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- Unavailability policy: The Ministry of Health explained plans to reform compulsory medical insurance
Unavailability policy: The Ministry of Health explained plans to reform compulsory medical insurance
Insurance companies operating in the compulsory medical insurance (CHI) system strongly opposed the draft law, which grants the heads of regions the right to transfer the powers of CHI insurers to territorial CHI funds. They are confident that this will inevitably lead to the elimination of independent quality control of medical care. The Ministry of Health, on the contrary, is confident that the initiative will provide patients with additional protection mechanisms. Details can be found in the Izvestia article.
Why insurers are strongly against it
The Ministry of Health has submitted for discussion an initiative designed to reform the compulsory health insurance system. We are talking about the draft law "On Amendments to the Federal Law "On Compulsory Medical Insurance in the Russian Federation." This is a large document, one of the points of which gives the heads of regions the right to transfer the powers of medical insurance organizations to the territorial compulsory medical insurance funds. The bill is currently under public discussion.
The All-Russian Union of Insurers strongly opposed this amendment, as it would primarily affect patients by limiting their rights to protection. The VSS explained to Izvestia that the initiative would eliminate quality control and a monopoly of territorial compulsory health insurance funds would arise in the compulsory health insurance system: they would simultaneously pay for medical care and evaluate its quality. That is, to control themselves.
In a statement from the BCC, obtained by Izvestia, Nadezhda Grishina, General Director of the Capital MS insurance medical organization, emphasizes that "the key function of insurance medical organizations is external control over the volume, timing and quality of medical care provided by institutions funded through TFOMS." If these functions are transferred to territorial funds, internal control in the compulsory health insurance system becomes meaningless, and the risks of financial violations increase dramatically, according to the VSS.
It is noted that insurers annually conduct 30 million examinations and identify more than 5 million "defects in the availability and quality of medical care." They receive more than 15 million patient requests and applications. And insurers are increasing the amount of compensation for moral damage in court cases.
Another consequence was the abolition of the institute of insurance representatives, who provided information support, counseling, and legal support to patients at all stages of medical care. It is argued that TFOMS has neither the motivation nor the financial capacity to reproduce and maintain the operation of this system. Moreover, patients who need high-tech care will suffer first of all, since the help of an insurance representative is very important for them.
Simply put, this is the liquidation of medical insurance organizations (CFOs) in the regions, Roman Shcheglevatykh, vice President of the VSS, told Izvestia.
— The bill stipulates that the decision taken by the head of the region will be valid for at least three years. Insurance companies will close in the first year of the solution's implementation, the expert is sure.
Roman Shcheglevatykh notes that the accompanying documents to the draft law completely lack a justification for the initiative that could be discussed or analyzed. He considers this project inconsistent and recalls that, quite recently, the functionality of insurance companies to support insured persons has been expanded.
— It can be assumed that we are talking about an attempt to legalize the "manual" regulation of insurance companies through administrative pressure. If the insurance company reveals a lot of violations in the provision of medical care or declares them in the public space, then it becomes objectionable. She can always be threatened with exclusion from the system," the source told Izvestia.
The position of the Ministry of Health
The Russian Ministry of Health, in a comment to Izvestia, noted that ensuring the protection of citizens' rights in compulsory medical insurance is the responsibility of the state, which was transferred to regional authorities, not insurance companies.
"The bill grants the heads of regions the right, but not the obligation, to transfer the functions of medical insurance organizations to the territorial compulsory health insurance funds," the Ministry of Health emphasized. — If the governor decides that the powers of the CFR will be carried out by territorial funds, the bill sets out in detail all the mechanisms for ensuring the constitutional right of citizens to free medical care.
It is indicated that granting the subjects of the Russian Federation the right to independently determine the format of work in the field of compulsory medical insurance "will create the necessary flexibility in the implementation of federal powers." This will make it possible to adapt the compulsory health insurance system to the specific needs of the population of each region, speed up the process of making managerial decisions and increase the effectiveness of the implementation of the territorial compulsory health insurance program, including quality control of medical services.
"It should also be borne in mind that the examination of the quality of medical care is not carried out by an insurance medical organization or a territorial compulsory health insurance fund, but by an independent expert included in the unified register of experts on the quality of medical care," the ministry stressed in response to a request from Izvestia.
Such an expert can only be a specialist doctor who has a higher education, an accreditation certificate or a certificate and at least 10 years of work experience in the relevant medical specialty. He must also receive training in expert work in the field of compulsory health insurance.
The territorial compulsory health insurance funds will retain the full functionality of insurance companies, including effective protection of citizens' rights in the field of medical insurance, maintaining a high level of quality control of medical care and strengthening constitutional guarantees for free and high-quality medical care, the ministry notes.
"Thus, the proposed changes not only do not infringe on the rights of citizens, but also create additional mechanisms for their protection, contributing to improving the quality of medical services in general," the Ministry of Health is confident. — Guaranteed protection of citizens' rights to receive free medical care is a priority area of state policy in the field of healthcare. The proposed changes create additional mechanisms for their provision.
The expert of the direction "Popular Front. Analytics" Sergey Voityuk emphasizes that the main goal of the initiative is the systemic optimization of the management of compulsory health insurance funds in the interests of patients and medical organizations. Unnecessary mediation in financial flows will be eliminated: now the state collects compulsory health insurance funds in the form of taxes and insurance premiums, then transfers them to private insurance companies so that they can return to the public health system. The new procedure will be beneficial for patients due to the possible acceleration of medical care payments and reduction of bureaucratic procedures.
—There is already a precedent for direct financing — since 2021, FFOMS has been authorized as an insurer for federal medical organizations, which confirmed the model's operability," he told Izvestia.
According to him, the manageability of the system will also increase, administrative barriers will be reduced.
There are supporters of the bill among insurers. Victoria Galitskaya, Head of the LMS Department at IC Twenty-first Century, believes that after the reform, the system will become more transparent.
"The money for medical organizations will be distributed by territorial funds, which have been accumulating and controlling them since 2010," she told Izvestia. — And the funds themselves will control the expenditure of funds, without an additional link in the form of CFOs. Expertise and quality control will be carried out as before — only directly by a budgetary state organization, and not by "independent" experts. Why should compulsory health insurance companies be more trusted than government agencies?
How will the bill affect independent monitoring
Alexey Kurinny, deputy chairman of the State Duma Committee on Health Protection, notes that he has long insisted on removing insurance companies from the compulsory health insurance system.
— They are actually an unnecessary intermediate link. And the independence of quality control on their part is greatly exaggerated. All insurance control activities are no longer aimed at identifying real errors, but at formal defects in filling out medical documentation with appropriate fines," he told Izvestia.
Sergey Voityuk also points out, with reference to the monitoring of the "Popular Front" for medical examinations and the analysis of appeals to the direct line, that "insurance companies do not always properly protect the rights of patients."
However, the co-chairman of the All-Russian Union of Patients, Yuri Zhulev, emphasizes that he does not yet see the advantages of the bill for patients.
— The transfer of functions to funds creates the illusion of simplifying the system, but in reality it is a step towards monopolization. Only officials who can administer the process without an "extra" participant will benefit. But the patient is deprived of the right to choose and an independent defender of his interests," the Izvestia interlocutor is sure.
Capital MS claims that every sixth or seventh violation identified by insurance company experts concerns serious risks to the insured's health. And they cite the example of a case from the Vladimir region, where a five-year-old child died due to inadequate medical care: he was not diagnosed with sepsis upon first admission to the hospital and no examination was conducted to confirm the preliminary diagnosis; numerous defects in treatment were admitted upon re-hospitalization. The medical organization tried to appeal the results of the CFR examination both to the terfond and to the arbitration court. CFR representatives participated in the courts for two years on the side of the parents in order to defend their right to compensation for moral damage. As a result, the court determined compensation in the amount of 11 million rubles.
— Hospitals complain about fines imposed on medical organizations. It should be understood that in the whole country, the relative amount of sanctions is less than 1% of the funds for medical care. Of these, more than 70% are returned to the healthcare system, to the normalized insurance stock of TFOMS. At the same time, each fine is a reflection of real problems that people pay for with their lives," said Nadezhda Grishina.
Yuri Zhulev emphasized that insurance companies are now the only independent participant in the compulsory health insurance system that looks at the situation through the eyes of the patient. They defend human rights, help resolve conflict situations, and ensure timely medical care.
— And this is not a theory, but a real practice. Every year, millions of people contact insurance companies with complaints and questions and receive help. Insurance representatives accompany patients, seek examinations, help speed up the receipt of high-tech care, and resolve disputes with medical organizations. We see tens of thousands of examples where it was the intervention of insurers that became decisive. Patients feel this, although they may not always understand that it is the insurance company that is behind them," said Yuri Zhulev.
Ekaterina Artsruni, Chairman of the Committee on Compulsory Medical Insurance of the National Association of Healthcare Managers, CEO and co-owner of Mositalmed JSC, also believes that the bill is beneficial only to territorial compulsory health insurance funds. At the same time, independent control will be lost, and the risk of conflicts of interest and corruption will increase. She also warned that reducing the role of insurers in compulsory medical insurance could lead to an increase in unit costs and an increase in the cost of VMI policies. However, the BCC does not agree with this: Roman Shcheglevatykh notes that the situation will not have a significant impact on this market.
Izvestia also sent a request to FFOMS.
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