulsory health insurance, policyholders differ. Insured for compulsory health insurance are: for the non-working population - government bodies of republics, territories, regions, cities, local administrations; for the working population – enterprises, institutions, individuals engaged in self-employment. Insured under voluntary health insurance are individual citizens with civil capacity, or enterprises and organizations representing the interests of citizens.

Medical institutions in the health insurance system are licensed medical and preventive institutions (HCI), research and medical institutes, other institutions providing medical care, as well as persons engaged in medical activities, both individually and collectively.

The object of compulsory health insurance is medical services provided for by compulsory medical insurance programs. The object of voluntary medical insurance is the insurance risk associated with the costs of providing medical care in the event of an insured event.

Both types of health insurance are discussed in more detail in the second chapter of this course work.

1.2.3. Health insurance contract

Health insurance is carried out in the form of an agreement concluded between the parties to health insurance. The terms of the medical insurance contract are regulated by Article 4 of the Law of the Russian Federation “On Medical Insurance of Citizens of the Russian Federation”.

The health insurance contract must contain:

Name of the parties;

Duration of the contract;

Number of insured;

Amount, terms and procedure for making insurance contributions;

List of medical services, relevant compulsory and voluntary health insurance programs;

Rights, obligations, responsibilities of the parties and other conditions that do not contradict the legislation of the Russian Federation.

1.2.4. Medical policy

Every citizen in respect of whom a health insurance contract has been concluded or who has concluded such an agreement independently receives a medical insurance policy. The medical insurance policy is in the hands of the insured.

The form of the medical insurance policy and instructions for its maintenance are approved by the Council of Ministers of the Russian Federation.

The medical insurance policy is valid throughout the Russian Federation, as well as in the territories of other states with which the Russian Federation has agreements on medical insurance of citizens.

1.3. Health Insurance Financing

1.3.1. Health insurance funds

The need to introduce health insurance in Russia during the transition to a market economy was largely predetermined by the search for new sources of healthcare financing.

Compared to the existing state healthcare system in Russia, financed from the budget, and on a residual basis, the health insurance system allows the use of additional sources of healthcare financing in order to create the most favorable conditions for the full realization of the rights of citizens to receive qualified medical care.

In connection with the introduction of the principles of health insurance in the country, the system of financing both the industry as a whole and individual medical institutions was practically revised.

The main sources of treatment, preventive, health and rehabilitation services are budgetary funds and insurance funds, formed through contributions from individuals and legal entities. The state budget performs a protective function in relation to socially vulnerable groups of the population (pensioners, disabled people, children) and workers in the spheres of education, culture, healthcare, and management. Contributions to the insurance funds of the working part of citizens are made through enterprises (institutions, organizations). These expenses are included in the cost of the enterprise's products (works or services).

Thus, insurance funds play the role of an intermediary between health care facilities and the population. However, the maximum effect of the functioning of insurance medicine can be achieved only when the consumer enjoys the freedom of choice of both health care facilities and doctors, and those intermediaries who guarantee the patient (the policyholder) the protection of his interests. Otherwise, the monopoly of the intermediary gives rise to corporate interests that are contrary to the interests of the final consumer.

In accordance with Article 10 of the Law of the Russian Federation “On Health Insurance”, the sources of financial resources of the healthcare system are:

Funds from the republican budget (Russian Federation), budgets of republics within the Russian Federation and local budgets;

Funds of state and public organizations (associations), enterprises and other economic entities;

Personal funds of citizens;

Free and (or) charitable contributions and donations;

Income from securities;

Loans from banks and other lenders;

Other sources not prohibited by law.

From these sources are formed:

Financial resources of state and municipal healthcare systems;

Financial resources of the state system of compulsory health insurance.

Financial resources of the state compulsory medical insurance system are intended for the implementation of state policy in the field of compulsory health insurance and are formed through contributions from policyholders for compulsory health insurance. In most foreign countries with a developed compulsory health insurance system, there are three main sources of financing compulsory health insurance:

Deductions from the budget;

Entrepreneurs' funds;

Personal funds of citizens.

In Russia, financial resources of the compulsory medical insurance system are generated from two sources:

Payments from the budget;

Contributions of enterprises, organizations and other legal entities to the compulsory health insurance fund are currently 3.6% of accrued wages.

Funds are received through banks into compulsory health insurance funds from policyholders who are required to register with these funds as payers of insurance premiums. The financial resources of compulsory medical insurance funds are state property, are not included in the budgets of other funds and are not subject to withdrawal for other purposes.

Voluntary health insurance is intended to finance medical care in excess of the social guaranteed volume determined by mandatory insurance programs. The financial resources of the voluntary health insurance system are formed through payments from policyholders, who in the case of collective insurance are enterprises, and in the case of individual insurance - citizens. Medical insurance companies pay at established rates for medical services provided by medical institutions within the framework of voluntary medical insurance programs. In accordance with the terms of the contract, part of the unspent funds may be returned to the policyholder (citizen).

The concentration of all financial resources in one hand - a territorial department (regional hospital) or local government authority - limits freedom of choice as the main principle of implementing an effective mechanism for providing citizens with treatment and preventive services. Therefore, a necessary condition for the development of the insurance medicine system is the freedom to conclude an insurance agreement by an interested group of persons (enterprise employees, individual citizens) with independent holders of insurance funds (independent medical insurance companies).

The formation and use of compulsory health insurance funds has its own characteristics. Conceived as insurance, they do not always comply with the principles of the formation and use of insurance funds. In their activities, the features of the budget approach are obvious: mandatory and normative contributions, planned spending of funds, lack of personification of savings, etc. In terms of their economic essence, these funds are not insurance; in form, they belong to extra-budgetary funds. However, it should be noted that, along with compulsory state insurance, non-state - voluntary - are developing.

1.3.2. Health insurance rates

Tariffs for medical services in the compulsory health insurance system are determined by agreement between medical insurance organizations, government bodies at all levels, local administration and professional medical organizations. Tariffs must ensure the profitability of medical institutions and the modern level of medical care.

The insurance rate of contributions for compulsory health insurance for enterprises, organizations, institutions and other economic entities, regardless of the form of ownership, is set as a percentage of the accrued wages (currently at the rate of 3.6%) for all reasons in accordance with the instructions on the procedure collection and accounting of insurance premiums (payments), approved by the Government of the Russian Federation on November 11, 1993.

Insurance premiums are established as payment rates for compulsory health insurance in amounts that ensure the implementation of health insurance programs and the activities of medical insurance organizations.

Tariffs for medical and other services under voluntary health insurance are established by agreement between medical insurance organizations and the enterprise, organization, institution or person providing these services.

1.4. Legislative support for health insurance

The legal basis for health care in Russia is, first of all, the fundamental law of the state - the Constitution of the Russian Federation.

In accordance with Article 41 of the Constitution of the Russian Federation, everyone has the right to health care and medical care. Medical care in state and municipal health care institutions is provided to citizens free of charge at the expense of the corresponding budget, insurance premiums, and other revenues. In the Russian Federation, federal programs for the protection and promotion of public health are financed, and measures are taken to develop state, municipal, and private health care systems.

The Declaration of Rights and Freedoms of Man and Citizen, adopted by the Supreme Council of the Russian Federation in 1991, declared that everyone has the right to qualified medical care in the state healthcare system. The state takes measures aimed at developing all forms of medical services, including free and paid medical care, as well as medical insurance, encourages activities that promote environmental well-being, strengthening everyone’s health, and the development of physical culture and sports (Article 25).

A significant event in the legal regulation of health issues of the Russian population and the protection of citizens' rights in the field of health care was the adoption by the Supreme Council of the Russian Federation in 1993 of the Fundamentals of Legislation of the Russian Federation on the protection of citizens' health.

The norms relating to the rights of patients established by the Fundamentals of Legislation on the Protection of Citizens' Health are fully consistent with the rights of citizens set out in the Law of the Russian Federation "On Medical Insurance of Citizens in the Russian Federation", adopted by the Supreme Council of the Russian Federation in 1991, as amended and supplemented as amended by 2 April 1993 No. 4741-1. The adoption of the law created a new legal situation.

For the first time in many decades, the relationship “patient – ​​healthcare system” has been transferred from the sphere of administrative law to the sphere of civil law regulation, in which the patient has acquired legal parity with other participants in the medical care process as an equal subject of health insurance.

In the health insurance system, interaction between insurance subjects, civil regulation of the relationship “patient – ​​insurer, patient – ​​policyholder” is implemented on the basis of health insurance contracts that provide for their rights and obligations and, most importantly, their responsibility. All this creates new opportunities for protecting the rights and legitimate interests of citizens.

The presence of a third party (medical insurance organizations, branches of territorial compulsory medical insurance funds performing the functions of an insurer) in the system of relations between the patient and other participants in the medical care process is an effective means of regulating the interaction of the two main parties (seller and consumer of services) in the field of medical care. This side serves as a real legal basis for protecting the rights of patients in the compulsory health insurance system and destroys the previous situation when the patient alone resisted the health care system.

The law provides for two equal participants (the insurer and the medical institution) of the contract for the provision of medical and preventive care to citizens under compulsory health insurance. If a violation of the rights of citizens is interpreted as a violation of contractual obligations, then this is followed by sanctions in accordance with the section of the contract “Responsibility of the Parties”, providing for fines, and not disciplinary sanctions, which, at best, a patient could count on under the state administrative system of a healthcare organization.

The main document in the compulsory medical insurance system is the insurance policy of compulsory health insurance for citizens, which is a legal registration of the patient’s rights and the obligation of the compulsory health insurance system to provide medical care.

The compulsory medical insurance insurance policy personalizes the patient’s right to receive medical care of the appropriate quality and volume established by the Basic Compulsory Medical Insurance Program throughout the Russian Federation, regardless of income level, social status and place of residence.

The law directly states: “Medical insurance organizations are not included in the healthcare system and healthcare management bodies, and medical institutions do not have the right to be founders of medical insurance organizations.” At the same time, it defines the responsibilities of the medical insurance organization to control the volume, timing and quality of medical care in accordance with the terms of the contract and to protect the interests of the insured. And in contrast to departmental control, which existed before the introduction of the law and still exists, based on the results of non-departmental control, measures of economic influence on medical institutions are provided, since in the event of a medical institution violating the terms of the contract in terms of the volume and quality of medical services provided, the medical insurance organization has the right not to partially or fully reimburse the costs of providing medical services.

These provisions are developed in by-laws: Regulations on medical insurance organizations providing compulsory medical insurance, Model rules for compulsory medical insurance and, finally, in contracts. In the Standard Compulsory Medical Insurance Agreements for working and non-working citizens, the insurer undertakes to the policyholder to monitor the quality and volume of medical services provided to insured persons by medical institutions, and in the Standard Compulsory Medical Insurance Financing Agreement, the insurer undertakes the same obligation to the territorial Compulsory Medical Insurance Fund. And finally, in the Model Agreement for the provision of treatment and preventive care (medical services) under compulsory health insurance, the insurer implements this obligation by indicating to the medical institution that it will control the latter’s obligation to provide insured citizens with medical care of adequate quality.

The implementation of state policy in the field of compulsory medical insurance in accordance with the law “On Medical Insurance of Citizens in the Russian Federation”, the increasing number of citizens’ appeals to territorial compulsory medical insurance funds, their branches, and medical insurance organizations determine the need for consistent actions to ensure the protection of citizens’ rights in the compulsory health insurance system. medical insurance, development of a system of non-departmental examination of the quality of medical care as the most important and fundamental part of protecting the rights of patients.

Chapter 2.

Organization of health insurance in the Russian Federation

2.1. Medical insurance in the Russian Federation

2.1.1. History of health insurance

Providing social assistance to citizens in case of illness has a fairly long tradition. Even in Greece and the Roman Empire, there were mutual aid organizations within professional colleges that collected and paid funds in the event of an accident, injury, or loss of ability to work due to long-term illness or injury. In the Middle Ages, the protection of the population in the event of the onset or onset of disability was carried out by guilds or craft guilds (unions) and the church. In the first case, assistance was provided through workshop funds created from membership fees. In the second case, material and medical assistance was provided to those in need free of charge through donations.

However, social assistance for illness received a form of medical or, as it was commonly called then, hospital insurance only in the second half of the 19th century. It was at this time that the trade union labor movement began to actively manifest itself, one of the important results of which was the creation of health insurance funds in many European countries. These cash desks were formed from contributions from employers and employees and were managed, respectively, by representatives of the enterprise administration and the trade union committee. The funds provided their members with monetary assistance in the form of benefits that partially compensated for labor income lost during illness, a lump sum payment and pension to the family in the event of the death of an employee, and compensation for mothers in labor. In addition, provision of medical and medicinal assistance was provided. England and Germany were pioneers in hospital insurance. It was in Germany in 1833 that the first state law on compulsory sickness insurance for workers was issued.

2.1.1. Development of health insurance in Russia

In Russia, the formation of a system of assistance to the population in case of illness is associated, first of all, with the development at the end of the 19th century. zemstvo medicine, subsidized by the treasury and allocations from provincial and district authorities. Medical insurance was not widespread in pre-revolutionary Russia due to its agrarian nature and the very short period of post-reform capitalist development.

The emergence of elements of social insurance and insurance medicine in Russia began in the 18th – early 19th centuries, when the first mutual aid funds appeared at the first capitalist enterprises that emerged. The workers themselves began to create, at their own expense (without the participation of employers), mutual aid societies - the predecessors of health insurance funds. The first insurance partnership in Russia, which dealt with accident and life insurance, appeared in 1827 in St. Petersburg.

The development and formation of the compulsory health insurance system in Russia took place in several stages.

Stage 1. From March 1861 to June 1903. In 1861, the first legislative act was adopted, introducing elements of compulsory insurance in Russia. In accordance with this law, partnerships were established at state-owned mining plants, and at partnerships - auxiliary cash offices, the tasks of which included: issuing benefits for temporary disability, as well as pensions to the participants of the partnership and their families, accepting deposits and issuing loans. Participants in the auxiliary cash fund at mining plants were workers who paid established contributions to the cash fund (within 2-3% of wages). In 1866, a law was passed providing for the creation of hospitals in factories. According to this Law, employers, owners of factories and factories were required to have hospitals, the number of beds in which was calculated according to the number of workers in the enterprise: 1 bed per 100 workers.

Opened in the 70-80s of the 19th century. In large factories, hospitals were few in number and could not provide for everyone in need of medical care. In general, medical care for factory workers was extremely unsatisfactory.

Factory insurance funds began to be created at the beginning of the 20th century. mainly at large enterprises in Moscow and St. Petersburg. The principles of their organization and functioning were similar to Western European ones.

Stage 2. From June 1903 to June 1912. Of particular importance in the establishment of compulsory health insurance in Russia was the Law “On remuneration of citizens injured as a result of accidents, workers and employees, as well as members of their families at factory enterprises”, adopted in 1903. , mining and metallurgical industry". According to this Law, the employer was responsible for damage caused to health in industrial accidents, and the obligation of the entrepreneur and the treasury to pay compensation to victims or members of their families in the form of benefits and pensions was provided.

Stage 3. From June 1912 to July 1917. In 1912, the III State Duma did a lot for the social renewal of the country, including on June 23, 1912, the Law on Insurance of Workers in Case of Sickness and Accidents was adopted - the law on the introduction of compulsory health insurance for working citizens.

In December 1912, the Insurance Council was established. In January 1913, Insurance Presences opened in Moscow and St. Petersburg. From June-July 1913, sickness funds were created in many territories of the Russian Empire. In January 1914, insurance partnerships began to appear to provide workers with accidents. According to the law of 1912 Medical care at the expense of the entrepreneur was provided to the participant of the health insurance fund in four types:

1. Initial assistance in case of sudden illnesses and accidents.

2. Outpatient treatment.

3. Obstetrics.

4. Hospital (bed) treatment with full care of the patient.

By 1916, there were already 2,403 health insurance funds in Russia, numbering 1,961 thousand members. Such cash offices existed before the revolution, and after the adoption of the ban on the introduction of a state monopoly in insurance, they lost not only their relevance, but also their legitimacy.

Stage 4. From July 1917 to October 1917. After the February Revolution of 1917, the Provisional Government came to power, which, from the first steps of its activities, began reforms in the field of compulsory health insurance (Novella dated July 25, 1917), including the following basic conceptual provisions:

Expanding the circle of insured, but not to all categories of workers (since it was technically impossible to do this at once, categories of insured were separated);

Granting the right to health insurance funds to merge, if necessary, into general funds without the consent of entrepreneurs and the Insurance Presence (district, citywide health insurance funds);

The requirements for independent health insurance funds in terms of the number of participants have been increased: they must have at least 500 people;

Full self-government of health insurance funds by employees, without the participation of entrepreneurs. The Provisional Government adopted four legislative acts on social insurance, which seriously revised and corrected many of the shortcomings of the Law adopted by the Third State Duma in 1912.

Stage 5. From October 1917 to November 1921, the Soviet government began its activities on social insurance reform with the Declaration of the People's Commissar of Labor of October 30 (November 12), 1917 on the introduction of “full social insurance” in Russia.

The main provisions of the Declaration were as follows:

Extending insurance to all wage workers without exception, as well as to the urban and rural poor;

Extension of insurance to all types of disability (in case of illness, injury, disability, old age, maternity, widowhood, orphanhood, unemployment).

The reforms carried out by the Soviet government contributed to the implementation of full social insurance on the basis of complete centralization.

A logical continuation of the initiated policy of merging the People's Commissar of Health and insurance medicine was the adoption of the Decree of October 31, 1918, which approved the “Regulations on Social Security of Workers.” In the new Regulations, the term “insurance” was replaced by the term “security”. This was in accordance with the concept of the Soviet government that a year after the October Revolution, capitalism had already been abolished and Russia had become “socialist” and, therefore, the capitalist institution of social insurance had to give way to the socialist institution of social security. The content of the Decree of October 31, 1918 was fully consistent with this.

February 19, 1919 V.I. Lenin signed the Decree "On the transfer of the entire medical part of the former sickness funds to the People's Commissariat of Health", as a result of which all medical work was transferred to the People's Commissariat of Health and its local departments. Thus, this Decree abolished cash medicine. The results of such a reform at first in the fight against infectious diseases were quite convincing. The incidence of social diseases (tuberculosis, syphilis, etc.), infant mortality, etc. have significantly decreased.

Stage 6. From November 1921 to 1929. From 1921, a new economic policy (NEP) was proclaimed in the country, and the Government again turned to elements of insurance medicine, as evidenced by the resolutions of the Council of People's Commissars and the All-Russian Central Executive Committee for the period from 1921 to 1929.

On November 15, 1921, the Decree “On Social Insurance of Persons Engaged in Hired Labor” was issued, in accordance with which social insurance was reintroduced, covering all cases of temporary and permanent disability. To organize social insurance in case of illness, insurance contributions were established, the rates of which were determined by the Council of People's Commissars and differentiated depending on the number of persons employed at the enterprise and working conditions.

For the first time, this Decree established the procedure for collecting contributions, with the labor protection and social security commissions becoming the main collectors. According to Resolution of the Council of People's Commissars No. 19, Article 124 of March 23, 1926, the following operating funds were formed from all social insurance funds:

1) Funds at the direct disposal of social insurance authorities.

2) Funds for medical assistance to the insured (FMPZ), at the disposal of health authorities.

Stage 7. From 1929 to June 1991. This stage can be characterized as a period of public health care, during which, due to the objective political and economic situation, a residual principle of financing the health care system was formed.

In Soviet times, there was no need for health insurance, since there was universal free medical care, and the healthcare sector was entirely supported by the state budget, government departments, ministries and social funds of the enterprises themselves.

Stage 8. From June 1991 to present. And only with the adoption of the RSFSR Law “On Health Insurance of Citizens in the RSFSR” on June 28, 1991, can we begin to talk about a new stage in the development and further promotion of the socially significant idea of ​​compulsory health insurance in our country.

During the period of economic and social reforms, a sharp decline in living standards, and an acute shortage of budgetary and departmental funds for the maintenance of medical institutions, a law was adopted in 1991 on the introduction of medical insurance for citizens in Russia in two forms: mandatory and voluntary. Moreover, all the provisions of this law that related to compulsory health insurance were put into effect only in 1993. Before this time, it was necessary to prepare an organizational and regulatory framework for the management and financing of the new state insurance system.

Currently, a multi-subject system of healthcare financing has emerged (Fig. 1). However, the overwhelming majority of funds for medicine are provided by budgetary allocations for compulsory health insurance.

Rice. 1. Health care financing system in the Russian Federation

2.1.3. Prospects for the development of the health insurance system

In modern conditions, a fundamentally new approach to the organization of healthcare is needed, guaranteeing the right of every citizen to receive medical care that corresponds to the level of development of both the country as a whole and its individual regions. The implementation of this approach can be ensured by the medical insurance system.

As world experience shows, the transition to insurance medicine is necessary in a market economy and the development of the medical services market, since it ensures, firstly, the guarantee and availability of high-quality medical services (even with the inevitable rise in prices) for the general population; secondly, it helps solve the problem of attracting additional financial resources to the healthcare sector.

Systems of additional (voluntary) health insurance, if properly organized, will ensure not only an improvement in the quality of service for those insured under these systems, but will also contribute to the development of medical services for the rest of the population by accumulating additional financial resources in the health care system.

An important argument in favor of health insurance is its widespread use in developed countries of the world, providing a high level of medical services to different categories of citizens.

The introduction of the principles of health insurance involves transferring the industry to market relations, under which strict economic laws apply. Therefore, a prerequisite for this transfer is the introduction of economic management methods into the practice of medical institutions.

The market model of the economic mechanism of the healthcare sector is based on the following principles of organization and functioning:

Multistructure (mixed nature) of the health care economy;

Economic and financial independence of healthcare institutions that base their activities on various forms of ownership;

Socio-economic and legal responsibility of medical institutions for performance results;

Providing medical services through their purchase and sale at prices that ensure not only covering the costs of these services, but also generating a certain profit. In addition, prices should be formed taking into account the quality of medical services and the relationship between supply and demand for them in the medical services market;

Financing of healthcare institutions in the form of self-financing from proceeds from the sale of medical services provided to the population, taking into account their quantity, quality and efficiency;

Expanding responsibility for protecting public health.

The fundamental principle of organizing the healthcare sector in a market economy can be formulated as the diversity of the healthcare economy and the variety of forms of organization of the medical population. The diversity of the health care economy is manifested, firstly, in the parallel existence and development of relatively separate, institutionalized sectors of medical care for the population: public, private, and insurance health care services, and secondly, in the existence and functioning of economically and legally independent medical institutions that establish their activities on various forms of ownership (state, collective, private).

The significance of this principle is determined by the fact that socially responsible competitive medicine is possible only with the parallel existence and development of various forms of ownership, forms and methods of organizing economic activities, management, sources of financing mechanisms for medical institutions, as well as various methods (planned and market) of regulating processes, occurring in the healthcare sector. As world experience shows, the existence of alternative sectors in the national healthcare system serves as the basis and guarantee of freedom of choice of place and working conditions for medical workers, and also, of course, expands the patient’s rights to free, independent choice of doctor, medical institution, type of medical services, to the greatest extent possible. to the extent consistent with his interests.

A necessary condition for the effective functioning of a multi-structured healthcare economy is the creation of a market for medical services, which should act as an “economic environment” for the activities of medical institutions, a mechanism that ensures the relationship between “producers” and consumers of medical services, as well as the most important regulator of the entire set of relations and social -economic processes in the healthcare sector. The formation of a market for medical services involves the creation of conditions and prerequisites for the implementation of a system of market freedoms and consumer rights.

The most important problem in the functioning of the medical services market is the problem of creating a pricing mechanism for services provided by healthcare institutions. The main requirement of the market pricing mechanism is the free formation of prices based on an agreement between the manufacturer of medical services (seller) and the buyer. In these conditions, it is necessary to formulate a well-thought-out state and regional price policy, taking into account that artificially restraining, “freezing” prices for health care services can lead to a decrease in the quality and efficiency of medical care to the population.

The economic transformations being carried out in our country, the transfer of the entire economy to market relations, will gradually create the necessary prerequisites and conditions for the implementation of the main provisions of the industry reform. Thus, the depth and scale of the upcoming changes dictates the advisability of gradually introducing into healthcare practice the provisions of the new financial model of the industry and their phased development.

2.2. Compulsory health insurance system in Russia

Compulsory health insurance (CHI) is one of the most important elements of the social protection system for the population in terms of health protection and obtaining necessary medical care in case of illness. In Russia, compulsory medical insurance is state and universal for the population. This means that the state, represented by its legislative and executive bodies, determines the basic principles of organizing compulsory health insurance, sets premium rates, the range of insurers and creates special state funds for the accumulation of contributions for compulsory health insurance. The universality of compulsory medical insurance is to provide all citizens with equal guaranteed opportunities to receive medical, medicinal, and preventive care in the amounts established by state compulsory medical insurance programs.

The compulsory health insurance system today plays a key role in solving this problem. The Law “On Medical Insurance of Citizens in the Russian Federation”, the Decree of the Government of the Russian Federation “On the program of state guarantees for the provision of free medical care to citizens of the Russian Federation” dated September 11, 1998 No. 1096 and its subsequent editions provide financial support for the main volume of guaranteed free medical care to the population (and this is more than 80%) is assigned to compulsory medical insurance funds.

2.2.1. The need to create

The main purpose of compulsory medical insurance is to collect and capitalize insurance premiums and provide, at the expense of the collected funds, medical care to all categories of citizens on legally established conditions and in guaranteed amounts. Therefore, the compulsory medical insurance system should be considered from two points of view. On the one hand, it is an integral part of the state social security system along with pension, social insurance and unemployment insurance. On the other hand, compulsory health insurance is a financial mechanism for providing additional funds to budget allocations for financing health care and paying for medical services. It should be noted that the scope of compulsory medical insurance includes only medical care for the population. Reimbursement of earnings lost during illness is already carried out under another state system - social insurance and is not the subject of compulsory medical insurance.

Medical care within the framework of compulsory medical insurance is provided in accordance with the basic and territorial compulsory health insurance programs developed at the level of the Federation as a whole and in the constituent entities of the Federation. Approved by Decree of the Government of the Russian Federation of September 11, 1998 No. 1096, the Basic Compulsory Medical Insurance Program for Russian Citizens contains the basic guarantees provided within the framework of compulsory medical insurance. These include outpatient and inpatient care provided in health care institutions, regardless of their organizational and legal form, for any diseases, with the exception of those whose treatment should be financed from the federal budget.

Receipts for compulsory medical insurance of the non-working population increased significantly (by 34.6%) - 24.1 billion rubles. However, this is only 1/3 of the estimated need, which is 76.0 billion rubles, because the non-working population makes up about 60% of the total population of the Russian Federation.

Currently, government obligations to provide free medical care are not supported by financial resources. The basic compulsory health insurance program has not yet been approved, and territorial compulsory health insurance programs are only 40-60% funded.

2.2.2. Central problems of compulsory medical insurance

In the current economic situation, maintaining state obligations to provide free medical care on a universal basis is practically unrealistic. Under the most favorable conditions (fulfillment of state budget obligations for contributions to compulsory medical insurance, attraction of additional sources of financing), financial resources to ensure freeness of all types of medical care will not be enough. At the same time, it is important to take into account that excessive obligations of the state lead to deformation of economic relations in the industry, since in the conditions of imbalance of compulsory medical insurance programs, the possibilities of full-fledged contractual relations between the financing party and health care facilities are limited, and therefore, increasing the efficiency and quality of medical care. This violates the most important condition for implementing health care reform—the predictability of financial resources.

No less obvious is the negative social and political effect of excessive declarative state obligations: free medical care is becoming more and more illusory, and population dissatisfaction with the state of health services is growing. By declaring medical care completely free, the state is increasingly losing the ability to provide such assistance to those who need it most. At the same time, the shadow market for medical services is intensifying, with far-reaching social and economic consequences. On the one hand, doctors respond more strongly to incentives arising in the shadow economy than to attempts by insurers to build a reasonable performance-based payment system in the public health sector. On the other hand, patients are sometimes forced to pay amounts out of their own pockets that do not correspond to the actual contribution of doctors.

The volume of paid medical services to the population from 1993 to 2001 increased from 1.7 to 4.6% of the total paid services to the population in the country.

Table 1

Structure of paid services to the population (% of total)

Rice. 2. Structure of paid services to the population in 2001

In the Volga Federal District, the Samara Region ranks first in terms of the volume of paid services provided per capita. At the end of 2001 it amounted to 5101 rubles! This can be explained by the strong difference in the living standards of the population in the regions of the district.

Fig.3. Volume of paid services to the population in the Volga Federal District in 2001

Compulsory medical insurance guarantees the provision of outpatient and inpatient care provided in health care institutions, regardless of their organizational and legal forms, and the provision of first aid. This, in my opinion, is far from reality, as evidenced by the stable downward trend in hospital facilities, as well as in the number of doctors and medical personnel by 2001.

Table 2

Treatment and preventive care for the population. Medical institutions

As can be seen from Table 2, the number of hospital facilities and hospital beds is steadily decreasing, having an inverse relationship with the dynamics of the number of medical and outpatient facilities. Despite the reduction in the number of medical personnel, the number of requests for medical help in them is growing.

Table 3

Treatment and preventive care for the population. Number of medical personnel

According to the Russian Statistical Yearbook in the Samara region, the number of doctors per 10,000 thousand population tended to constantly increase until 1998, and then rapidly fell from 48.7 to 47.1 people per 10,000 population. While for our “neighbors” in the Orenburg and Ulyanovsk regions, this figure is slowly but continuing to grow.

It is gratifying that the number of emergency medical care stations is growing, this contributes to the provision of emergency medical care within the framework of compulsory medical insurance to more people in need - this is evidenced by the data in Table 4.

Table 4

Emergency medical services for the population

In 1997-2001, the territorial compulsory health insurance funds, their branches and medical insurance organizations received about 4 million requests from citizens on various aspects of the protection of their rights. The amount of damages compensated for claims satisfied in court increases every year. The importance of conducting non-departmental examination of the quality of medical care cannot be underestimated. In essence, we have divided the functions of providing medical care and the functions of assessing it between entities, involving professionally trained, highly qualified specialists in protecting the interests of patients.

In the current situation, it is necessary to abandon declarations and soberly assess the financial capabilities of healthcare. In practice, this means the need to adopt a new procedure for creating a basic compulsory medical insurance program. The minimum social standard determined by this program, below which the volume and conditions for the provision of medical care in territorial compulsory medical insurance programs cannot be established, must be approved along with the amount of the compulsory medical insurance contribution and the budget revenues necessary to achieve this standard.

The government develops and provides a basic compulsory medical insurance program along with financial and economic justifications for approval by the State Duma.

To avoid excessive declarative obligations under the basic compulsory medical insurance program, it should be calculated as a minimum social standard in the form of a minimum funding standard per capita. This standard should be a guideline for calculating the territorial compulsory health insurance program at the level of the federal subject. In other words, each territory must have its own basic program in the amount of minimum government obligations. After assessing its capabilities, the subject of the federation accepts additional obligations, which are financed in the territorial compulsory medical insurance program.

News from Samara province

In the Samara region, no more than 9 rubles are spent on feeding one patient per day, instead of the 44 rubles recommended by the government. Each hospital patient is provided with medicines in the amount of 32 rubles, while the federal authorities planned that up to 87 rubles per day would be allocated for these purposes. The lion's share of funds for medicine is consumed by payments for utilities and repair work of healthcare institutions. Since 2004, in accordance with the Government Decree, money from the regional compulsory health insurance fund will go exclusively to salaries of medical staff, providing patients with medicines, food and soft equipment. But the maintenance of hospitals and payment of utilities will fall on the shoulders of municipalities. The head of the Samara Regional Department of Health, Galina Gusarova, reported this to the heads of administration at a meeting of the Samara Regional Administration Board. Due to this, in 2004, provincial medicine will receive an additional at least 1 billion rubles. To date, out of 37 municipalities, less than 30 have signed an agreement with the TFOMS.

2.2.3. Participants of the compulsory medical insurance system

The main participants in the compulsory health insurance system, in addition to citizens, are the policyholders themselves and the insurers themselves.

Insured in the compulsory medical insurance system are individuals and legal entities who have entered into an insurance agreement with the insurer. Insurers for the working population are enterprises, institutions, organizations, individuals engaged in self-employment and free professions; for the unemployed – executive authorities at different levels.

Compulsory medical insurance policyholders, i.e. Those who pay insurance premiums to provide all citizens with health insurance are employers and local executive authorities.

Employers are required to pay insurance premiums for the working population. The insurance premium rate is established by federal law and currently amounts to 3.6% of the wage fund. The rules for calculating and paying insurance premiums are presented in the Instructions on the procedure for collecting and accounting for insurance premiums (payments) for compulsory health insurance, approved by Resolution of the Council of Ministers of the Government of the Russian Federation dated October 11, 1993 No. 1018. In accordance with this document, insurance contributions to compulsory medical insurance funds are required all economic entities must pay, regardless of their form of ownership and organizational and legal forms of activity. These include:

Organizations, institutions, enterprises;

Peasant (farmer) households and tribal family communities of small peoples of the North engaged in traditional types of farming;

Citizens engaged in self-employment, entrepreneurial activity without forming a legal entity, private practice;

Citizens using hired labor in their personal households;

Persons of creative professions.

Public organizations of people with disabilities and their owned enterprises, associations, and institutions created to implement their statutory goals are exempt from paying insurance premiums for compulsory health insurance.

Policyholders are responsible for the correct calculation and timely payment of insurance premiums. For violation of the procedure for paying insurance premiums, various financial sanctions (fines, penalties) are applied to them.

The amounts of accrued contributions are paid to compulsory medical insurance funds monthly, no later than the 15th day of the following month. The amount of contributions in the amount of 3.4% of the wage fund is transferred to the account of the territorial compulsory medical insurance fund, and 0.2% - to the account of the federal compulsory medical insurance fund.

Compulsory medical insurance funds are independent state credit institutions that implement state policy in the field of compulsory health insurance. Compulsory medical insurance funds are intended to accumulate insurance premiums, ensure the financial stability of the state compulsory medical insurance system and equalize financial resources for its implementation.

According to the Law “On Medical Insurance of Citizens in the Russian Federation,” there are three groups of subjects managing the organization and financing of compulsory medical insurance. These entities enter into contracts for the implementation of compulsory medical insurance, collect and accumulate insurance premiums, and allocate funds to pay for medical services. From the point of view of insurance theory, they act as insurers, but they have significant differences and have strictly delimited powers to carry out specific insurance operations.

Federal compulsory medical insurance funds are created by the highest legislative body and the Government of the Russian Federation. Territorial compulsory health insurance funds are created by the relevant legislative and executive authorities of the constituent entities of the Federation. The financial resources of compulsory medical insurance funds are the state property of the Russian Federation, are not included in the budgets or other funds and are not subject to seizure.

1st level of insurance in the compulsory medical insurance system represents Federal Compulsory Medical Insurance Fund (FFOMS), which provides general regulatory and organizational management of the compulsory medical insurance system. He himself does not carry out insurance operations and does not finance the compulsory medical insurance system for citizens. The fund was created to implement state policy in the field of health insurance, and its role in compulsory medical insurance is reduced to general regulation of the system, which is achieved both through regulatory regulation of the main provisions of compulsory medical insurance on the territory of the Russian Federation, and through financial regulation of the implementation of medical insurance of citizens in the constituent entities of the Federation .

The MHIF is an independent state non-profit financial and credit institution, accountable to the Legislative Assembly and the Government of the Russian Federation. Every year, the fund’s budget and a report on its implementation are approved by the State Duma.

The fund's financial assets are generated from part of the insurance premiums of enterprises (0.2% of the FOP), contributions from territorial compulsory medical insurance funds for the implementation of joint programs and other sources determined by the legislation of the Russian Federation.

The Federal Compulsory Medical Insurance equalizes the conditions for the activities of territorial Compulsory Medical Insurance to ensure financing of compulsory medical insurance through the provision of financial assistance, finances target programs within the framework of compulsory medical insurance, approves standard rules for compulsory medical insurance for citizens, develops regulatory documents, participates in the development of a basic compulsory medical insurance program for the entire territory of the Russian Federation, and carries out international cooperation in the field medical insurance, participates in the organization of territorial compulsory medical insurance funds, carries out financial and credit activities to fulfill the tasks of financing compulsory medical insurance and conducts research and training of specialists for compulsory medical insurance.

The fund's activities are managed by its board and permanent executive directorate. The board includes representatives of federal legislative and executive authorities and public associations.

2nd level of organization of compulsory health insurance presented territorial compulsory medical insurance funds and their branches. This level is the main one in the system, since it is the territorial funds that collect, accumulate and distribute compulsory medical insurance funds.

Territorial Compulsory Medical Insurance Funds are created in the territories of the constituent entities of the Russian Federation, are independent state non-profit financial and credit institutions and are accountable to the relevant bodies of representative and executive power.

TFOMS financial resources are state property, are not included in budgets or other funds and are not subject to withdrawal. They are formed due to:

Parts of insurance premiums paid by enterprises for compulsory health insurance of the working population (3.4% of the payroll);

Funds provided in the budgets of the constituent entities of the Russian Federation for compulsory health insurance of the non-working population;

Funds collected as a result of filing recourse claims against policyholders, medical institutions and other entities;

Funds received from the application of financial sanctions to policyholders for violating the procedure for paying insurance premiums;

Other sources provided for by the legislation of the Russian Federation.

The main task of the TFOMS is to ensure the implementation of compulsory medical insurance in each territory of the constituent entities of the Russian Federation on the principles of universality and social justice. The TFOMS is entrusted with the main work of ensuring the financial balance and sustainability of the compulsory health insurance system.

TFOMS collect insurance premiums for compulsory medical insurance, finance territorial compulsory health insurance programs, enter into agreements with medical insurance organizations to finance compulsory health insurance programs conducted by health insurance organizations according to differentiated per capita standards approved by the TFOMS, carry out investment and other financial and credit activities, form financial reserves to ensure the sustainability of compulsory health insurance, carry out equalization of financing conditions, compulsory medical insurance across the territories of peoples and regions, develop and approve compulsory medical insurance rules for citizens in the relevant territory, organize a data bank for all policyholders and monitor the procedure for calculating and timely payment of insurance premiums and perform other important functions.

The management of the activities of the TFOMS is also carried out by the board and executive directorate. The chairman of the board is elected by the board, and the executive director is appointed by the local administration.

To perform its functions, TFOMS can create branches in cities and regions. The branches carry out the tasks of the TFOMS in collecting insurance premiums and financing medical insurance organizations. In the absence of medical insurance organizations (IMOs) in a given territory, branches are allowed to carry out compulsory medical insurance of citizens themselves, i.e. and accumulate insurance premiums and make payments to medical institutions.

3rd level in the implementation of compulsory medical insurance represent medical insurance organizations (IMO). They are the ones who are assigned the direct role of insurer by law. HMOs receive financial resources for the implementation of compulsory medical insurance from the Federal Compulsory Medical Insurance Fund according to per capita standards, depending on the size and age and gender structure of the population insured by them and make insurance payments in the form of payment for medical services provided to insured citizens.

According to the Regulations on medical insurance organizations providing compulsory medical insurance, a legal entity of any form of ownership and organization provided for by Russian legislation, and having a license to conduct compulsory medical insurance, issued by the department of insurance supervision, can act as a medical insurance company.

The health insurance company has the right to simultaneously provide compulsory and voluntary medical insurance to citizens, but does not have the right to carry out other types of insurance activities. At the same time, financial resources for compulsory and voluntary insurance are taken into account by the insurance company separately. CMOs do not have the right to use the funds transferred to them for the implementation of compulsory medical insurance for commercial purposes.

HMOs act as intermediaries between citizens, treatment and prevention institutions (HCIs) and financing organizations - territorial compulsory medical insurance funds. CMOs build their insurance activities on a contractual basis, concluding four groups of contracts:

1) Insurance contracts with enterprises, organizations, other business entities and local administration, in other words, with all policyholders obligated to pay insurance premiums to the Federal Compulsory Compulsory Medical Insurance Fund. According to such contracts, the contingent of those insured in a given health insurance company is determined.

2) Agreements with the Federal Compulsory Medical Insurance Fund for the financing of compulsory medical insurance for the population in accordance with the number and categories of insured persons.

3) Agreements with medical institutions for payment of services provided to citizens insured by this health insurance company.

4) Individual compulsory medical insurance agreements with citizens, i.e. compulsory medical insurance policies, according to which free medical care is provided within the framework of the territorial compulsory medical insurance program.

All relationships within the compulsory medical insurance system are regulated on the basis of territorial compulsory medical insurance rules, which must comply with the standard compulsory medical insurance rules of December 1, 1993, approved by the Federal Compulsory Medical Insurance Fund and agreed upon with Rosstrakhnadzor.

The main functions of the QS are:

Participation in the selection and accreditation of medical institutions;

Payment for medical services provided to the insured;

Monitoring the volume and quality of medical services provided, including filing recourse claims and claims against medical institutions based on violations of compulsory medical insurance conditions or causing damage to the insured;

Formation of insurance reserves: reserve for payment of medical services, reserve for financing preventive measures and reserve reserve, etc.

Thus, the activities of the CMO represent the final stage in the implementation of the provisions of the compulsory medical insurance. Medical insurance organizations are an important link in the compulsory health insurance system. The purpose of a medical insurance organization is to ensure payment for medical care, monitor the completeness and quality of the medical services provided, and protect the rights of the insured.

The general scheme for organizing and financing compulsory health insurance is presented in the figure “Scheme for organizing the financing of compulsory medical insurance” (Appendix No. 2). The mechanism for the functioning of compulsory health insurance presented in the diagram reflects the principles of organizing the financing of the system that were laid down by the legislation on medical insurance of citizens.

2.2.4. Models of implementation of compulsory medical insurance in the Russian Federation

The compulsory medical insurance system is very diverse, multifactorial and complex, since its infrastructure absorbs a huge range of political, social and economic problems, and each of these models can have several types of implementation, depending on the options for the financial interaction of the subsystems included in the compulsory medical insurance system, the presence of connections of a different nature between them, the influence of subsystems on ensuring state policy in the implementation of compulsory medical insurance.

The primary role in the formation of the compulsory health insurance system model belongs to the place occupied by the territorial fund in the compulsory health insurance system. Sometimes the foundation loses its independence by ceding the reins to a medical insurance organization or health care management body. In such conditions, the formation of a model of the compulsory medical insurance system occurs according to the following type:

2. Health authority

3. Medical insurance organization

This is done through a direct strong vertical connection coming from the authorities (administration) of the territory of the board of the territorial fund, i.e. bodies authorized to manage the territorial fund.

In 1997, in the territories of 29 constituent entities of the Russian Federation, compulsory health insurance fully complied with the legislative model. The chain of financial support for subjects was built from the territorial compulsory medical insurance fund through the CMO.

The practice of implementing compulsory medical insurance in the constituent entities of the Russian Federation shows that at present it is not yet possible to achieve full compliance of the functioning territorial compulsory medical insurance systems with the requirements of the law. Today, we can name four options for organizing compulsory medical insurance in various regions of the Federation.

First option basically complies with the legislative framework and most fully takes into account the basic principles of implementation of state policy in the field of health insurance. According to this option, all required entities work in the compulsory medical insurance system. Funds from policyholders (enterprises and executive authorities) are transferred to the TFOMS account. The Fund accumulates the collected funds and, upon concluding agreements with health insurance organizations, transfers to these organizations the shares due to them to finance compulsory medical insurance. CMOs work directly with medical institutions and the population. The greatest problems with such an organization of compulsory medical insurance arise when concluding contracts for insurance of the population. The legislation establishes two principles for concluding such agreements: either with the local administration or with employers. Unfortunately, at present, the conclusion of industrial insurance contracts directly between employers and HMOs has not become widespread. Basically, representatives of local administrations are involved in concluding insurance contracts, which removes the main payers of insurance premiums - employers from the sphere of control over the implementation of compulsory medical insurance and the choice of medical institutions for their employees. According to the first option, compulsory medical insurance systems operate in 19 constituent entities of the Russian Federation, covering more than 30% of the population: the cities of Moscow, St. Petersburg, Vologda, Moscow, Kaliningrad, Novosibirsk, Kemerovo regions, Stavropol Territory and some others.

Second option represents a combined compulsory medical insurance system. This means that insurance of citizens (issuance of policies and financing of medical institutions) is carried out not only by health insurance companies, but also by branches of TFYUMS. This is the most common scheme for organizing compulsory medical insurance, which covers 36 constituent entities of the Russian Federation, or 44.8% of the population.

Third option characterized by the complete absence of medical insurance organizations in the compulsory medical insurance system. Their functions were taken over by TFOMS and their branches. This type of compulsory medical insurance organization has developed in 17 constituent entities of the Russian Federation and covers 15% of the population. The implementation by the TFOMS of all functions within the framework of compulsory medical insurance is proposed by many experts as the main principle of possible reform of compulsory medical insurance. However, these facilities are not currently experiencing significant improvements in medical care. Rather, on the contrary, such an organization of compulsory health insurance is associated with the weak socio-economic development of the region.

Fourth option characterized by the absence of compulsory health insurance as such in the regions in principle. In these constituent entities of the Russian Federation, compulsory medical insurance is carried out only in terms of collecting insurance premiums for the working population. Local health authorities manage the collected funds, directly financing medical institutions. This situation characterizes 17 regions and covers 9.2% of the country’s population: the republics of the North Caucasus, the East Siberian region, the Smolensk, Kirov, Nizhny Novgorod regions, etc.

For the stable functioning of the compulsory medical insurance system, it is necessary to develop measures aimed at strengthening the influence of the Federal Fund, on compliance with the legislative framework of compulsory medical insurance in the formation of various models of the compulsory medical insurance system during the implementation of the Law “On Medical Insurance of Citizens in the Russian Federation”, and in the territories it is necessary to review the interrelations of the compulsory medical insurance system and reorganize formed models in accordance with the legislative framework.

2.3. Voluntary health insurance (VHI)

The Constitution of the Russian Federation in Article 41 proclaims the right to health care and medical care, placing it on a par with such social rights as the right to pension and social security, the right to housing, and the right to protection of motherhood and childhood. Economic guarantees themselves are a system in which state (budget) financing, compulsory health insurance (CHI) and voluntary health insurance (VHI) occupy a central place. VHI should have taken its rightful place among the economic guarantees of the right to health care and become one of the most effective among them.

People first started talking about VHI in the 90s, towards the end of Gorbachev’s perestroika, when it finally became clear that the state was unable to fulfill its obligations to finance healthcare. An economic catastrophe was approaching, which increasingly affected the implementation of social functions by the state. In these conditions, it was decided to turn to the experience of other countries where national health care systems have different sources of financing that complement each other. Health care organizers, economists and legislators equally understood the need for reforms in the industry, first of all, a revision of the concept of financial support for health care.

From an economic point of view, VHI is a mechanism for compensating citizens for expenses and losses associated with the onset of an illness or accident, i.e. insured event - (in VHI) the insured person’s visit to a medical institution (to a doctor) for medical care. The insured event is considered settled when, for medical reasons, the need for further treatment no longer exists. The number of insurance cases according to VHI rules can be unlimited.

Useful information for assessing the possibilities for the development of VHI is provided by sociological research data, in particular a study conducted in 2000 by employees of OJSC ROSNO. The number of respondents was 10 thousand people aged from 18 to 80 years, including 6 thousand patients of the Moscow APU, 3 thousand patients of the St. Petersburg APU and 1 thousand patients of the Saratov APU. 70% of the respondents were patients of state medical institutions, 20.8% - departmental and 8.2% - independent. More than half of the respondents were pensioners or did not work (68.2%). The survey was conducted using a questionnaire method.

Only 2% of respondents were covered by voluntary health insurance. At the same time, almost all respondents (98.2%) noted that they more or less regularly pay for medical care. Among them, 81% of respondents paid personally to the doctor, 36% - to the cash desk of a medical institution (several answer options were allowed, so the sum of the percentages exceeds 100). The structure of the population's costs for paying for medical care is shown in Figure 4.

Rice. 4 Structure of the population’s costs of paying for medical care

80% of respondents expressed their willingness to spend part of their income on paying for medical care in order to ensure an increased level of quality of medical services, use advanced medical technologies, and receive additional services. But only 10% of respondents are fundamentally ready to enter into a voluntary health insurance agreement. Thus, the system of “direct payment” for medical services for the population looks more familiar and simpler.

2.3.1. Objects and subjects of VHI

Voluntary health insurance is a significant addition to public health care systems or compulsory medical insurance.

In Russia, VHI as an economic and legal category and type of insurance activity arose in 1991 with the adoption of the RSFSR Law “On Medical Insurance of Citizens in the RSFSR” dated June 28, 1991 No. 1499-1. The insurance model provided for by law was fundamentally different from the types of personal insurance that existed at that time. We were talking about a qualitatively new legal relationship for our legal system. The novelty was in the object of the insurance legal relationship arising under VHI. Its subject composition also looked new. Personal insurance, including health insurance, common in the Soviet period, provided for payments directly to the insured upon the occurrence of an insured event (illness or other harm to health). The purpose of such insurance is to smooth out possible financial losses of the insured person incurred as a result of damage to health. The object of insurance in this case was the property interests of the insured person. The most common was the “simple” structure of the insurance legal relationship, which included the insurer and the policyholder as subjects, and the policyholder usually personally coincided with the insured.

3Law of the Russian Federation “On medical insurance of citizens in the Russian Federation” as object of voluntary medical insurance determines the risk associated with the costs of providing medical care in the event of an insured event.” At the same time, the Law states that voluntary health insurance “ensures citizens receive additional medical services and other services in addition to those established by compulsory insurance programs.” The objects of VHI are two groups of insurance risks: 1) the occurrence of expenses for medical services for health restoration, rehabilitation, care; 2) loss of income due to the inability to work both during the illness and after - upon the onset of disability. The legislation of the Russian Federation limited the object of medical insurance to only reimbursement of medical care costs.

Insured under voluntary health insurance are individual citizens with civil legal capacity and/or enterprises representing the interests of citizens.

Voluntary medical insurance provided for a qualitatively new and previously unknown type of insurance legal relationship in domestic insurance practice. Its object should have been the property interests of third parties, and not the insured himself. The concept of an object was explained in the law as “costs for the provision of medical care.” The subject structure of the legal relationship became more complicated; in addition to the insurer, the policyholder and the insured person, a medical institution was introduced into it as a person directly providing medical care.

The interaction of VHI subjects is presented in Fig. 5.

Fig.5. Scheme of interaction between VHI subjects

Another innovation was the legally enshrined rejection of the state monopoly in the field of insurance. The departure from state monopoly and the first mention of private insurance followed in the “Fundamentals of Civil Legislation of the USSR and Union Republics” of 1991. Therefore, the private nature of VHI, emphasized in the RSFSR Law “On Medical Insurance of Citizens in the RSFSR” of 1991, was quite new.

2.3.2. Economic necessity of VHI

Since one or another compulsory medical insurance system in many countries covers the majority of the population, insurers have developed types of insurance that would allow citizens participating in compulsory medical insurance to, with the help of private insurance, fully cover the costs of those medical services that are partially paid for by compulsory medical insurance programs or improve conditions your medical care under compulsory medical insurance. Additional VHI provides coverage for the costs of expensive operations, attracting leading specialist doctors, choosing a hospital and doctor, creating comfortable treatment conditions, providing care, and some other things.

Independent health insurance involves medical policies: for citizens who do not participate in compulsory medical insurance; certain groups of the population that have particularities of treatment (children, women, some other groups); for treatment in private clinics and private practitioners; to provide medical insurance when traveling abroad.

VHI appears and successfully develops where and when the need to pay for (full or partial) medical services arises. If medical care is provided free of charge and is fully financed by the state or the compulsory medical insurance system, then there is no need for additional medical insurance.

The frequency of the onset of disease risk during a person’s life cycle makes it possible to classify this risk as insurable by leveling its consequences for large groups of the population. The risk of the disease actually affects every person, but a stable statistical pattern has been identified that allows us to divide a person’s life into four periods characterizing the frequency of the disease:

I) from birth to the 15th birthday – a period of childhood illnesses characterized by a fairly high level of morbidity;

II) from 15 to 40 years – a period of stability, characterized by the lowest incidence;

III) from 40 to 60 years – a period of gradual increase in risk;

IV) after 60 years – the period of highest risk of morbidity.

This dynamics of risk made it possible to distribute it evenly in society through insurance using equalized insurance premiums for different age groups.

The need for VHI directly depends on the extent to which the risk of disease is covered by compulsory health insurance systems. The narrower the range of compulsory medical insurance guarantees, the higher the demand for private health insurance, and vice versa. The demand for private health insurance is determined in many cases by the desire to receive a guarantee not only of treatment, but also of a high level of service in a medical institution (private room, nurse, treatment by leading specialists and some other services). The need for voluntary health insurance becomes very relevant when traveling abroad, especially to those countries where obtaining a visa is impossible without presenting medical insurance for the duration of the trip.

2.3.3. Development, with current state and prospects of VHI in Russia

Voluntary health insurance is a deeply private phenomenon in the legal sense; any kind of government intervention in private relations is impossible, if, of course, these relations develop normally.

It is no coincidence that in 1999, on the initiative of the Federal Compulsory Medical Insurance Fund, a discussion took place of the bill “On Amendments and Additions to the Law of the Russian Federation “On Medical Insurance of Citizens in the Russian Federation.” According to this bill, the law should have been split into two: “On compulsory health insurance” and “On health insurance”. This was an attempt to separate compulsory health insurance with its specific legal regime from voluntary health insurance.

According to the legislator, VHI should have received independent, almost spontaneous development in the period 1991-1993. and give impetus to further development of healthcare. VHI was planned as a serious financial flow into domestic healthcare.

Life has shown that the legislator's plan did not come true. VHI has not become widespread; in any case, it has not become a significant financial “support” for healthcare. There are many reasons for this, the main one being economic problems. But certain shortcomings are inherent in the law itself. Thus, the tax benefits provided for in Part 2 of Article 13 of the Law for enterprises that allocate funds from VHI profits are not implemented in practice. Meanwhile, enterprises today are the only real insurers on whom it is necessary to place a bet. Only a collective insurer is able to give impetus to the further development of VHI. An individual policyholder currently does not have the funds to pay for a VHI policy, and if he applies for the services of an insurer, then only when he already needs medical care, and how. usually expensive. In this sense, working with an individual policyholder is unprofitable for the insurer. A collective insurer usually enters into voluntary health insurance contracts for the benefit of its employees - people of working age who are less likely to require medical care. Working with group insurance is beneficial for the insurer and, ultimately, for the VHI and healthcare systems.

Individual insurance will not become widespread in our country also because our society is traditionally oriented towards collectivism and collective forms of realization of rights.

In addition to the collective form of VHI, the so-called corporate form is possible, when the policyholder is a public association, insuring its members, or an association of policyholders is created. An association of policyholders is a form of association of citizens for joint participation in any (in our case, VHI) type of personal or property insurance. Corporate insurance, unfortunately, has not yet become widespread. Although it could develop, for example, in small municipalities, where the organization of the association of insurers would be taken over by the municipal authorities, and the association would include all residents of the municipality.

In general, many companies across the country are engaged in voluntary health insurance, and the most successful are Ingosstrakh, Industrial Construction Company, SK Spasskie Vorota, and in the Samara region - SK AskoMED, SamaraMed, etc.

The potential of VHI is obvious. But it is necessary to interest the collective and corporate insurers (the latter must also be formed). It is necessary to create a system of effective tax, economic, and legal benefits for enterprises that enter into VHI agreements in relation to their employees, to extend these benefits to private entrepreneurs using hired labor, to provide for the opportunity for small (and possibly large) municipalities to act as a corporate insurer for the population of these municipalities.

The creation of preferential treatment for policyholders is possible both at the federal and regional levels. The regional level seems even more optimal. Firstly, regional authorities are closer to the population, and secondly, health care problems are confined to regional authorities.

2.4. Distinctive features of compulsory and voluntary health insurance

Voluntary insurance is similar to compulsory health insurance and follows the same social goal - providing citizens with a guarantee of receiving medical care through insurance financing. However, this common goal is achieved by the two systems through different means.

Firstly, voluntary medical insurance, unlike compulsory medical insurance (CHI), is a non-social sector. , and commercial insurance. VHI, along with life insurance and accident insurance, belongs to the field of personal insurance.

Secondly, as a rule, this is an addition to the compulsory medical insurance system, providing citizens with the opportunity to receive medical services in excess of those established in compulsory health insurance programs or guaranteed within the framework of state budgetary medicine.

Thirdly, despite the fact that both systems are insurance, compulsory medical insurance uses the principle of insurance solidarity, and VHI uses the principle of insurance equivalence. Under a voluntary health insurance agreement, the insured receives those types of medical services and in the amounts for which the insurance premium was paid.

Fourthly, participation in voluntary health insurance programs is not regulated by the state and realizes the needs and capabilities of each individual citizen or professional team.

There are other equally significant differences between compulsory and voluntary health insurance.

In accordance with Art. 1 of the Law of the Russian Federation “On Medical Insurance...” compulsory medical insurance is an integral part of state social insurance and provides all citizens of the Russian Federation with equal opportunities to receive medical and pharmaceutical care provided at the expense of compulsory medical insurance. Voluntary medical insurance is carried out on the basis of voluntary medical insurance programs and provides citizens with additional medical and other services in addition to those established by compulsory medical insurance programs.

Compulsory health insurance, unlike voluntary health insurance, covers all insurance risks, regardless of their type.

Compulsory medical insurance is universal, but voluntary health insurance can be collective and individual.

The insurers of compulsory health insurance are employers for working citizens, and the state (local executive authorities) for non-working citizens. With compulsory health insurance, the policyholder is required to include an agreement with the medical insurance company, and with voluntary health insurance, the agreement is concluded only on a voluntary basis.

Compulsory medical insurance activities are carried out on a non-commercial basis, and voluntary medical insurance is one of the types of financial and commercial activities and is carried out in accordance not only with the Law of the Russian Federation “On Medical Insurance of Citizens of the Russian Federation”, but also with other laws regulating business activities.

Unlike voluntary health insurance, with compulsory health insurance, the duration of the insurance period does not depend on the period for payment of insurance premiums, and the insurer is liable even in the event of failure to pay insurance premiums.

Financial resources of the compulsory medical insurance system are generated through budget payments and contributions from enterprises and government bodies at the appropriate level. The amount of contributions for compulsory health insurance for enterprises, organizations and other economic entities is set as a percentage of accrued wages. Voluntary health insurance is carried out at the expense of the profit (income) of the enterprise and the personal funds of citizens, the amount of insurance premiums is established by agreement of the parties.

The basic compulsory health insurance program is determined by the Government of the Russian Federation and on its basis a territorial program is approved, representing a list of medical services provided to all citizens in a given territory. With voluntary health insurance, the list of services and other conditions are determined by the agreement between the policyholder and the insurer.

Tariffs for medical services for compulsory health insurance are determined at the territorial level by agreement between medical insurance organizations, government bodies at the appropriate level and professional medical organizations. Tariffs for medical services under voluntary health insurance are established by agreement between the medical insurance organization and the medical institution, enterprise, organization or person providing these services.

The quality control system for compulsory health insurance is determined by agreement of the parties, with the leading role of government authorities, and for voluntary health insurance it is established by agreement.

2.5. Prospects for combining compulsory medical insurance and voluntary medical insurance

The question of the forms of the continued existence of compulsory health insurance as an element of state guarantees is connected primarily with the question of possible ways to cover the financial deficit of funds allocated to finance medical care. There are three main strategies for achieving financial security of government guarantees.

The first strategy involves increasing public funding for health care combined with limited efforts to restructure the health care system and improve its efficiency. This strategy focuses on the development of VHI as a system replacing compulsory medical insurance, while maintaining unchanged state guarantees of medical care for the population.

The second strategy focuses on a significant increase in the efficiency of using available resources, achieved through a deep restructuring of medical care with the transfer of the maximum possible part of it to the outpatient stage while simultaneously eliminating funding from public sources for the released capacity. It does not generate new options for combining VHI and compulsory medical insurance compared to the first strategy.

The third strategy involves a combination of measures to improve the efficiency of the healthcare system with a partial revision of guarantees and a reduction in medical care (by type, guaranteed volume and conditions of provision), fully paid for by public sources. This option creates fundamentally different conditions for the development of voluntary health insurance compared to the first two strategies. Here we are talking about transferring the provision of some types of medical care to a paid basis for certain categories of the population, or introducing legal participation of a number of categories of the population in the financing of medical care provided under the compulsory medical insurance program (co-payments at the time of receiving medical care or the introduction of an additional insurance premium). Accordingly, the subject of voluntary medical insurance is expanding. Forms of combination of VHI and compulsory medical insurance appear as forms of a multi-level health insurance system.

The main condition for the successful implementation of any of these strategies is a clear description of the program of state guarantees - the types, volumes and conditions for the provision of free medical care.

Creating a multi-level health insurance system involves making the following key decisions:

A clear definition of the types of medical care provided to any citizen free of charge (paid for from compulsory medical insurance funds) under any conditions;

Determining the categories of citizens entitled to receive the widest package of medical services under compulsory medical insurance, and the criteria for classifying citizens into one category or another (family income level, social status, etc.);

Determination of criteria for limiting the types and (or) volumes of medical care for different categories of citizens.

Medical insurance companies should be considered as structures ensuring the implementation and monitoring of the implementation of the compulsory medical insurance program and differentiated voluntary health insurance programs. Insurance companies must ensure effective management of medical care, based on the integration and analysis of financial and clinical information, managing patient flows and achieving the necessary balance between costs, quality and availability of medical care. Along with the increase in powers, the requirements for insurance companies participating in the system should increase. These should be structures with high personnel and technical potential, capable of implementing diverse differentiated health insurance programs that complement and expand the guaranteed state minimum of providing the population of the Russian Federation with free medical care.

In Russian reality, the process of combining compulsory and voluntary health insurance occurs largely spontaneously. The inadequacy of medical care received in the public health sector forces patients to seek ways to obtain missing medical services at the expense of personal income or employer funds. At the same time, such opportunities can be used to a much lesser extent by citizens belonging to the category of socially vulnerable people - chronically ill and low-income people. But they are the ones who need more medical care. If there is insufficient medical care for this category, the need for it increases. As a result, the disproportion between the volumes of medical care needed and available to these citizens is growing.

Chapter 3.

Medical insurance abroad

3.1. Foreign experience of health insurance

Health insurance, or more precisely, medical expense insurance, is an important component of the social infrastructure of any developed country.

There are several models of national healthcare in the world. The United States adheres to an individualistic model, in which the public health sector, which is insignificant in terms of the volume of medical care provided, is supplemented by a developed health insurance system. The public health sector provides mainly urgent care and treatment of socially significant diseases. Medical insurance, private, is carried out in two types - collective and individual. Moreover, every working American insured by his employer strives to insure himself individually in case of illness and insure his family members. There is no compulsory medical insurance as an element of state guarantees for the provision of medical care. The existing state health insurance applies only to certain categories of workers: civil servants, police officers, and military personnel. The insurers are private companies; insurance is called state-owned only because insurance premiums are paid from the budget.

Germany adheres to a mixed system, where there is a developed public health sector and developed systems of compulsory and private (non-state) health insurance. If necessary, the insured may, in addition to services within the framework of compulsory insurance, resort to services provided by private insurance companies.

France adheres to a model in which every citizen is forced to be insured through private insurance programs, because... the state and the compulsory medical insurance system cover only 75-80% of treatment costs (this system is sometimes called “complementary”). The existing compulsory medical insurance system, in addition, does not cover the entire population as insured.

Compulsory health insurance abroad is based on the formation of non-state insurance funds through mandatory payments from employees and employers with partial subsidization from the state. These funds are used to pay for medical services.

As a rule, financing of the health care system is based on a combination of various elements with the predominance of one form or another. Most medical services are financed through mandatory legal forms of health insurance or directly by the state through the budget. Medical services are partly purchased by the population on a voluntary basis. This occurs either on the basis of direct payment for health services or through voluntary health insurance.

The proportion of cash flows through these four channels varies significantly across countries. For example, in Germany, this ratio is as follows: medicine receives about 5% through prices, voluntary insurance premiums - 10%, compulsory insurance premiums - 75%, taxes - 10% of all financial resources.

Compulsory health insurance uses two methods. In Germany and the Netherlands the service principle applies. This means that the patient is served free of charge, as in countries with a public health care system. He just has to show proof of insurance. In Belgium, France and Luxembourg, a different principle is practiced - cost recovery. There, the insured patient must first pay for medical services himself. And then they will be reimbursed in full or in part in accordance with the tariffs established by the health insurance funds, taking into account a certain own contribution.

Table 5

Contributions for compulsory health insurance

(in % of wage fund)

Compulsory health insurance is established by the law of the relevant country not for everyone, but only for certain categories of the population. For example, in Germany, where this system is most developed, all wage earners, peasants, students, and the unemployed are subject to compulsory insurance. Pensioners and family members are insured up to certain monthly income levels. In addition, there is a certain level of average monthly income, above which mandatory payments are not charged.

Non-state, or private, health insurance in a number of foreign countries is the main way to cover the costs of treatment. In other countries, it complements the level of free health care guaranteed by the state.

In the United States, out-of-pocket expenses are covered in various ways by both private organizations (health insurance) and the government. For both of these sources of funding in the late 90s. accounted for more than 70% of the total medical expenses of the population, equal to 440 billion dollars, incl. for the share of private insurance organizations - over 30% of the specified amount.

In insurance companies, medical insurance is often practiced along with other types of insurance activities (life insurance, property insurance, etc.), because it is less profitable than other types. Insurance companies, as a rule, act as intermediaries, limiting themselves to only covering the relevant expenses of their clients. They themselves are not involved in either organizing or providing medical care, giving the insured the right to independently choose a doctor and hospital, albeit with some restrictions. Large firms create their own insurance systems to provide group health insurance for their employees. Often, an entrepreneur acts as an insured in favor of an employee, who pays up to 80% of the cost of the insurance contract. Medical insurance conditions are an important criterion when choosing a place of work.

Unlike insurance companies, specialized organizations themselves provide treatment in their clinics or otherwise, and the client does not enter into a financial relationship with the clinic or doctor. The specialized organizations that appeared first, according to their charter, were and remain non-profit. All income from the investment of free reserves formed from insurance payments goes entirely to the members of these organizations. In other words, profit is taken into account when determining insurance rates. Note that organizations created recently usually provide for the receipt of some income from their activities. In this regard, they are similar to insurance companies.

Health maintenance organizations (HMOs) themselves develop and pay for the complete treatment process. The client pays a fixed amount in advance for medical care for a certain time, regardless of the actual (expected) cost of treatment. The activities of HMOs are regulated by the state.

It is appropriate to trace the differences between HMOs and insurance organizations (IOs). In CO – the free choice of a doctor or hospital by the insured, in HMO – the client agrees to receive medical care from a doctor provided or recommended by this organization, and it is also responsible for the quality of treatment.

In Western Europe, the share of insured people in the total population (insurance coverage) and the amount of premiums per insured person vary significantly across countries (Table 6). As for the size of contributions, the observed high differentiation (maximum contributions in Germany, minimum in Denmark and England) is apparently explained by differences in the range of medical services provided. The range of medical services is specified in the contract.

The figures given in the table may be somewhat outdated. However, anecdotal, more recent data suggests that the prevalence of private health insurance has changed little to date. Contributions are constantly increasing due to the rise in cost of medical services, which has been happening in all developed countries in the last two decades (progress in “technology”).

Table 6

Private health insurance in Western European countries in 1992

3.2. Possibilities of using foreign experience of medical insurance in Russia

A health care system based on insurance principles makes it possible to achieve high-quality medical care at significantly lower costs than with private financing. European countries with a developed healthcare insurance system spend about 6-9% of GDP annually on health care (the exception is Germany, where about 11% of GDP is spent on healthcare), while in the United States with a liberal healthcare system and widespread use of private payment for medical services, costs constitute about 14% of GDP with similar quality of medical services.

The model of compulsory health insurance (CHI) in Germany has been steadily existing and developing for decades, has similar principles of construction to Russian ones, and its experience deserves attention. Let's stop there.

The system of national health care and social protection in Germany was created gradually, not by a one-time decree, but by a series of legislative acts expanding the scope of social guarantees. And each new step was measured against real possibilities, and the adoption of new programs was preceded by a thorough analysis of the industry’s resource base.

A comparative analysis of the health insurance systems of Germany and Russia made it possible to identify the following areas of reform of the domestic health insurance model, taking into account the possibility of applying the positive experience of Germany: these changes relate to the principles of organization, financing of the compulsory medical insurance system, ensuring the relationship between compulsory and voluntary health insurance, and protecting the rights of the insured.

Due to economic reasons, full financing of the State Guarantees Program for the provision of free medical care (SGG) for the entire population of the Russian Federation, annually approved by the Government of the Russian Federation, is impossible, therefore it is necessary to abandon the declaration of providing all citizens with the same volume of free medical care, which is not feasible in practice. In the vast majority of regions, this program, and within its framework the Basic Compulsory Medical Insurance Program, is not provided with government funds.

The problem of a lack of funds in the compulsory medical insurance system as a whole is also typical for such a seemingly prosperous country as Germany. According to official statistics, the deficit of sickness funds at the end of 2001 as a whole amounted to 2.5 billion euros, despite the fact that the total expenditure of all sickness funds in Germany in 2001 amounted to 138 billion euros. For comparison, for the same period, the expenses of Russian territorial compulsory medical insurance funds (including MHIF subventions) amounted to 87,401.7 million rubles. It has become impossible to provide the health insurance system with financial resources to provide the entire volume of medical services declared by compulsory medical insurance to each insured person. In Germany, where compulsory medical insurance programs, like in Russia, include a wide range of medical activities, there are now active discussions on the issues of limiting the volume of medical services provided within the framework of compulsory medical insurance programs. In the near future, the basic volume of medical care in the compulsory medical insurance system will be determined in Germany, which is supposed to be provided to each insured person free of charge. All types of medical care not included in the basic program will have to be paid for by the patient privately from personal funds or by concluding an additional VHI agreement. Exceptions will be made only for seriously ill insured persons. Persons with low incomes will receive support from budget funds.

The Russian health insurance system also faces an important task - to achieve a balance between compulsory medical insurance programs and the financing of the compulsory medical insurance system as a whole. To this end, it is proposed to develop a multi-level health insurance program with a list of services provided to the entire population of the Russian Federation free of charge within the scope of the basic compulsory medical insurance program, and a list of services provided in addition to this within the framework of voluntary health insurance programs supplementing compulsory medical insurance or at the expense of citizens’ personal funds. At the same time, the basic volume of medical care in compulsory medical insurance must be determined with the calculation of the financial need for its full implementation based on accumulated insurance statistics. It is advisable to provide services beyond the basic program free of charge only to socially vulnerable categories of citizens after confirmation of the need for them by the conclusion of a clinical expert commission.

The basis of the basic compulsory medical insurance program should be a differentiated list (classifier) ​​of services performed within each medical specialty. It is necessary to refuse funding for general categories - specialized visits, etc., since using them in work it is impossible to verify the intended use of funds.

To work in a multi-level health insurance system, a combination of compulsory and voluntary health insurance (VHI) is required. According to German legislation, about 90% of the total population of Germany is covered by compulsory health insurance. Only a small part of the country's residents (mostly people with high stable incomes) are not required by law to insure their health. If an insured person wants to receive an expanded volume of medical and services compared to the compulsory medical insurance program, he can enter into an additional medical insurance agreement with the insurance company.

In Russia, a situation has arisen where legal and shadow payments by the population for medical services and medicines amount, according to various estimates, from 25 to 45% of the total expenditures of the state and the population on healthcare. At the same time, it is extremely important that funds received by medical institutions do not increase shadow income in the economy, but are spent on the development of healthcare.

An important task for Russia, therefore, is to develop a systematic approach to the development of VHI, which should become a rationally designed “superstructure” to free medicine. The backbone of the VHI system will be standard, unified insurance programs, which should be developed taking into account the specifics of the basic compulsory health insurance program. Joint compulsory medical insurance and voluntary medical insurance programs in the future would become the basis for building financial relationships in the health insurance system and financing the healthcare system. The current situation corresponds to economic logic. All payers of the single social tax (enterprises, entrepreneurs, citizens) accept the VHI prices set by the insurer without any reduction in them by the cost of the state-guaranteed minimum volumes of medical care, for which they monthly transfer 3.6% of the wage fund to the budget.

It is necessary to introduce in Russia a unified organizational and financial model of compulsory medical insurance in all territories by law. This will help improve the functioning of the entire compulsory health insurance system as a whole and will facilitate interaction within the system between its subjects. At the same time, a fundamental point is the issue of including medical insurance organizations in the social protection system. The experience of Germany shows that the compulsory health insurance system functions effectively when there are three insurance entities (the policyholder, the insurer - the health insurance fund - the medical institution). In the classic compulsory medical insurance model used in Germany, sickness insurance funds (analogues of Russian compulsory medical insurance funds) successfully combine the functions of assigning services to the population, collecting and accumulating insurance premiums, concluding contracts for medical care for their insured with medical institutions and private practitioners, as well as directly pay medical institutions the cost of medical services provided to citizens. This combination of functions allows you to clearly monitor financial flows, make the management system less cumbersome and more efficient, and also significantly reduce its costs. Currently, in Russia, it seems possible to shift the functions performed by medical insurance organizations to territorial compulsory medical insurance funds, which will reduce the organizational costs of the compulsory medical insurance system and simplify the mechanisms of internal and external control. A unified compulsory medical insurance system will also ensure in practice the right of the insured to freely choose an insurer, basic medical institution and attending physician.

From the general principles of medical insurance abroad, Russia would do well to adopt the experience of actuarial specialists (insurance mathematicians). In order to properly organize and reliably conduct a business, in addition to solving various organizational and legal problems, serious work of actuaries is required - developing insurance conditions and specific insurance schemes, justifying premiums and insurance rates, determining the amount of reserves, conducting an actuarial assessment of group insurance, i.e. to check the adequacy of savings to the obligations of the insurance company over the insured.

The most acute problem that has already been encountered in organizing health insurance in our country is the insufficiency, and in some cases the complete absence of the necessary statistical data. For example, to calculate short-term insurance, at least information about the cost of treatment in individual clinics and territories is required. You can't get by with averages here. In turn, long-term insurance, especially group insurance, requires a huge amount of information. For example, data is needed to develop a table of retirement of the insured (you can’t get by with mortality tables), data on patterns of growth in the cost of treatment by age, etc.

This is due to a number of objective and subjective reasons - economic instability, inflation, lack of necessary funds at enterprises, as well as an understanding of the importance of this type of service, lack of actuarial calculation methods and trained personnel for competent business management, etc. At the same time, it should be expected that serious Russian insurance companies will sooner or later pay attention to this type of health insurance, which is prevalent in Western countries.

Lastly

Since the beginning of February, the district compulsory health insurance fund began issuing new policies on plastic cards with a microchip. They are awarded only to those who permanently reside in the territory Nenets Autonomous Okrug .

The new policy contains only initials and year of birth. All other information - address, phone number, place of work - is embedded in the chip. About two thousand new cards have already been issued, the rest will be distributed throughout the year. To obtain a policy, you must present a passport, a certificate from your place of work, and birth certificates of your children. Those who do not work need a work book, and for non-working pensioners - a pension certificate.

Students studying outside the district can obtain a temporary insurance policy from the Compulsory Medical Insurance Fund at their place of study. And no one has the right to refuse them this. In Naryan-Mar, all students with temporary registration will also be given a policy, but only if they have a passport and student ID.

The cards are planned to be distributed in populated areas of the district within two years, since not everyone has the opportunity to travel to the city.

“In a year, when everyone has a new type of card in their hands, we plan to enter more information into them,” says Dmitry Ruzhnikov, executive director of the Compulsory Compulsory Medical Insurance Fund. – We hope to implement this system in hospitals and pharmacies, that is, to completely automate everything. In essence, the policy will be a miniature patient’s outpatient card containing everything that concerns the patient: blood type, benefits, drug intolerance, etc.

Conclusion

Population health is the most important element of the country’s social, cultural and economic development. In this regard, providing the population with a guaranteed volume of free medical care, financed from budgets of all levels and compulsory medical insurance funds, is the most important state task. And this situation is especially emphasized in the Program for the socio-economic development of the Russian Federation for the medium term.

The most important condition for organizing a health insurance system is the creation of sufficient guarantees for the fulfillment of contractual obligations by insurance firms (companies). This requires diversification of medical insurance activities, thanks to which the proceeds from highly profitable contracts are used to pay for health care facilities. A health insurance company is interested in investing in its business activities, for example, by raising funds from enterprises, issuing securities, etc., which allows it to attract additional financial sources to pay for healthcare services.

The potential patient must be encouraged to take care of his own health and, if necessary, actively seek medical help. A corresponding material interest in this will appear provided that partial payment for health care services is introduced at the expense of citizens (in addition to payments under insurance policies). Unfortunately, the introduction of a paid healthcare system for broad sections and groups of the population is hardly acceptable due to the relatively low real wages with a significant differentiation in the incomes of workers. This approach is justified in the context of additional medical insurance.

It is more promising to use various types of insurance policies for personal insurance of citizens - the so-called return insurance with compensation, which involves paying the client insurance premiums in full or in part by deducting the cost of all types of diagnostic and treatment services provided over a certain, for example, 10-year period of time. Thus, with health insurance for survival, the insured (depending on the frequency of his requests for medical help) is paid a pre-agreed amount of money upon reaching a certain age.

Competition between medical institutions of various forms of ownership has a positive impact on the quality of treatment and preventive services and the growth of the professional level of staff. At the same time, conditions are being created to increase the property (economic) and legal responsibility of health care facilities to financial authorities and the professional responsibility of doctors to patients for the results of clinical diagnostic examinations and treatment measures. A prerequisite for the progress of insurance medicine is the development of property relations in healthcare.

The current federal standards of medical care are developed taking into account the best achievements of medical science and include a significant number of manipulations necessary for more accurate diagnosis and the best treatment. There is no doubt that ensuring such standards for the entire population will have extremely beneficial consequences for citizens. However, the realities of Russian healthcare show that not only within the framework of compulsory medical insurance, but also within the framework of combining compulsory medical insurance and paid one-time services, patients do not receive the full volume of services and manipulations provided for by these standards. Analysis of the statistical data presented earlier proves exactly this. To comply with federal standards, it is necessary to either revise them in the direction of reduction, or determine the sources of covering the costs of their implementation. Otherwise, these standards will be declarative.

Federal medical standards should be focused on the material, technical, personnel and other resource capabilities of standard treatment and preventive institutions such as city and central district hospitals and clinics, other medical institutions with similar levels of medical care (types of medical activities) and serve as an information base for the development of territorial medical and economic standards according to the recommended scheme for their description.

Insurance premiums from public and private sources for the compulsory medical insurance program will be determined on the basis of actuarial calculations, and under conditions of mandatory payment for all categories of insurers, payment will be lower than the costs at the time of contacting a medical institution.

The social satisfaction of the insured patient (consumer of medical services) is closely related to the quality of medical care provided. But at the same time as receiving therapeutic and diagnostic procedures directly related to the scope of medical care provided, the patient also receives non-medical services to ensure social and psychological well-being. These include: the level of comfort in the institution, sanitary and hygienic conditions, daily routine not related to treatment, relationships between staff and patients not related to the implementation of treatment and diagnostic appointments, leisure opportunities, conditions for meeting relatives, means of communication with the outside world etc. Therefore, the concept of “quality of medical care” also includes the concept of “subjective quality,” which allows us to highlight the subjective component of quality, which is closely related to the personality of the medical worker and the level of social protection of citizens (level of service + quality of medical staff). When performing diagnostic, treatment and preventive measures, it is possible to take into account and most fully realize all the components of the concept of “subjective quality” of medical care, if appropriate material resources and financial support are provided for this.

Financing of medical programs at higher levels comes only from private sources. The policyholders are employers and the insured themselves. The calculation of insurance premiums is carried out on the basis of actuarial calculations, taking into account the levels of need of the insured and market demand.

Financial costs, as far as possible in the current economic conditions, must be adequate to the volume and quality of medical services provided. Financial and settlement relationships between health insurance subjects are closely related to solving the problem of calculating and agreeing on tariffs for medical services under health insurance programs.

Insurance rates are calculated in such a way as to ensure the “zero principle” for insurance reserves - the amount of money collected to pay compensation for insured events is paid out. Therefore, the most important thing when calculating the tariff is the availability of reliable insurance statistics, which allows one to assess the likelihood of an insured event occurring, and the availability of data on the unprofitability of the insured amount - i.e. the ratio of average payments to average insurance amounts. Based on the insurance tariff and the amount of the insured amount, the insurance premium is determined, which ensures the amount of the insurance reserve necessary for the payment of insurance compensation.

For modern Russia, it is extremely important to ensure the rights of those insured in the health insurance system in terms of receiving medical services of the required volume and quality. In addition to developing a regulatory framework that ensures the rights of the insured, it is necessary to determine specific mechanisms for compensation for damage caused to victims. The simultaneous introduction of compulsory professional liability insurance for doctors will ensure the protection of not only the rights of the patient, but also the protection of the professional and property rights of health workers. Resolving regulatory issues regarding the sources of payment of insurance premiums and the payment of funds when fines are imposed will make financial sanctions against a medical institution or a specific medical worker an important factor in improving the quality of medical care.

References

1. Constitution of the Russian Federation of 1993 (as amended on 06/09/01)

2. Law of the Russian Federation of June 28, 1991 No. 1499-1 (as amended on July 1, 1994) “On medical insurance of citizens in the Russian Federation”

3. Russian statistical yearbook 2002: Statistical collection/Goskomstat of Russia. – M., 2002

4. Sociological research of ROSNO in 2000.

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Chapter 8. Development of health insurance in the Russian Federation

Chapter 8. Development of health insurance in the Russian Federation

8.1. GENERAL PROVISIONS

Health insurance- one of the forms of social insurance, which, in turn, is part of the insurance system as a whole. Let's look at this in more detail.

Insurance is a system of legal and economic relations to protect the interests of individuals and legal entities upon the occurrence of certain events (insured events) at the expense of monetary funds formed from the insurance premiums (insurance contributions) they pay, as well as other funds of insurers.

The peculiarity of insurance as a type of business activity is that it has a certain risk associated with the insurer’s obligation to compensate for damages agreed upon in advance. Insurance is carried out in cases where the probability of the occurrence of risks can be assessed, and there are certain financial guarantees from the insurer for compensation for damage.

Insurance can be classified as follows:

by insurance object: personal, property, liability insurance;

according to the form: mandatory, voluntary;

by the method of formation and use of insurance reserves: risky, accumulative;

by the number of insured (in one contract): individual, collective.

The main function of insurance in a market economy is compensation for financial and material losses of a citizen or legal entity resulting from illnesses, accidents, natural disasters, man-made disasters, failure to fulfill obligations by counterparties (partners), etc.

Social insurance in a broad sense is understood as a system that ensures citizens the right to work and earnings

and fair distribution of the social product, as well as legally guaranteed social protection, compensation for losses, provision of social assistance and services. Thus, social insurance is a system that protects citizens from social risk factors, which include: illness, accident, disability, unemployment, old age, loss of a breadwinner, death, etc. In addition, social insurance provides financing for preventive and health measures, provides social guarantees for case of pregnancy and childbirth, birth of a child.

Health insurance is a form of social insurance. The first regulatory act that laid the foundation for medical insurance in Russia is the Law “On Medical Insurance of Citizens in the RSFSR,” which was adopted in 1991. Later, in 1993, the legislator made a number of significant changes to it, and from that moment on, the legal basis The development of medical insurance in the state was the Law of the Russian Federation “On medical insurance of citizens in the Russian Federation”.

According to the law, health insurance is a form of social protection of the population’s interests in health care, the purpose of which is to guarantee that citizens, in the event of an insured event, receive medical care from accumulated funds and finance preventive measures.

The Law “On Medical Insurance of Citizens in the Russian Federation” defines the legal, economic and organizational foundations of medical insurance in the Russian Federation. The law is aimed at strengthening the interest and responsibility of government bodies, enterprises, institutions, organizations in protecting the health of citizens in a market economy and ensures the constitutional right of citizens of the Russian Federation to guaranteed (free) medical care.

In a broad sense, health insurance is a new form of legal and economic relations in the field of healthcare, ensuring the preservation and restoration of public health in a market economy.

In the Russian Federation, health insurance is provided in two types: mandatory And voluntary. Let us consider the organizational, legal and financial basis of each of these types separately.

8.2. MANDATORY MEDICAL

INSURANCE

8.2.1. Problems of establishing compulsory health insurance in Russia

The adoption in 1993 of a new edition of the Law of the Russian Federation “On Medical Insurance of Citizens in the Russian Federation” could not immediately change the situation in one of the most difficult areas of society - healthcare.

The introduction of compulsory health insurance in Russia was carried out in a difficult political and socio-economic situation. The goals initially set in the law and the mechanism for their implementation became outdated, unable to keep up with the ongoing changes in legislation and economics, so medical workers and the population in the first years of implementation of the law did not see the expected changes in the healthcare system, improvement in the organization and quality of medical care. Moreover, at that time, social expectations so far exceeded the achieved results that they raised doubts about the correctness of the choice made - the transition to the principles of health insurance.

One of the reasons for the lack of expected results with the introduction of the law was the sharp reduction in budget funding for the health care system. Another reason is the inability of medical insurance organizations to fulfill the functions assigned to them by law as an additional source of financing and protection of patients' rights. This was primarily due to a pronounced funding deficit (insurance organizations could not increase financial resources by placing free financial resources on bank deposits and in securities), as well as to the imperfections of the current legislation, therefore, subsequently the legislator introduced new insurance entities into the legal field , - Federal and territorial compulsory health insurance funds,- as independent state non-profit financial and credit institutions implementing state policy in the field of compulsory health insurance.

At the same time, the financial situation in the compulsory medical insurance system did not improve due to the preservation of the insurance tariff at the initially low level.

contribution to the working population. The situation was aggravated by the fact that the planned volume of funding in the compulsory health insurance system was decreasing due to a pronounced shortfall in payments from local budgets for the non-working population, as well as direct withdrawals by executive authorities of financial funds from the compulsory medical insurance system for purposes not related to the protection of the health of citizens. In addition, financial authorities, from the moment additional funds were received from compulsory medical insurance funds, reduced, in proportion to them, the budget share of healthcare costs, thereby negating the increase in funding for the healthcare system.

The situation was aggravated by a number of circumstances. The shift in the emphasis of financing from the budget to compulsory medical insurance funds has led in a number of constituent entities of the Russian Federation to a shift in the center of control from healthcare management bodies to the Federal Compulsory Medical Insurance Fund, which, in turn, has caused conflict situations.

An ambiguous attitude was caused by the provision provided by law that allows compulsory health insurance funds to increase financial resources by placing them in securities and bank deposits. At that time, this legislative norm in itself was so revolutionary that, in conditions of severe financial deficit, it naturally could not help but cause a negative reaction from the medical community.

The introduction of compulsory health insurance took place in the context of an aggravation of the economic crisis in the country, delays in the payment of wages, and a decline in the standard of living of the population. Against this background, the formation of new organizational structures (funds, medical insurance organizations), which had financial resources other than healthcare organizations for their development, gave rise to a feeling of social injustice among healthcare workers and, as a consequence, rejection of the compulsory medical insurance system itself.

The compulsory medical insurance system was planned as an effective form of social protection for citizens in the upcoming market reforms. Compulsory medical insurance was supposed to protect citizens who received medical care under the Soviet health care system from the accidents of the market and preserve the guarantee of free medicine for them. In the future, we will create an effective system for managing the quality of medical care, increase the legal responsibility of medical workers when carrying out their professional activities, and ensure the patient’s rights to receive guaranteed (free) medical care.

Qing care, freedom of choice of doctor and medical institutions. Not everything that was planned was successful.

Another significant problem with the implementation of compulsory medical insurance was the excessively large obligations of the state to provide citizens with free medical care in the scope of the State Guarantees Program.

The persistence of an imbalance between government obligations in the compulsory medical insurance system and their actual financial support turned out to be a serious obstacle to the development of compulsory medical insurance. At the same time, two ways to solve the problem are realistic: the first is a revision of the state’s obligations towards their reduction, the second is the redistribution of consumption funds in favor of healthcare.

During the formation of compulsory medical insurance, there were other negative aspects: rising prices for medicines, medical products, medical nutrition products, medical services, which, of course, placed a heavy burden on patients and the healthcare system as a whole. The process of providing paid medical services has become unmanageable, which has led to the formation of a shadow sector in healthcare. The state began to allocate less and less funds for general health activities, prevention, and sanatorium and resort treatment, which ultimately had a negative impact on the health of the nation.

These and other problems, of course, did not contribute to the popularization of compulsory health insurance and slowed down the improvement and development of its legal, organizational and financial mechanisms.

In general, despite the mistakes and difficulties of the initial period, the introduction of compulsory medical insurance ensured not only the survival, but also the development of the healthcare system in the conditions of the extremely unstable political and economic situation of the 90s of the last century. The compulsory medical insurance system ensured the provision of a minimum of guaranteed (free) medical care, made it possible to introduce non-departmental control over its quality, begin the structural restructuring of healthcare in accordance with the real need of the population for basic types of medical care and move to a more rational use of available healthcare resources.

The created financing mechanisms have ensured greater transparency of financial flows in healthcare. It is important to note that the introduction of compulsory health insurance contributed to the creation of organizational and legal mechanisms for protecting the rights of the patient as a consumer of medical services.

8.2.2. Organization of compulsory health insurance at the present stage of healthcare development

Compulsory medical insurance is designed to provide all citizens of Russia with equal opportunities to receive medical and medicinal care provided at the expense of compulsory medical insurance funds in the amount and on conditions corresponding to compulsory medical insurance programs, as an integral part of the Program of State Guarantees for the provision of free medical care to citizens of the Russian Federation.

In the compulsory medical insurance system, the object of insurance is the insurance risk associated with the costs of providing medical care in the event of an insured event. At the same time insurance risk- this is an expected, possible event, and insured event- an event that has already occurred, provided for by the insurance contract (illness, injury, pregnancy, childbirth).

Participants (subjects) of compulsory health insurance are a citizen, policyholder, medical insurance organization (IMO), medical institution, compulsory health insurance funds (MHIF) (Fig. 8.1). Compulsory health insurance is carried out on the basis of contracts concluded between health insurance entities.

Rice. 8.1. Subjects of compulsory health insurance

Policyholders with compulsory health insurance are: for the non-working population - executive bodies

authorities of the constituent entities of the Russian Federation and local governments; for the working population - organizations, individual entrepreneurs, private notaries, lawyers, individuals who have entered into employment contracts with employees, as well as paying remuneration under civil contracts, on which taxes are charged in the part subject to credit to compulsory health insurance funds.

Every citizen in respect of whom a compulsory health insurance agreement has been concluded or who has independently concluded such an agreement receives a medical insurance policy that is equally valid throughout the entire territory of the Russian Federation.

Citizens of the Russian Federation in the compulsory medical insurance system have the right to:

Choosing a medical insurance organization, medical institution and doctor;

Receiving guaranteed (free) medical care throughout the Russian Federation, including outside your permanent place of residence;

Receipt of medical services that correspond in volume and quality to the terms of the contract, regardless of the amount of the insurance premium actually paid;

Filing a claim against the insured, medical insurance organization, medical institution, including for material compensation for damage caused through their fault.

Along with citizens of the Russian Federation, stateless persons located on the territory of Russia and foreign citizens permanently residing in Russia have the same rights in the compulsory medical insurance system.

The functions of insurers in compulsory health insurance are performed by medical insurance organizations And territorial compulsory health insurance funds.

Medical insurance organizations with any form of ownership that have a state permit (license) for the right to engage in medical insurance can participate in compulsory health insurance of citizens. The main task of a medical insurance organization is to implement compulsory medical insurance by paying for medical care provided to citizens in accordance with territorial compulsory health insurance program. CMOs monitor the volume and quality of medical services, and also ensure the protection of the rights of the insured, up to the point of filing lawsuits against the medical institution or medical

to the employee for material compensation for material or moral damage caused to the insured through their fault.

The financial resources of the compulsory medical insurance system are generated through contributions from policyholders for all working and non-working citizens. The amount of the insurance premium for the working population is established by federal law as a percentage of the accrued wages of each employee as part of the unified social tax. In 2008, the compulsory medical insurance contribution for the working population was 3.1%. The amount of the insurance premium for non-working citizens is annually established by the state authorities of the constituent entity of the Russian Federation when approving the territorial program of state guarantees for the provision of free medical care to citizens of the Russian Federation at the expense of funds allocated for these purposes in the budget of the constituent entity of the Russian Federation. These contributions are accumulated in the Federal and territorial compulsory medical insurance funds.

Financing of medical insurance organizations is carried out by TFOMS on the basis of differentiated per capita standards and the number of insured citizens. Financial relations between medical insurance organizations and TFOMS are regulated by the agreement on the financing of compulsory medical insurance and the territorial rules of compulsory medical insurance, which are approved by the relevant government bodies of the constituent entity of the Russian Federation.

An important role in protecting the interests of citizens when receiving medical care is played by experts from medical insurance organizations, who monitor the volume, timing and quality of medical care (medical services) in the event of an insured event.

Federal and territorial compulsory medical insurance funds are independent state non-profit financial and credit institutions that implement state policy in the field of compulsory medical insurance. The Federal Compulsory Medical Insurance Fund is created by the highest legislative body of Russia and the Government of the Russian Federation. Territorial compulsory medical insurance funds are created by the relevant legislative and executive authorities of the constituent entities of the Russian Federation. Compulsory medical insurance funds are legal entities, and their funds are separated from the state budget. Compulsory medical insurance funds are intended to accumulate financial resources, ensure the financial stability of the state compulsory medical insurance system and equalize financial resources for its implementation.

Medical care in the compulsory medical insurance system is provided by healthcare organizations of any form of ownership that have received the appropriate license in the prescribed manner (for more details, see Chapter 9).

In the context of decentralization of management of state and municipal medical institutions by state health authorities, the licensing mechanism allows solving issues of optimizing the structure of medical care and increasing the level of technical equipment of medical institutions, bringing the volumes and conditions of providing medical care to the insured population in accordance with compulsory medical insurance programs.

In recent years, it has become a practice to allow private health care organizations to participate in the implementation of territorial compulsory medical insurance programs on a competitive basis. This helps create a competitive environment and is a factor in improving the quality and reducing the costs of providing medical care to the insured.

Medical institutions are financed by medical insurance organizations based on their invoices. Payment of bills is carried out at tariffs in accordance with the volume of medical care provided by the institution. For outpatient clinics, such a unit of care is a medical visit, for inpatient facilities - a completed case of hospitalization.

An analysis of the implementation of compulsory medical insurance in individual constituent entities of the Russian Federation shows that today it is possible to distinguish four models of organizing compulsory medical insurance in various constituent entities of the Russian Federation.

First model basically complies with the legislative framework and most fully takes into account the basic principles of implementation of state policy in the field of compulsory medical insurance. Funds from policyholders (enterprises and executive authorities) are transferred to the TFOMS account. The Fund accumulates financial resources and, under agreements with health insurance organizations, transfers them to finance the activities of healthcare organizations. CMOs enter into contracts directly with medical organizations and insurers.

Second model represents a combined compulsory medical insurance system. This means that insurance of citizens (issuance of policies and financing of medical institutions) is carried out not only by health insurance organizations, but also by branches of TFOMS.

Third model characterized by the absence of medical insurance organizations in the compulsory medical insurance system. These functions are performed by TFOMS and their branches.

Fourth model characterized by the absence of a compulsory medical insurance system as such in the regions. In these constituent entities of the Russian Federation, the Law of the Russian Federation “On Compulsory Medical Insurance of Citizens in the Russian Federation” is implemented only in terms of collecting insurance premiums for the working population. These funds are managed by local health authorities, directly financing medical institutions.

An analysis of many years of experience in the development of the compulsory health insurance system in the Russian Federation has shown that to ensure efficient spending of financial resources and provision of high-quality medical care to the population, the first model of organizing compulsory health insurance is most suitable.

Thus, being an integral part of state social insurance, compulsory medical insurance has a pronounced social character. Its main principles are:

universal and mandatory: all citizens of the Russian Federation, regardless of gender, age, state of health, place of residence, level of personal income, have the right to free medical services included in the basic and territorial compulsory medical insurance programs;

state nature of compulsory health insurance: The implementation of the state financial policy in the field of protecting the health of citizens is ensured by the Federal and territorial compulsory medical insurance funds as independent non-profit financial and credit organizations. All compulsory medical insurance funds are state property;

social solidarity and social justice: insurance premiums and payments are transferred for all citizens, but these funds are spent only when seeking medical help (the “healthy person pays for the sick” principle); citizens with different income levels have the same rights to receive free medical care (the “rich pays for the poor” principle); despite the fact that the costs of providing medical care to older citizens are higher than to younger ones, insurance premiums and payments are transferred in the same amount for all citizens, regardless of age (the “young pays for the old” principle).

The main direction for further improvement of the compulsory medical insurance system is the creation of conditions for sustainable financing of medical organizations to provide the population with guaranteed (free) medical care within the framework of basic and territorial compulsory medical insurance programs.

To do this, it is necessary to consistently solve a number of problems:

Ensure a balance between the income of the compulsory medical insurance system and the state’s obligations to provide guaranteed (free) medical care to insured citizens;

Develop legal mechanisms for the responsibility of the executive authorities of the constituent entities of the Russian Federation for fulfilling the obligations of the insurer of the non-working population living in a given territory;

Develop new approaches to the formation of basic and territorial compulsory medical insurance programs within the framework of the Program of State Guarantees for the provision of free medical care to citizens of the Russian Federation.

The most important task remains the search for mechanisms to increase funding for the compulsory medical insurance system.

An additional source of funding may be funds from the Pension Fund of the Russian Federation to finance costs associated with providing targeted medical care to non-working pensioners.

As the compulsory health insurance reform develops, tasks related to expanding the participation of the population in the compulsory health insurance system must be solved. At the same time, an increase in the share of financial participation of the population should be accompanied by an increase in the quality and expansion of the list of medical services. A prerequisite for the civilized development of the compulsory health insurance system should be the development of legal and financial mechanisms to eliminate informal payments from patients to medical workers.

One of the forms of citizen participation in health insurance may be the provision of the opportunity to voluntarily refuse to participate in the compulsory medical insurance system and resolve the issue of payment for medical care through the voluntary health insurance system.

And finally, the main direction of the compulsory health insurance reform is the creation in the future of a unified system of medical and social insurance that could provide the population with the necessary set of social guarantees, including the provision of guaranteed (free) medical care.

A prerequisite for this should be the transition to single-channel financing of the healthcare system.

8.3. VOLUNTARY HEALTH INSURANCE

Unlike compulsory medical insurance as part of the social insurance system, voluntary medical insurance is part of personal insurance and a type of financial and commercial activity, which is regulated by the Law of the Russian Federation “On the organization of insurance business in the Russian Federation.”

VHI is carried out on the basis of voluntary health insurance programs and provides citizens with additional medical and other services in addition to those established by compulsory health insurance programs.

In the history of the formation of VHI in modern Russia, four main stages can be distinguished.

The first stage - 1991-1993.

At this time, a campaign was carried out to conclude contracts providing for the payment by the insured of an insurance premium, which included the cost of guaranteed payment for treatment, as well as the costs of maintaining an insurance business. The insured contingent was also assigned to medical institutions chosen by the policyholder.

The second stage - 1993-1994.

During this period, voluntary health insurance contracts established a limit on the insurer’s liability for paying the insured for medical services in the amount of the insured amount exceeding the amount of the insurance premium. However, no refund of the insurance premium was provided.

The third stage - 1995-1998.

It was characterized by a ban on carrying out VHI operations under contracts providing for the return to the policyholder of the portion of the premium not spent on treatment at the end of the insurance period. From this moment on, the question of the need for medical insurance as one of the classical types of insurance, which allows the insurance company to bear liability within the limits of the insured amount, which is determined by the health status of the insured and the financial capabilities of the insured, has become relevant.

Fourth stage - from 1998 to present

After the August crisis of 1998, a qualitatively new stage in the development of VHI began.

Since then, one of the main tasks of VHI has been to ensure a high level of provision of certain medical services in addition to the compulsory medical insurance program. It is implemented at the expense of own funds received directly from citizens or funds from the employer, who additionally insures its employees.

The amounts of VHI insurance premiums are set by medical insurance organizations independently and depend on the type of risks, insurance rules adopted by a particular insurer, the cost of medical and other services, the number of insured, etc.

Voluntary insurance is carried out on the basis of an agreement between the policyholder (employer), the insurer and the healthcare organization. The rules of voluntary insurance, which determine the general conditions and procedure for its implementation, are established by the insurer independently, but in accordance with the Law of the Russian Federation “On the organization of insurance business in the Russian Federation.”

The development of health insurance involves cooperation between the state healthcare system and the VHI system. The determining conditions for such interaction are, first of all, the expansion of the market for paid medical services and, in connection with this, the intensification of the activities of companies operating under VHI programs, as well as the desire of insurance companies to participate in the financing of regional targeted medical and social programs. In this case, the interests of all participants in health insurance are realized. For healthcare organizations, this means receiving additional funding for targeted medical and social programs, the opportunity to improve the quality of medical care and develop services. For territorial compulsory medical insurance funds - the possibility of joint implementation of compulsory medical insurance and voluntary medical insurance programs and thereby eliminating the practice of “double payment” for the same medical service in healthcare institutions. For insurance companies, this is an opportunity to increase the number of policyholders and insured persons. For enterprises - obtaining additional, high-quality medical services provided to employees within the framework of collective labor agreements.