Scientific Justification of Procedures for Protecting the Rights of Insured Patients under a Contract of Indemnity

The dissertation is devoted to the scientific justification of procedures for protecting the rights of insured patients under a contract of indemnity within the system of mandatory medical insurance. The research focuses on the formation of mechanisms for non-departmental expert assessment of the quality of medical care, analysis of citizens' appeals and erroneous actions of medical specialists, as well as the development of a comprehensive system for ensuring the quality of medical services and protecting patients' rights at the stages of production of medical services. The author examines the interaction of healthcare and preventive institutions, insurance medical organizations, and the territorial fund of mandatory medical insurance as subjects of contractual relations aimed at achieving a predictable level of quality of medical care.

specialized measures ensuring proper conditions and technologies for the provision of medical services. Evidence of this is the decision of the European Regional Office of the World Health Organization, which prescribes the implementation of a program in the territories of the global community under the general title «Model Programs of Medical Service and Its Quality». The protection of the rights of consumers of medical services and the satisfaction of patients with the medical care provided to them is an organizational manifestation of the quality system. The system provides for contractual relations between the subjects of mandatory medical insurance, which are represented by healthcare and preventive institutions, an insurance medical organization, and the policyholder. Thus, ensuring the quality of medical care and protecting the rights of consumers of medical services is the principal subject of contractual obligations within the system of mandatory medical insurance and an integral element of state policy. Evidence of the importance of protecting consumers' rights is the issuance of the Law of the Russian Federation «On Protection of Consumer Rights» in the edition of the Federal Law «On Amendments and Additions to the Law of the Russian Federation «On Protection of Consumer Rights» and the Code of the RSFSR «On Administrative Offenses» of 09.01.96, which state that this Law regulates the relations arising between consumers and manufacturers, sellers in the sale of goods (performance of works, provision of services), establishes the rights of consumers to acquire goods (works, services) of proper quality and safe for the life and health of consumers, to receive information about goods (works, services) and about their manufacturers (executors, sellers), education, state and public protection of their interests, and also defines the mechanism for realizing these rights. Within the framework of the tasks addressed by this system, in 2004 changes were made in the government apparatus, as a result of which a number of ministries were merged, on the basis of which the Ministry of Health and Social Development was created, in which a department for the protection of consumers' rights to medical care was established, and so on. All these measures constituted a lawful transition from quantitative changes to qualitative ones through the development of expert assessment of the quality of medical care, its improvement, and the conduct of a number of other measures. Thus, ensuring proper quality of medical care is the definition of actually provided medical care in accordance with modern and prospective concepts of its necessary level and volume with corresponding types of pathology, taking into account the individual characteristics of the patient and the specific conditions of the provision of medical services. This is a classificatory and qualitative assessment of healthcare and preventive institutions, the state of resources, the structure of management, organizational and administrative forms of work of medical institutions, the qualifications of personnel, technical and technological equipment, where any approach to assessing the quality of medical care includes an element of control and social protection. All these changes are being carried out in recent years at the stage of modernization of the system of mandatory medical insurance with the participation of the territorial fund, which performs the functions of a state regulator and controlling body for the development of mandatory medical insurance. At the same time, the role of the insurance medical organization in the development of conditions of management is increasing, which presupposes the introduction in the near future of new contractual principles of responsibility not only of healthcare and preventive institutions toward the patient within the framework of contractual obligations between the medical institution and the insurance medical organization, but also of the insurance medical organization toward the healthcare and preventive institution for its resource provision. Large insurance medical organizations «ROSO-MS», SMC «MAX-MS», «Spasskie Vorota», and others, each of which has a powerful regional network in the form of branches, possess a powerful economic base that allows them to maintain various services and, in particular, effective functional managements, departments ensuring the protection of patients' rights at all stages of the development of conflict situations. The consolidation of this position by an entire set of regulatory acts is a significant step in the development of Russian statehood. In the recent period, the social policy of the state has undergone a serious rethinking and improvement. The crisis of the social sphere in connection with the depletion of its resource base and the inadequacy of the system of management of the social sphere in the changing market infrastructure of the economy created a gap between state guarantees of free provision of medical care to the population and their financial provision. The incompleteness of the introduction of the insurance system of healthcare financing, the eclectic combination of elements of the old and new systems of financing, the absence of incentives for the efficient use of resources, the strengthening of the principles of decentralization, the redistribution of powers between the center and the regions, and within the regions — between the regional and municipal levels determined the priorities of healthcare development and led to a new understanding of the concept «quality of medical care», applied to the category «quality of life». Healthcare is the most important branch of the social sphere, absorbing all the problems of the current period of development of society. Their resolution requires the formation of effective mechanisms for reforming the system of medical care provision. The problems of the formation and development of the system of mandatory medical insurance, the quality of medical care, expert assessment, structural-functional transformations, and the reform of the healthcare financing system are widely discussed in modern literature and scientific research. (Lisitsyn Yu.P., Starodubov V.I., Grishin V.V., Semenov V.Yu., Savel'eva E.N., 1994, Vishnyakov N.I., Danilov E.O., 1995, Grishin V.V., Semenov V.Yu., Polyakov I.V., 1995, Gerasimenko N.F., 1997, Komarov Yu.M., 1997, 1998). The effectiveness of social policy in the field of healthcare, associated with questions of protecting the rights of insured persons and the quality of medical care in a large administrative city-subject of the Russian Federation, has not found sufficient reflection in existing publications. The problem of ensuring QMP is given great importance in all developed states of the world. In many countries, systems of healthcare management, organizations, and technologies of QMP control in conditions of medical insurance have been formed and function successfully, which have fully justified themselves and ultimately contribute to ensuring a high level of health and social protection of the population (Kucherenko V.Z., Mylnikova I.S., 1991, Grishin V.V., Semenov V.Yu. et al., 1995, Komarov Yu.M., 1996, 1997, Shchepin O.P., Lindenbraten A.L., Golodenko V.N., Zvolinskaya P.M., 1996, Shchepin O.P., Starodubov V.I. et al., 2002; Donabedian A., 1968, 1978, 1990, 1993, McLaughlin, Curtis P., Kaluzny Arnold D., 1994). The Russian national system of ensuring QMP, like the system of protecting the rights of insured persons, is in the stage of formation. It is noted that at present in most regions of the Russian Federation there is still no established and effective system of ensuring QMP, and unified methodological principles for conducting expert control of QMP have not been developed (Chavpetsov V.F., Grishin V.V., Semenov V.Yu., Gluchenko P.P., 1995, Zakharov I.A. et al., 1997, Vishnyakov N.I. et al., 1997; Lastovetsky A.G., 1998, 2000, Kucherenko V.Z., Golubeva A.P., 2001, 2002; Ptashinsky R.I., 2002; Savashinsky S.I. et al. 2003, Pavlenko-Mikhailova N.Yu., 2004; Golovanova O.Yu., 2004 and others). It should be noted that in no legislative act of the federal level has the system of bodies, organizations, and institutions called upon to ensure the quality and effectiveness of medical care and to protect the rights and legitimate interests of insured persons in the provision of medical care of proper volume and quality received due legal assessment. Moreover, the system of control and ensuring QMP itself is not systemic in character. The OMS system provoked the development of the control function, which is represented as departmental and non-departmental and is carried out by healthcare bodies and insurance medical organizations. However, outside the sphere of non-departmental influence remain emergency and urgent medical care, pharmaceutical provision, maternity hospitals, and a number of other medical institutions, which testifies to the imperfection and incomplete coverage of the protection of consumers' rights to medical services, with the functions of control being mainly entrusted to public administration bodies. As a result, the system of expert control and assessment of QMP does not provide full coverage of medical institutions, which does not ensure the completeness of protecting the rights of citizens at all stages of the conduct of the treatment process. The rights of patients (citizens) in receiving medical care on the territory of the Russian Federation are regulated by the Civil Code of the Russian Federation, the Law of the RSFSR «On Medical Insurance of Citizens of the RSFSR», the Fundamentals of the Legislation of the Russian Federation on the Protection of Citizens' Health, and a number of other regulatory acts. By this time, experience has been accumulated in the creation of a territorial system for protecting the legitimate interests and subjective rights of insured persons, both in pre-trial and judicial proceedings. The territorial system should ensure the interaction of various state, public, and other organizations whose competence includes questions of control over the observance of citizens' rights and their protection in the changed socio-economic situation and in conditions of the development of new mechanisms of insurance of the non-working population, new requirements for insurers, and an increase in the share of contributions received by the Federal Fund of OMS (FFOMS). At the same time, in addition to existing ones, new requirements are proposed for insurance companies, which presuppose the right of the insured to choose an insurer, the availability of an operational plan, and the provision of a quarterly report by the TFOMS on the fulfillment of contractual obligations with medical organizations, and so on. In addition, questions of ensuring the risks of catastrophic costs and conditions for protecting the rights of insured persons in such situations are being considered. At the same time, the problems of protecting the rights of insured persons and QMP are not considered in interrelation with social policy at the regional and federal levels. The relevance of the conducted research is also determined by the insufficient development in domestic science of the problems of modern regional and local social policy, the absence of scientifically grounded comprehensive approaches to solving social problems at the municipal level. Thus, the protection of the rights of insured persons is not only an organizational and managerial problem, but also a task of solving economic problems in healthcare and preventive institutions, insurance medical organizations, and in general in the policy of development of medical and social insurance. Thus, the protection of the rights of insured persons on the basis of quality medical care is an organizational, managerial, and economic task in the activities of a healthcare and preventive institution and an insurance medical organization.