Socio-economic Aspects of the Organization of Hospital Care at the Regional Level

The dissertation is devoted to a comprehensive study of the socio-economic aspects of the organization of hospital care at the regional level in the context of the reform of healthcare and the modernization of the system of mandatory health insurance in the Russian Federation. The research is conducted on the materials of the Ryazan and Tula regions and encompasses a wide range of issues: the analysis of the health status of the population and the healthcare system of the region, the assessment of accessibility and satisfaction of the population with hospital care, the socio-economic analysis of the fulfillment of state guarantees, as well as the problems of managing the volumes, cost, and quality of medical care. Special attention is devoted to the mechanisms of municipal assignments as an instrument for the fulfillment of territorial programs of state guarantees, the transition from payment for actual volumes to planned volumes, the implementation of substitutive technologies, and the re-profiling of inefficiently operating bed capacities. The work also examines the socio-psychological aspects of personnel management during reforms and the assessment of managerial and leadership qualities of administrators of hospital institutions of various levels. The scientific significance of the work is determined by the development and practical implementation of technologies of municipal assignments, the substantiation of norms of the population's need for inpatient and alternative medical care, and the formation of forecasts of the socio-economic development of the region and plans for the financing of the territorial program of Mandatory Health Insurance.

Relevance of the Research

One of the principal objectives of the Concept for the Development of Healthcare and Medical Science in the Russian Federation is to enhance the efficiency of healthcare resource utilization. Accessibility of medical care for the population and the economic efficiency of healthcare institution operations constitute its fundamental principles (Resolution of the Government of the Russian Federation dated 05.11.1997, No. 1387). In his annual address to the Federal Assembly of the Russian Federation, the President of Russia noted the high levels of morbidity and mortality among Russian citizens, the demographic decline in the country, and called for the accelerated resolution of healthcare issues (Putin V.V., 2003).

The foundational principle of the national healthcare system is the federative structure, combining the advantages of centralized authority with the autonomy of its constituent entities. Healthcare is predominantly a sphere of local governance and self-governance, which determines the objective difficulties of state policy in reforming the sector at the regional level (Shchepin O.P., 1999).

In the view of domestic scholars, the regional healthcare system should extensively employ the results of scientific research to substantiate managerial decisions, the formulation of plans, and programs (Shchepin O.P., 1999).

During the pre-reform period in Russia, the majority of budgetary funds were allocated to the development of inpatient healthcare institutions at the expense of less costly ambulatory-polyclinic care (Lisitsyn Yu.P., 1999). In this connection, hospital institutions currently consume more than 60.0% of healthcare resources (Kucherenko V.Z., 1996; Vyalkov A.I., 2002; Starodubov V.I., 2003). Foreign scholars consider that the management of inpatient medical care volumes is, in fact, the most important aspect of controlling overall medical expenditures (Congstedt P.R., 2000).

The Program of State Guarantees, mandatory for execution in the regions at the level of federal standards, on the one hand, presupposes the reduction of significant volumes of inpatient care and the introduction of alternative resource-saving technologies, and on the other hand, the rational and efficient utilization thereof, as well as the increase in expenditures per unit of medical care (bed-day, day of treatment in a daytime hospital, etc.) (Kravchenko N.A., 1998; Taranov A.M., 2001).

However, in the majority of constituent entities of the Russian Federation, reforms are "stalling": the Program of State Guarantees is not fulfilled either in volumes or in the cost of medical care. The deficit of regional programs averages 40.0-50.0% and is covered by forced patient expenditures on the purchase of medications and medical services. The number of patients who refuse treatment and the acquisition of prescribed medications increases annually [269].

In connection with this, the necessity of reforming the healthcare system is currently widely discussed in scientific and public circles. In the opinion of some scholars, reforming is a natural process of development of regional healthcare systems (Matveev E.N., 2003), while others define it as a forced measure in connection with the deficit of sector financing (Sheyman I.M., 1998).

The Government of the Russian Federation considers it expedient not to reduce the level of constitutional guarantees, seeking to resolve the problem of the financial deficit through the search for additional sources of revenue (the project of creating a fund of medical and social insurance, the attraction of excise taxes, funds of the Pension Fund of the Russian Federation), as well as through the modification of financial flows (the project of increasing the share of the unified social tax, in part, credited to the Federal Fund of Mandatory Health Insurance from 0.2% in 2003 to 1.7% in 2007 at the expense of the proportional reduction of revenues of territorial funds of Mandatory Health Insurance) and the rationalization of the utilization of available healthcare resources. The latter constitutes the fundamental doctrine of the reform of regional healthcare — the reduction of the inefficiently operating bed fund, the directing of financial flows toward the development of ambulatory and substitutive technologies, and the introduction of the institution of the general practitioner (Denisov I.N., 1996; Vyalkov A.I., Taranov A.M., 2000; Shevchenko L.Yu., 2003).

The reform of the sector presupposes the necessity of reforming the healthcare financing system — the transition to a per capita principle, which should encompass all stages of the movement of financial resources: formation, distribution, and expenditure. However, at present, corresponding changes have not been introduced into the legislation of the country (Putin V.V., 2003). Per capita financing, a unified procedure for the movement of financial resources, the balance of revenues and expenditures, the harmonization of the legislative base, new approaches to the formation of the territorial program of state guarantees, and the unification of methods of medical care payment — should become the basis for the modernization of the system of mandatory health insurance. The reform of healthcare at the present stage, in the opinion of domestic specialists, is impossible without the modernization of the system of mandatory health insurance (Mandatory Health Insurance) (Starodubov V.I., 2003).

Methods of financing and payment for medical care should be subordinated to the task of stimulating the process of restructuring of healthcare, which presupposes the transition from payment for actually rendered volumes to payment for planned volumes of medical care, determined on the basis of state (municipal) assignments to medical organizations. The development, financing, and control over the fulfillment of such assignments are of state importance and have been approved by the Resolution of the Government of the Russian Federation (dated 06.05.2003, No. 255). Nevertheless, at present, the practice of municipal assignments in the sphere of fulfillment of regional programs of state guarantees and their guaranteed financial coverage is used far from by all constituent entities of the Federation [269].

For the Central Federal District of Russia, the problems of the deficit of sector financing are exacerbated by an unfavorable demographic situation: a significant excess of the mortality level over the birth rate, that is, a "negative" natural increase — population loss. A tendency toward a decrease in the working-age population is observed. For regions with a predominating rural sector, healthcare has until now been characterized by traditional significant consumption of hospital care in connection with a high level and duration of hospitalization, as well as a stable bed fund (Shchepin O.P., 1999).

The reform of the sector, in its essence, presupposes orientation toward norms and standards of various levels and types, the primary one being the territorial program of state guarantees. Standardization in hospital care is the development of protocols of patient management, a formulary system of pharmaceutical provision, etc. At present, among domestic specialists there is no unified opinion on the expediency of developing and implementing industry standards of inpatient treatment (Vorobiev P.A., 2003; Chuchalin A.G., 1999).

Research by domestic authors shows that at present, a coherent mechanism for the management of hospital care at the regional level has not been created. The information available in the literature on the influence of individual medical, social, economic, and other factors on the optimization of hospital care is not numerous and is of a general character. We did not encounter scientific data on the results of a comprehensive socio-economic study of the problem of the organization of hospital care at the level of a constituent entity of the Federation. The limitation of information in the scientific literature on this problem is largely due to the absence of unified methodological approaches to the conduct of such research. In view of the above, the relevance of the work is determined by: the necessity of scientific substantiation and financial coverage at the level of constituent entities of the Russian Federation of state-guaranteed volumes of free hospital care; the necessity of optimizing the expenditure of healthcare resources at the regional level through the reduction and re-profiling of the bed network; the necessity of unifying methods of hospital care payment within the system of budget-medicine; the necessity of improving the quality of medical and pharmaceutical hospital care on the basis of standardization.

Goal: on the basis of a comprehensive study, to scientifically substantiate the socio-economic aspects of the organization of hospital care at the regional level during the reform of healthcare.

Main Tasks of the Research

1. To conduct a sociological and medical-economic study of the level of accessibility and satisfaction of the population with hospital care.

2. To conduct a socio-economic analysis of the fulfillment of state guarantees in providing the population of the region with hospital care.

3. To determine the rationality of the utilization of healthcare resources at the regional level.

4. To determine the possibility and expediency of reducing the volumes of hospital care, implementing substitutive technologies, and re-profiling a portion of inpatient capacities into institutions (units) of social care.

5. To substantiate and implement in the region a technology of municipal assignments for the fulfillment of standards of hospital care.

6. To identify forms of management, disciplinary authority, and leadership qualities of administrators of various levels, and their readiness for the restructuring of hospitals.

Scientific Novelty of the Research

The scientific novelty of the research consists in the fact that, for the first time:

• the accessibility and satisfaction of patients with hospital care provided by institutions of various levels during the socio-economic reforms have been identified;

• a socio-economic assessment of the fulfillment of state guarantees in the provision of hospital care to the population at the regional level has been given;

• the need of the population of the region in hospital and substitutive care has been substantiated;

• an economic assessment of the expediency of re-profiling inefficiently operating rural hospitals into institutions of medical and social provision has been given;

• methods of payment for inpatient care "by completed case of treatment" within the framework of municipal assignments have been optimized as a transitional stage to the principle of financing by "global hospital budget";

• factors of financial sustainability of hospital institutions during the restructuring of the bed fund have been identified;

• a technology of municipal assignments for the fulfillment of the territorial program of state guarantees has been developed, economically substantiated, and implemented;

• a technology for the assessment of managerial, leadership qualities of hospital administrators of various levels, disciplinary relations, and situational management during reforms has been implemented.

Scientific and Practical Significance

The results of the research, possessing significant scientific and practical and methodological importance for the development of the science of public health, for the reform of regional healthcare and the modernization of the system of Mandatory Health Insurance, have made it possible:

• to scientifically substantiate the norms of the population's need for inpatient and alternative types of medical care and to legislatively approve a plan for the restructuring of the bed fund at the regional level;

• to implement at the regional level a technology of municipal assignments (orders);

• to reduce the bed network of round-the-clock observation hospitals, expand the network of daytime hospitals and nursing care departments;

• to organize work on the planning of the transfer of a portion of hospital institutions from the healthcare system to the social protection system;

• to present materials for the formation of medium-term forecast plans of the socio-economic development of the region for 2004-2005, as well as for the prospect up to 2010;

• to form a forecast of the budget of the territorial fund of Mandatory Health Insurance and a plan for the financing of the territorial program of Mandatory Health Insurance for 2004-2006;

• to improve methods of hospital care payment within the system of Mandatory Health Insurance;

• to identify factors that increase the level of accessibility and satisfaction of patients with hospital care;

• to enhance the qualifications of deputies on social issues of the heads of administrations of municipal formations on questions of healthcare reform, restructuring of the network of municipal hospital institutions, and municipal assignments for the fulfillment of the territorial program of state guarantees.