Marketing Analysis of the Functioning of Voluntary Medical Insurance (Based on the Central Clinical Hospital of the Medical Center of the Presidential Administration of the Russian Federation)

The dissertation is devoted to the study of the functioning of voluntary medical insurance (VMI) in the healthcare system of the Russian Federation, employing a marketing approach. The work examines the basic concepts and essence of VMI, its role in healthcare, as well as the experience of foreign countries in this field. Special attention is given to the analysis of the marketing macro- and microenvironment of a healthcare facility operating within the framework of VMI, based on the Central Clinical Hospital of the Medical Center of the Presidential Administration of the Russian Federation.

The research addresses issues of the interaction of VMI market participants, the legislative and regulatory-legal framework of voluntary medical insurance, as well as consumer behavior in the market of medical services. The work is aimed at developing an organizational-functional model of marketing analysis of a healthcare facility under conditions of VMI and at scientifically substantiating the factors influencing the quality of medical assistance provided within the framework of voluntary insurance.

The relevance of the topic is determined by the need to study the issues of the functioning of the voluntary medical insurance (VMI) market.

Providing high-quality medical care within the framework of VMI, identifying opportunities for the delivery of quality medical assistance; the necessity of studying the role, functions, and characteristics of the interaction of all participants in the VMI market, has become an urgent requirement of the present time.

Healthcare is a large dynamic system that changes under the influence of demographic, socio-hygienic, and economic factors, which transforms the needs for medical assistance. Radical economic reforms of recent years have predetermined significant transformations of the healthcare system (Ziborova I.V., 1999 et al.).

Reforms of the healthcare sector should contribute to improving the health indicators of the population (Kucherchenko V.Z., 1995; Lisitsyn Yu.P., 2001; Shamshurina N.G., 2001 et al.).

Over the last decade, at the stage of reforming domestic healthcare, medical insurance has occupied an important position (Azarov A.V., 1999; Kucherchenko V.Z., 1995, 1999, 2001; Lisitsyn Yu.P., 1994, 2001; Martynchik S.A., 1997, 1999; Reshetnikov A.V., 1998; Rubal V.P., 2002; Togunov, 2000; Yurkin G., 2001 et al.). The state (budget) form of healthcare financing has been replaced by a budget-insurance form. The adoption of the Law of the Russian Federation of July 28, 1991 No. 1499-1 "On Medical Insurance of Citizens in the Russian Federation" (with amendments of December 24, 1993 and July 1, 1994) established the legal, economic, and organizational foundations of medical insurance in the country.

Medical insurance as a form of social protection of the population in the sphere of healthcare represents insurance against the loss of health for any reason, including in connection with illness or accident.

In Section 1 of the aforementioned law, it is stipulated that medical insurance is carried out in two forms: compulsory (OMS) and voluntary (VMI). Compulsory medical insurance is classified as a constituent part of state social insurance, ensuring all citizens of the Russian Federation equal opportunities in receiving medical and pharmaceutical assistance in the volume and on the conditions corresponding to the OMS programs.

By the Law "On Medical Insurance of Citizens in the Russian Federation," Article 12, as well as the "Standard Rules for OMS" of December 1, 1993, Article 1.4, the hierarchical subordination structure of non-commercial financial and credit institutions (the Federal and territorial funds) has been defined, which implement state policy in the field of OMS and carry out management, control, coordination, and analysis of the activities of healthcare facilities providing medical assistance within the OMS system.

In accordance with Article 2.1 of the "Standard Rules for OMS," territorial funds accumulate insurance contributions and payments, ensuring financial stability, universality of the state OMS system, and equalization of financial resources through the financing of Medical Insurance Organizations (MIOs). Medical insurance organizations carrying out medical insurance under OMS programs organize and finance the provision of medical assistance to the insured contingent in the volume of guaranteed free medical assistance in accordance with the state Basic Program of Medical Assistance on the principles of solidarity at the expense of OMS funds.

Thus, the transition of healthcare to a budget-insurance form defined the fundamental task of ensuring additional financing of healthcare on the condition of universal free medical assistance in the volume guaranteed by the state in the field of population protection in the sphere of citizen healthcare.

However, in his report at the XIX (XX) All-Russian Pirogov Congress of Physicians, the Minister of Healthcare, Academician of RAMN, Professor Shevchenko Yu.L., analyzing the results of the OMS system's activities and discussing the issue of transitioning to a unified medical-social insurance system, noted that at present, the financial resources allocated by the Ministry of Health of Russia do not reflect the needs of the sector but are determined by the country's capabilities. During the period from 1991 to 1999 inclusive, state financing of healthcare, including budget appropriations and OMS funds, decreased in real terms by no less than one-third. The imbalance between state obligations and actual financial flows has a destructive impact on the entire healthcare system (Shevchenko Yu.L., 2001).

By the share of personal expenditures of the population in the total volume of healthcare spending, Russia is at the level of developing countries with low per capita income, while by the level of state obligations in the sphere of healthcare, it is ahead of many countries with a developed market economy. Excessive state obligations hinder the construction of a rational system of economic relations in healthcare (Boykov V.E., Sheiman I.M. et al., 2000; Butkovsky 2002; Vyalkov A.I., 2001; Gololobova T.V., 2002; Ziborova I.V., 1999 et al.).

In recent times, increasing attention is being paid to income from paid medical activity, including the provision of medical services within the framework of VMI (Andreev A.A., 2000; Shamshurina N.G., Dolgaya V.M., 1997; Spiryakina Yu.Yu., 1999; Shamshurina N.G., 2001).

Many authors (Zakharov V.P., 1998; Kadyrov F.N., 1999, 2001; Klimenko G.Ya., 1998; Kuzin V.F., 2000 et al.), considering VMI as a form of paid medical services, note that VMI is implemented for the purpose of ensuring additional social protection of citizens' interests at the expense of personal funds or the profits of enterprises (organizations, institutions) by providing additional medical assistance beyond the Basic Program of OMS, through Medical Insurance Organizations on a voluntary basis in accordance with the Law "On Medical Insurance of Citizens of the Russian Federation."

VMI is theoretically considered as a supplement to compulsory medical insurance programs. In practice, medical assistance within the framework of VMI significantly exceeds the volumes of medical assistance regulated by law. VMI represents financial and commercial activity with its own characteristics and principles of organizing medical assistance and medical insurance. Medical assistance within the framework of VMI is provided in all directions, as a rule, on the basis of healthcare facilities of departmental subordination, most of which operate outside the OMS system.

It should be noted that the financing and organization of medical assistance within insurance programs in the OMS medical services market have by now acquired a certain organizational and economic structure, supported by a legal framework. Voluntary medical insurance is regarded merely as a supplement to compulsory medical insurance programs.

The development of voluntary medical insurance and the market of paid medical services, on the condition of their subordinate, supplementary character in relation to the compulsory medical insurance system, is considered by many authors to be one of the important problems (Vishnyakov N.I. et al., 2002; Grishchenko N.B., 2002; Nabedrik A.B., 2000; Petrovsky A.S., Podoltsev A.I. et al., 2001; Solovyov P.A., 1999; Shamshurina N.G., 2001 et al.).

Insufficient attention is paid to the possibilities and prospects for providing medical assistance within the framework of VMI. Interest in studying the issues of the functioning of the VMI insurance market is shown, in most cases, by insurers and financiers. From the side of healthcare facilities, interest in VMI issues is manifested only among institutions that currently provide medical assistance in the market sector of voluntary medical insurance.

Unfortunately, from the side of healthcare organizers and the medical community, interest in the development of voluntary medical insurance is negligible. Most often, this is expressed in the mere acknowledgment of the existence of the voluntary medical insurance market. VMI is not recognized as a socially oriented direction of healthcare development at the present stage. The main emphasis is placed on studying the functioning of compulsory medical insurance.

The experience of foreign countries that utilize voluntary medical insurance will help assess the role, place, and possibilities of providing medical assistance within the framework of VMI in the national healthcare system.

Another characteristic feature of domestic healthcare is the "shadow" payment for medical services (Nakatis Ya.A., Kadyrov F.N., 2002; Boykov V.E., Sheiman I.M. et al., 2000; Shevchenko Yu.L., 2001 et al.). At present, legal and shadow payments for medical services and the purchase of medicines by the population constitute, by various estimates, from 20 to 45 percent of the total expenditures of the state and the population on healthcare. (Shevchenko Yu.L., 2001)

According to a study conducted during 1997-1998 (Boykov V.E., Fili F., Sheiman I.M., Shishkin S.V., 2000), the estimates of population expenditures on medicines and medical services on a national scale showed that the amount of population expenditures on pharmaceutical provision and medical assistance amounted to 4.5 percent of GDP in 1998, which exceeded the volume of state financing of healthcare (3.2 percent). The total volume of population expenditures on healthcare in our country amounted to 7.7 percent of GDP. This is substantially higher than previously published estimates of healthcare expenditures in Russia in the 1990s, the values of which ranged from 3.3 to 4.5 percent of GDP.

The same authors note that "per capita in Russia, the amount of "shadow" payments in healthcare amounted to... during 1998 approximately 11.6 billion rubles (0.43 percent of GDP), including "shadow" payment for medical assistance amounted to 8.8 billion rubles."

Emphasizing the need to achieve a real balance between state guarantees of medical service for the population and their financial support, and to reduce the size of the "shadow" market in healthcare, the Minister of Healthcare proposes to legalize what exists in reality.

As an alternative to "shadow" payment, voluntary medical insurance can be considered.

VMI represents an example of civilized attitude of society toward the protection of the health of the insured and the prevention of the risk of developing diseases, implying high quality and efficiency of the provision of medical services, as well as the management of insurance risks (Andreev N.A., 2001; Biryukov A.V., Sorokina O.S., 1999; Vlasov V.V., 2000; Gabueva L.A., 2001; Grishchenko N.B., 2001; Lin'kova I.V., Martynchik S.A., 1999; Palyanova S.Yu., 2002; Sorokina O.S., 2000; Spiryakina Yu.Yu., 1999; Khaidarova T.S., 2000 et al.).

At present, the voluntary medical insurance market is receiving increasing development.

Under modern conditions, taking into account the prospect of reducing the Basic Program of OMS, the transition to a unified medical-social insurance system, special significance is acquired by the development of voluntary medical insurance, including for the purpose of absorbing the bulk of the "shadow" payments of the population for medical assistance (Martynchik S.A., Khudyakov M.B., 1999).

It is necessary to study the organizational and economic characteristics of the VMI market, scientifically substantiating the factors for providing quality medical care in the sphere of voluntary medical insurance.

The VMI market in Russia has been functioning for more than 10 years. During this period, many authors (Andreev N.A., 2001; Biryukov A.V., Sorokina O.S., 1999; Vlasov V.V., 2000; Gabueva L.A., 2001; Grishchenko N.B., 2001; Zakharov V.P., 1998; Kadyrov F.N., 1999, 2001; Klimenko G.Ya., 1998; Kuzin V.F., 2000; Lin'kova I.V., Martynchik S.A., 1999; Palyanova S.Yu., 2002; Sorokina O.S., 2000; Spiryakina Yu.Yu., 1999; Khaidarova T.S., 2000 et al.) have studied the issues of VMI functioning, but a comprehensive analysis of the functioning of a healthcare facility within the framework of VMI using the concept of marketing has not been conducted. The need for scientific substantiation, as well as the study of prospects and possibilities of marketing analysis of medical assistance provided by healthcare institutions under conditions of VMI, has become an urgent requirement of the present time and has determined the topic of this research.

Regarding the functioning of voluntary medical insurance, Russian specialists have certain disagreements, which also makes this research relevant.

The relevance of the selected topic is also determined by the aspiration not only to analyze the existing VMI market but also to develop a methodology for conducting marketing analysis of the quantitative and qualitative characteristics of medical services provided within the framework of voluntary medical insurance.

The GOAL of the research was the development and scientific substantiation of an organizational-functional model of marketing analysis of the functioning of a healthcare facility under conditions of voluntary medical insurance (based on the Central Clinical Hospital of the Medical Center of the Presidential Administration of the Russian Federation).

To achieve the goal, the following tasks were set:

1. To study and synthesize the problems of VMI functioning in the domestic healthcare system. Determine the role, functions, and characteristics of the interaction of VMI participants.

2. To develop a methodology for marketing analysis of healthcare facility functioning in the VMI market.

3. To scientifically substantiate the factors of the marketing macro- and microenvironment of a healthcare facility operating within the framework of VMI.

4. To study the marketing micro- and macroenvironment of a healthcare facility within the framework of VMI taking into account consumer behavior in the market of medical services.

5. To develop an organizational-functional model of marketing analysis of healthcare facility functioning under conditions of VMI.

The scientific novelty of the dissertation lies in the development of a model of marketing analysis of the provision of medical services within the framework of VMI.

In the work, for the first time:

- a comprehensive multifactor study of the market of medical services of voluntary medical insurance has been conducted with identification of problems of its functioning,

- the characteristics of the interaction, role, and functions of all participants in the voluntary medical insurance market from the perspective of marketing have been determined;

- the experience of providing medical assistance within the framework of VMI (based on inpatient care) has been synthesized;

- an organizational-functional model of marketing analysis of healthcare facility functioning under conditions of VMI has been presented.

The main provisions put forward for defense:

1. The results of the analysis and synthesis of problems arising in the provision of medical assistance within the framework of VMI at the present stage make it possible to determine ways of solving them in order to improve the accessibility and quality of medical services provided within the framework of VMI and to prevent the further development of the "shadow" market in healthcare.

2. The results of marketing analysis of a healthcare facility operating within the framework of VMI make it possible to take into account the characteristics of the functioning of all participants in the VMI market and to identify the weak and strong sides of factors affecting the provision of medical assistance within the framework of insurance medicine.

3. The adapted methodology of marketing analysis of healthcare facility functioning under conditions of VMI, taking into account consumer behavior, makes it possible to obtain a holistic understanding of the mechanisms of consumer behavior when receiving medical assistance.

4. The organizational-functional model of marketing analysis of healthcare facility functioning under conditions of VMI introduces adjustments to the process of management and organization of the provision of high-quality medical care within the framework of voluntary medical insurance.

The practical significance of the work lies in:

- the possibility of wide use of the developed marketing analysis method in the process of organizing and providing medical assistance within the framework of VMI at the level of healthcare facilities and in making managerial decisions;

- the obtained results can be used in the process of improving state regulation of medical assistance within the framework of VMI and in developing draft legislation on the problems of voluntary medical insurance, in forming a concept for the development of the domestic voluntary medical insurance market;

- the proposed marketing analysis methodology will make it possible to identify problems and find opportunities for improving the quality of medical care offered by participants in the VMI market;

- the research materials are used in the educational process at the Department of Public Health and Healthcare with a Course in Economics of the Sechenov First Moscow State Medical University in the sections of "Marketing," "Social and Medical Insurance," "Healthcare Financing," and others.

Verification of research results:

The results of the research have been verified and used at the Central Clinical Hospital of the Medical Center of the Presidential Administration of the Russian Federation; at medical insurance organizations in Moscow (49 MIOs) having contracts with the hospital within the framework of VMI, which contributed to attracting attention to the issues of organizing the provision of medical assistance within the framework of VMI and improving its quality, and they were also reported at the III International Scientific and Practical Conference "Health and Education in the 21st Century" (2002).

The work was verified at a joint meeting of the Departments of "Public Health and Healthcare with a Course in Economics" of the Medical Prevention Faculty and "Healthcare Management" of the Faculty of Advanced Training of Sechenov First Moscow State Medical University.

The theoretical and methodological basis of the research consists of the works of domestic scientists and specialists in the field of healthcare organization, marketing, and medical insurance (Azarov A.V., Alekseeva V.M., Biryukov A.V., Vasnetsova O.A., Vyalkov A.I., Galkin R.A., Gerchikova I.N., Golubkov E.P., Glukhov G.N., Grishin V.V., Gerasimenko N.F., Zakirova S.A., Zubets A.N., Kadyrov F.N., Kucherchenko V.Z., Lebedev A.A., Lisitsyn Yu.P., Lidibraten A.L., Malakhova N.G., Martynchik S.A., Nakatis Ya.A., Novatorov E.V., Okeanova Z.K., Petrovsky A.S., Reshetnikov A.V., Sorokina O.S., Starodubov V.I., Taranov A.M., Togunov I.A., Khudyakov M.B., Shamshurina N.G., Shchepin O.P., Sheiman I.M.) and foreign researchers (Banvari Mittal, Gilbert A., Churchill, Erwin Dichtl, MacDonald M., Poli M., Philip Kotler, Evans J., Berman B.).

An important direction of the research is the developing services sector, during the reform of domestic healthcare and the dynamically developing voluntary medical insurance market. The short period of formation of the insurance services market in Russia is explained by the fact that the study and theoretical generalization of the associated problems are at an early stage. Monographic and dissertation research are extremely few. At the same time, the deep changes taking place in Russia in the field of medical insurance are reflected in detail in the periodical press, which made it possible to fill to a certain extent the shortage of monographic literature.

Implementation of results.

The main provisions of the dissertation and the results of the marketing research were reported at the III International Scientific and Practical Conference "Health and Education in the 21st Century," held in Moscow in 2002. Seven works on the dissertation topic have been published.

The substantiation of the main results of the dissertation research is confirmed by the implementation in the practice of the Central Clinical Hospital with Polyclinic of the Medical Center of the Presidential Administration of the Russian Federation and a number of medical insurance organizations having contracts with the hospital within the framework of VMI, of the proposed methodology of marketing analysis of medical assistance within the framework of VMI.