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- It doesn't work that way: how the Accounting Chamber revealed the systemic crisis in compulsory health insurance funds
It doesn't work that way: how the Accounting Chamber revealed the systemic crisis in compulsory health insurance funds
Audit of the Accounting Chamber (the document is at the disposal of Izvestia) It revealed large—scale violations in the work of compulsory medical insurance funds, including a huge shortage of branches and suspiciously heavy loads on individual experts - up to 85,000 examinations per day. Against this background, auditors record the irrational use of budget funds and fictitious inspections, which undermines the quality of healthcare in the Russian Federation, as well as patient confidence.
Why are territorial funds unable to cope with the workload
The Accounting Chamber has verified the effectiveness of the use of funds allocated to support the activities of the Federal Compulsory Medical Insurance Fund and territorial compulsory Medical Insurance funds. And I came to disappointing conclusions: there were a number of systemic shortcomings in the work of compulsory medical insurance funds, including insufficient control over the activities of medical insurance organizations. In particular, the formal approach of experts from insurance medical organizations to conducting medical and economic expertise is noted, which calls into question both the quality of such examinations and the validity of the expert conclusions formed, the Accounting Chamber told Izvestia.
The problem of a shortage of branches in the regions is getting worse against the background of upcoming changes in legislation, when medical insurance organizations (CFOs) will be liquidated with the transfer of their powers to territorial funds, experts warn. Alexey Starchenko, a member of the Public Council for the Protection of Patients' Rights under Roszdravnadzor, warns that without expanding the branch network, terfonds simply will not be able to perform complex tasks: from examinations to protecting the rights of insured persons in courts.
"The lack of a sufficient number of terfund branches increases the risks of reducing the quality of medical services and leads to a shortage of finances to pay for medical care due to the additional costs of organizing the work of new departments," he points out.
A similar opinion is shared by associate professor of RANHiGS (St. Petersburg) Linda Ryzhikh.
— An insufficient number of branches reduces the overall effectiveness of the compulsory health insurance system, negatively affecting the timely payment of services and the availability of medical care, creating an imbalance in the distribution of resources between regions and generating paid services where they should not be needed.
The expert adds that delays and bureaucracy reduce patients' trust in healthcare.
In turn, the press service of the Federal Compulsory Medical Insurance Fund (FFOMS) informed Izvestia that a draft federal law is currently under consideration in the State Duma, providing for amendments to the Federal Law "On Compulsory Medical Insurance" in terms of establishing the authority of the Federal Fund to approve the procedure for approving expenditure standards to ensure that terfonds perform their functions., as well as the procedure for determining the size of these standards. This procedure, if adopted, will ensure from January 1, 2027, a unified approach to the formation of the standard, including, among other things, the issues of determining the number of territorial compulsory health insurance funds, the need to create branches, the need for vehicles, etc., the FFOMS said.
Tens of thousands of examinations per day — what's wrong
An unusually high workload for one specialist sounds like an alarming symptom that raises doubts about the quality of control. At the same time, experts emphasize the systemic features of accounting for expertise. Timur Gizitdinov from Qms Reso-Med LLC explains that the large volumes of examinations per specialist are due to the fact that the dates of registration of certificates may coincide, and the inspections themselves last for weeks. Thanks to remote monitoring through a single information system, experts can process several institutions in one day, he points out.
The same is said by the Ingosstrakh-M press service.
— Batch processing of documents makes visible the statistical effect when tens of thousands of examinations are "conducted" in one day, although in fact they are distributed over time. Full digitalization of document management will help to correct these distortions.
However, Linda Ryzhykh once again draws attention to the quality problem.:
— Such a burden means that the examination becomes a formal procedure, without the possibility of in-depth analysis and identification of clinical errors, and the system itself loses qualified specialists.
Meanwhile, Polina Gabai, chairman of the Board of Founders of the National Analytical and Expert Center for Healthcare, notes that such a number of examinations may indicate the possible use of automated mechanisms with elements of artificial intelligence, without proper quality control and expert verification.
In order to restore quality, in her opinion, it is advisable to consolidate the regime of regular unscheduled inspections of CFR activities by not only TFOMS, but also FFOMS, as well as establish the personal responsibility of experts and the responsibility of CFR for repeated errors.
Budget Spending Funnel: Why money doesn't go to medicine
Weak controls and corruption risks hinder the rational use of funds in the compulsory health insurance system, says Vladimir Vinogradov, CEO of Pro-Vision Communications, and states that about 7% of the compulsory health insurance fund's budget is spent inappropriately. Delays in payment to doctors in the regions reach up to 60 days, which negatively affects the quality of medicine.
He also points to large-scale corruption and inefficiency of control. According to him, more than 200 cases of abuse were identified by Rosfinmonitoring in 2023, while up to 20% of the funds are spent on bureaucracy and fictitious checks.
Alexey Starchenko, in turn, notes that the existing verification mechanism itself is insufficient.
— Roszdravnadzor has not checked territorial funds for the last three years, and repeated inspections of insurance companies by terfonds are often formal. Transferring the powers of insurance medical organizations to terfonds will exacerbate this irrationality," the expert warns.
According to Starchenko, it would be more logical to transfer the FMS under the control of the Central Bank of the Russian Federation as a financial institution and make the territorial funds part of the federal structure, which would ensure transparency and daily online accounting of funds.
How to get out of the crisis
Olga Epifanova, Chairman of the Social Democratic Union of Women of Russia, expresses particular concern about the inefficient use of budget funds and the practice of conducting imaginary inspections.
"It is becoming obvious that the current surveillance system needs significant modernization," she says. — It requires the introduction of innovative digital solutions to optimize work processes, strengthen the role of independent inspection bodies and the formation of effective civil control tools.
Roman Shcheglevatykh, Vice President of the All-Russian Union of Insurers (VSS), suggests radically changing the approach to quality control. He believes that it would be advisable to switch to a risk-based selection of cases for examination using checklists based on clinical recommendations.
According to him, this approach will make it possible to concentrate the resources of the compulsory medical insurance system in areas of maximum risk to the patient's health and the financial stability of the compulsory medical insurance system, make the necessary management decisions in a timely manner and significantly reduce the burden on medical organizations. In addition, the latter will always be able to prevent violations detected during the examination, since all the parameters evaluated by the expert will be immersed in the checklist.
Linda Ryzhykh calls for a review of the standards for the workload of experts, setting limits — no more than 30-40 examinations per day, taking into account the complexity of cases, as well as using AI for routine tasks. The analysis should remain with the specialists, she is convinced.
"At the same time, it is necessary to increase human resources and regularly upgrade the qualifications of experts so that the quality of assessments remains at a high level," the expert adds.
At the same time, Sergey Plekhov, Deputy General Director of Sogaz-Med Insurance medical company, believes that there are no specific problems with the reduction of TFOMS branches. All TFOMS functions can be performed centrally, including using modern information technologies, he is confident.
Associate Professor of RUDN University Andrey Girinsky draws attention to organizational problems:
—The imbalance in the number of branches and their necessity leads to lower productivity, expert fatigue and a deterioration in the quality of work, which underlines the importance of proportionate planning and the introduction of online monitoring tools," the source points out.
Sergey Shkitin, Deputy Medical Director of AlfaStrakhovanie — OMS, believes that the examination of insurance companies is a tool for identifying real defects in medical care, where the introduction of risk indicators increases the effectiveness of screening and detection of violations with a minimum of checks, for example, the problem with the treatment of anemia in malignant tumors revealed by the examination, when the lack of additional payments forced patients to postpone treatment, reducing the effectiveness of therapy and provoking complications.
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