Medical-Economic Approaches to Financing Inpatient Medical Care Provided under the Territorial Program of State Guarantees

The dissertation is devoted to the development of medical-economic approaches to financing inpatient medical care provided within the framework of the territorial program of state guarantees for providing free medical care to the population of the Russian Federation. The research was conducted on the materials of Saint Petersburg for the period 2000–2005. The work analyzes normative legal acts regulating the provision of free inpatient medical care, including high-tech care, studies the structure and dynamics of financing of the territorial program of state guarantees, and the system of tariffication and payment of inpatient care. Special attention is given to the problem of financial deficit in the healthcare sphere, the imbalance between state-declared guarantees and actual financing, as well as the inaccessibility of high-tech medical care for a significant portion of patients. On the basis of clinical-economic analysis, recommendations were developed for improving the planning of financial provision of inpatient medical care through the application of standards and clinical protocols.

Relevance of the Problem. The Program of State Guarantees for Providing Free Medical Care to Citizens of the Russian Federation, approved by Resolution of the Government of the Russian Federation dated September 11, 1998, No. 1096, defines the types, conditions, volumes of medical care, and sources of financial provision. In this context, the volume of medical care is understood not as a list of medical procedures, but as performance indicators of healthcare institutions—the number of outpatient visits and patient days in inpatient settings, and the number of emergency medical team calls.

The formation of the program, in terms of the list of types and volumes, is based on the population's need for medical care, and in terms of financial provision—on the magnitude of financial resources of the healthcare system. A consequence of the existing principle of forming the program for providing free medical care to the population of the Russian Federation is the imbalance between declared and state-financed guarantees, the declarative nature of free medical care (Vyalkov A.I., 2002, Shpnyov O.P., 2002, Kadyrov F.A., 2003).

Over the last 10 years, the share of healthcare expenditures in the structure of the budget of Saint Petersburg has substantially decreased from 15.9% in 1993 to 10% in 2001. The combined share of healthcare expenditures (including employer contributions) decreased from 19.6% in 1993 to 13.5% in 2001. In 1993, the contribution of employers to the structure of healthcare expenditures amounted to 18.8%, whereas in 2001 it was 25.9%, meaning that the budget increasingly transfers financial responsibility for the health of city residents to employers.

In particular, the following fact is indicative: only 25% of the cost of the territorial program of compulsory medical insurance is ensured by payments from the administration for the non-working population, while the share of this group of citizens constitutes more than 60% and has increased by 8.4% over the last 10 years. The figures cited allow the conclusion to be drawn about the constant reduction of the administration's financial responsibility for the state of the healthcare sphere.

The results of this trend are a 50% deficit of funds for providing assistance within the framework of compulsory medical insurance, an acute deficit of funds for implementing the program of privileged pharmaceutical provision, also constituting approximately 50%, and an acute shortage of funds for maintaining and renewing fixed assets—from 70 to 90% (Starodubov V.I., 2005).

The existing financial deficit limits the accessibility of adequate medical care and forms an extremely negative and stable trend toward patient cost-sharing associated with treatment. In this situation, neither the patient nor the healthcare institution has a legal basis for determining the share of financial participation of a medical organization or a patient in the implementation of necessary and unfunded by compulsory medical insurance (OMS) volumes of medical measures.

Moreover, neither in the budgetary component of the territorial program of state guarantees for providing free medical care, nor in the OMS program are the volumes specified in any way mentioned, nor are the types of medical care classified by the Order of the Ministry of Health of the Russian Federation "On the Organization of High-Tech (Costly) Types of Medical Care in Healthcare Institutions of Federal Subordination" as high-tech.

The aforementioned Order provides for financing only of medical care provided in clinics of federal subordination. The financing volumes and quotas for federal clinics constitute 10% of the population's need in Saint Petersburg alone for the mentioned types of care, and high-tech medical care provided in urban healthcare institutions (except those accounted for by the order of the Committee on Healthcare) is not financed from any other sources, as a result of which high-tech medical care is inaccessible to a significant portion of patients.

The forthcoming revision of the basic principles of the system of medical insurance of citizens of the Russian Federation presupposes the formation of a basic program of compulsory medical insurance based on standards of medical care provision and in accordance with the amounts of insurance premiums and payments for OMS.

Part of healthcare institutions implementing the program of state guarantees are financed according to the estimate without taking into account the volumes of medical services, the quality, and the results of treatment. This circumstance practically excludes the aspiration of institutions toward intensification of the use of fixed assets, which determine the cost reduction of medical services.

Thus, a large portion of directed funds is spent not on ensuring activity, but on maintaining the institution and its staff. In his Address to the Federal Assembly dated May 26, 2004, President of the Russian Federation V.V. Putin pointed to the necessity of transitioning from the "estimate principle of maintaining medical institutions" to payment for the volume and quality of medical care provided.

Moreover, the existing methods of forming the territorial program of state guarantees, in terms of determining the volumes of financial provision for various types of medical care, do not provide for a differentiated approach to the reallocation of financial funds depending on the socio-economic significance of types of care.

The goal of the research was the development of recommendations for improving the financing of inpatient medical care provided within the framework of the territorial program of state guarantees for providing free inpatient medical care to the population under contemporary conditions.

In order to realize the above-mentioned goal, the following research tasks were set:

1. Analysis of normative legal acts regulating the provision of free inpatient medical care, including high-tech inpatient medical care; development and application of standards and clinical protocols in healthcare;

2. Study of the structure and volume of financing of the territorial program of state guarantees for providing free medical care to citizens of the Russian Federation in Saint Petersburg in dynamics for the period 2002–2005;

3. Study of the system of tariffication and payment of inpatient medical care, analysis of the size and structure of reimbursement of actual costs for providing inpatient care to patients with various diseases;

4. Study of the level of hospitalization and the structure of hospitalized morbidity of the population under different conditions of financing of healthcare institutions of Saint Petersburg for the period from 2000 to 2004;

5. Medico-economic analysis of the existing procedure for planning volumes of hospital care and its financing within the framework of the compulsory medical insurance program;

6. Scientific substantiation of medico-economic and organizational-legal approaches to planning financial provision of inpatient medical care within the territorial program.

Scientific Novelty of the Research. For the first time on representative samples there was conducted:

— study of the influence of a complex of various factors (economic, organizational, normative-legal) on the volumes of inpatient medical care; a medico-economic characterization of the provision of inpatient medical care within the framework of the territorial program of state guarantees was presented; mechanisms were presented that take into account the specifics of inter-budgetary relations, the participation of healthcare institutions under the jurisdiction of healthcare management bodies of subjects of the Russian Federation, in the provision of high-tech (costly) medical care; the prospects for the use of clinical-economic standards and the mechanisms for ensuring the universality of compliance with their requirements were determined; priorities were established in the development of standards that take into account changes in legislation and the established resource provision of the industry; scientifically grounded approaches to the formation of the territorial program of state guarantees in terms of providing citizens of the Russian Federation with free inpatient medical care under new legal conditions were proposed.

Scientific and Practical Significance of the Research. The practical significance of the work is determined by the fact that, on the basis of the results of the research, recommendations were developed for the formation of new approaches to financing inpatient medical care within the framework of the territorial program of state guarantees for ensuring free medical care to the population of the Russian Federation based on the implementation of clinical protocols and the standardization of medical care. The proposed procedure for forming tariffs for payment of hospital treatment makes it possible to substantiate the necessary financial volume of funds for ensuring inpatient care in accordance with the declared guarantees of free care within the territorial program. The substantiated principles of forming tariffs for inpatient medical care were applied in the development of proposals for changes in tariffication and the system of payment of inpatient medical care in Saint Petersburg. The Committee on Healthcare of the Government of Saint Petersburg took a decision on the introduction of a new system of tariffication and payment of inpatient medical care provided in three major inpatient institutions of Saint Petersburg. The transition to new principles of forming tariffs for inpatient care allows: to bring the regulatory framework of healthcare into compliance in terms of ensuring the constitutional rights of citizens of the Russian Federation to medical care; to eliminate the existing contradiction of the regulatory base regarding the provision of paid medical services in state and municipal healthcare institutions; to stimulate the development of DMS and other forms of participation of citizens of the Russian Federation in ensuring medical care; to optimize the structure of financial reimbursement of costs for inpatient medical care (funds of budgets of various levels, OMS, other sources not prohibited by legislation).

The results of the research were used in the preparation of:

— Resolution of the Committee on Healthcare of the Government of Saint Petersburg "On the Procedure for Providing Paid Medical Services in State Healthcare Institutions" (dated April 4, 2005, No. 112-r);

— Decision of the Collegium of the Committee on Healthcare of the Government of Saint Petersburg on the improvement of the organization of paid medical services (dated October 10, 2004);

— Resolution of the Committee on Healthcare of the Government of Saint Petersburg on the organization of emergency medical care for the population of Saint Petersburg for 2005 (dated January 9, 2003, No. 5-r);

— Concept of Healthcare Development of Saint Petersburg for 2005–2010 (Resolution of the Government of Saint Petersburg dated December 7, 2004, No. 1917);

— Resolution of the Committee on Healthcare of the Government of Saint Petersburg "On the Structure of Inpatient Healthcare Institutions of Saint Petersburg" (dated April 15, 2005, No. 13E-r);

— Preparation of decisions of the tariff commission of Saint Petersburg on the optimization of tariffication of inpatient medical care (dated September 15, 2005).

The results of the research were used in the work of:

— the Administration for the Organization of Medical Care for the Adult Population and Sanatorium-Curative Care of the Committee on Healthcare of the Government of Saint Petersburg;

— the Territorial Fund of OMS of Saint Petersburg; clinics of the State Educational Institution of Higher Professional Education "Saint Petersburg Scientific Research Institute of Emergency Medicine named after I.I. Janelidze";

— the "Association of Medical Organizations of Saint Petersburg";

— in the educational process at the Department of Public Health and Healthcare of Saint Petersburg State Medical University named after academician I.P. Pavlov.

The main provisions to be defended:

1. The level of financial provision of inpatient medical care provided within the framework of the territorial program of state guarantees does not correspond either to the calculated indicators of the necessary financial resource or to the actual costs of providing inpatient care.

2. The structure of reimbursement of actual costs for providing inpatient medical care within the approved cost of the territorial program of state guarantees testifies to the necessity of participation of various subjects of financing (patients, employers, voluntary medical insurance organizations, etc.) in the financial provision of care.

3. For planning adequate financial provision of inpatient medical care within the framework of the territorial program of state guarantees, it is necessary to develop clinical-economic standards taking into account the priority of resource-intensive diseases and.