Justification of the unacceptability of medical savings accounts system introduction in the healthcare financing system in Russia
On November 23, 2022, the project on amendments to the Federal Law «On Compulsory Medical Insurance in the Russian Federation» using individual medical savings accounts (IMNS) was discussed in the State Duma of the Russian Federation on the platform of “The Fair Russia” party. This project was prepared by specialists of the Finance Department of the Bauman Moscow State Technical University. The research team of the Higher School of Healthcare Management under the leadership of Dr. G.E. Ulumbekova analyzed this project and an explanatory note to it. The article presents the results of this analysis, including a description of the essence of the bill, explanations about the incorrect assumptions of the authors, data on international experience and proposals for urgent measures in the healthcare of the Russian Federation, including in terms of the volume and model of financing. The main conclusion of the Higher School of Healthcare Management specialists is that the IMNS model cannot be implemented in the Russian Federation, since it will lead to a decrease in the availability of government financed healthcare, especially for people with low income (in the Russian Federation, almost half of the population has incomes of up to 27 thousand rubles in months) and people with chronic diseases, as well as to managerial chaos and collapse of whole healthcare system. As a result, this will cause an increase in mortality and an increase in social tension in the country.
A systematic analysis of the lessons of the introduction of the IMNS system in the world, which was limited by the number of countries and the proportion of the population in them (Singapore ~3 mln people, China – a pilot project, South Africa ~9 mln people, USA ~8 mln people), showed that the IMNS model is acceptable only for countries with a high proportion of the young population with high incomes at the same time. This system is ineffective for countries with a high proportion of chronically ill and low-income citizens, such as the Russian Federation. That is why the IMNS experience has not been widespread in the world: China and South Africa have switched from experiments with them to a unified system of compulsory health insurance, and Singapore additionally has several solidarity funds to pay for healthcare care for citizens. As a rule, the lobbyist and beneficiary of the IMNS system is the banking sector, which receives additional working capital to its accounts.
Differentiation of Russian regions on the level of the standardized mortality rates from COVID-19 in 2021
The policy of protection, restoration and improvement of health of the population of Russia which is carried out by the state gives relevance to researches of rates of mortality of the population in various regions of the country, especially during the periods of infectious pandemics.
Research aim. The analysis of rates of mortality from COVID-19 in territorial subjects of the Russian Federation in 2021 for the purpose of justification of the management decisions in the sphere of public health and health care in the conditions of pandemic spread of dangerous viral infections.
Material and methods. A source of information on mortality are records about death cases in federal the state information system "Unified State Register of Civil Status Records" (FGIS EGR ZAGS). For elimination of the distorting influence of an age factor by comparison of rates of mortality in different territorial subjects of the Russian Federation age structure of the population of each of territorial subjects of the Russian Federation was replaced with average Russian with method of indirect standardization of mortality rates.
Results. According to FGIS EGR ZAGS for 2021 in the Russian Federation all 2 446 922 cases of death were registered that on 648615 cases (for 36.1%) it is more, than in 2019 and on 163 645 cases (for 7.2%) it is more, than in 2020. From the total number of the dead in 2021 in FGIS EGR ZAGS 424 252 cases of death (17.3%) with the indication of an initial cause of death COVID-19 are registered that is almost three times more, than in 2020 (144 691 cases of death from COVID-19). At the age of 18 flyings is also more senior 424 090 people (99.95%) died. Standardization of mortality rates from COVID-19 led to increase in an average on regions of mortality rate for 5% (from 265.3 to 279.3 on 100 000 population), however statistically abnormal differences between territorial subjects of the Russian Federation on death rate from COVID-19 including which are in borders of the same federal district remained.
Conclusions. The set of factors affects the death rate reflected in statistics from COVID-19. It results in abnormal variability of an indicator as between the countries, and regions in one country. The presumable reasons – the wrong classification and coding of causes of death and also different approaches to accounting of diseases and death from COVID-19. Extremely high variability of intensive rates of mortality from COVID-19 makes impossible its use for assessment of overall performance of regional systems. As the most objective indicator of the death toll during the periods of infectious pandemics not a concrete infectious disease mortality, but the excess mortality defined as increase in mortality from all reasons in comparison with the expected mortality has to be considered.
Restrictions: data of FGIS EGR ZAGS can differ from data of Rosstat which became available to authors in later terms, than data of FGIS EGR ZAGS consisting of files of preliminary certificates on death.
Features of the work of healthcare organizations of the Republic of Belarus in the conditions of the third wave of the COVID-19 pandemic
Aim – to study the opinion of medical workers of the Republic of Belarus on the specifics of the functioning of outpatient and inpatient healthcare organizations in the conditions of the spread of the third wave of coronavirus infection COVID-19, the impact of the current situation on the provision of medical care to the population.
Material and methods. A survey was conducted of 479 medical workers, including doctors of inpatient healthcare organizations (group 1, n=268), heads of outpatient (group 2, n=140) and inpatient healthcare organizations (group 3, n=71). During the survey, respondents expressed their opinion about the peculiarities of working in conditions of increasing incidence of COVID-19, including the difficulties encountered in connection with the pandemic.
Results. The greatest difficulties during the pandemic, according to respondents, were: the transfer of patients who are not sick with COVID-19 to other hospitals, sometimes insufficient professional qualifications of medical personnel to work with covid patients. They also expressed their opinion on the quality of vaccines against COVID-19, assessed the moral and psychological climate in the teams and the psycho-emotional status of the heads of inpatient and outpatient healthcare organizations during the COVID-19 pandemic.
Conclusion. The survey showed that, in general, healthcare organizations are successfully coping with the difficulties that arose as a result of the widespread spread of coronavirus infection. At the same time, according to the respondents, when organizing work in emergency situations, which is the COVID-19 pandemic, it is necessary to solve a number of urgent problems. Common for the respondents of all three groups were such problems as the duration and intensity of the work of medical personnel during the pandemic, difficulties with zoning areas, etc.
Analysis of the results of the implementation of state programs in the field of healthcare in 2018–2021: regional aspect
The article presents the results of the analysis of the implementation of state programs in the field of healthcare in the period 2018–2021 on the example of two regions: Kuzbass and Moscow. The influence of COVID-19 on the achievement of the values of forecast indicators and the need for a significant increase in funding for the healthcare industry was noted. Recommendations on evaluating the effectiveness of the implementation of state programs and comparing the results achieved in different subjects of the Russian Federation are proposed for discussion.
Assessment of the impact of the “health” component of human capital on the socio-economic development of the region
Currently, human capital is a key driver of regional development. Therefore, it is important to develop a strategy for managing regional development, taking into account the effective and balanced use of the human capital of the region. For these purposes, the author has developed a methodological approach to assessing the human capital of the region, taking into account its component structure. The results of the evaluation of the human capital of the region, taking into account its component structure, indicate that developed regions form a more “high-quality” human capital. Also, a study of the “health” component of the human capital of the region shows that at present its share in the component structure is only 18–19%. This state of affairs indicates that a number of problems remain unresolved in the regions, such as: cuts in health care costs, insufficient provision of hospital beds and doctors, and many others, and all this negatively affects the socio-economic development of the region.
Integration of military and civilian medicine: a new method of paying for medical care with separate coverage of fixed and variable costs
The special military operation in Ukraine significantly increased the load on the military medical service: the flow of the wounded, the increase in the incidence of military personnel due to adverse field conditions and the mobilization of reservists. The experience of the USSR’s participation in major military conflicts shows that effective medical care in these conditions requires the organizational, financial, and economic integration of the military medical service with civilian health care. An obstacle to such integration in the Russian Federation is the difference in the financing of civilian and military medical organizations. If in the USSR they were financed in the same way by the budget-estimate method, today this approach has been preserved in the financing of medical care for military personnel, and the main channel for financing medical guarantees for the population is compulsory medical insurance. As a solution, the authors propose not to oppose the insurance and budgetary mechanism, but to complement their strengths and level out the shortcomings within the framework of a new method of paying for medical services with a two-part tariff (Two-Part Tariff – TPT), which is common for civil and military medical organizations, when fixed costs are prospectively billed, and variable costs are retrospectively reimbursed by the insurance mechanism by micro-calculating clinically reasonable variable costs actually incurred for each case of care.
Analysis of the effectiveness of the internal quality control system in medical organizations of the Chelyabinsk Region
The obligation to organize and implement medical activities internal quality and safety control in healthcare of applies to all medical organizations and affects the interests of a wide range of specialists. At the same time, in the scientific literature there are contradictory estimates of the effectiveness of this activity, including in the regional health segments.
Aim – to study regional features of internal control organization.
Material and methods. Among the representatives of medical organizations of the Chelyabinsk region, a sociological study was conducted to assess the processes of internal control organization and implementation, including: general and structural characteristics of medical organizations; forms of organization of internal control and involvement of various entities in these processes. During the analysis, descriptive statistics of respondents’ responses were determined, as well as a search for statistically significant relationships with the resulting parameter for assessing the effectiveness of internal control.
Results. It was determined that the overall assessment of the effectiveness of internal control in medical organizations (n=89) is influenced by their profile and age category of the attached population (p=0.002, p=0.034, respectively), as well as the presence of a surgical and obstetric hospital, emergency medical and palliative care units (p=0.030, p=0.021, p=0.007, p=0.007, respectively). The presence of an authorized internal control service in the medical organization, an approved internal control structure, as well as the involvement of experts contribute to a higher assessment of the effectiveness of this type of activity (p=0.050, p=0.033, p=0.032, p=0.017, respectively), as well as the expansion of the degree of participation of medical organization doctors as internal experts (p<0.001).
Conclusions. 1. The effectiveness of internal control in multidisciplinary and specialized medical organizations is interrelated with their structural characteristics. 2. Changes in the nature of a medical organization activities may affect sustainability in the internal control effectiveness. 3. Determination and consolidation of specific areas several medical and other employees’ responsibilities in the formal internal control system structure leads to higher efficiency of this activity.
The role of electronic health records in creating patients' data base in the unified information system (the example of patients with chronic heart failures)
Aim was to determine the role of the electronic health record (EHR) in assessing the quality of health care service provided to patients with chronic heart failures (CHF) in the Moscow region.
Materials and methods. The author analized 683 health electronic records (HER) from medical institutions of urban districts of the Moscow region, who applied for health care services in 2021 and had heart failure code I50 as one of the diagnosis codes (complications).
Results. Comparison of the frequency of prescription of main drugs for treatment of chronic heart failure patients according to EHR with clinical guidelines revealed 32.6% of cases, in which it was not possible to judge the correctness of therapy and the quality of health care on the basis of information provided in EHR due to insufficient information. Remote one-stage evaluation of patients’ EHR is not a sufficient measure to assess the quality of medical care in CHF. Regular monitoring of EHC should be used, which will improve achievement of optimal results of treatment of patients. Problems in entering information into EHRs have been discovered. Continuous assessment of the quality of the information entered into EHR is required. Only should these conditions be met, can we count on the validity and reliability of medical databases.
Conclusion. EHR data-bases do not allow to fully assess the treatment tactics of CHF patients according to the clinical recommendations and to judge the effectiveness of patient treatment. The EHR form should be adapted to allow filling in specific fields CHF patients to enter information about patients with chronic heart failures according to clinical recommendations.