Socio-economic Mechanisms of Interaction between Insurance Medical Organizations and Healthcare and Preventive Institutions

The dissertation is devoted to the study of socio-economic mechanisms of interaction between insurance medical organizations (IMOs) and healthcare and preventive institutions (HPI) within the system of compulsory medical insurance (CMI) in the Russian Federation. The relevance of the research is determined by the necessity of improving relationships between the main subjects of OMS, which, over more than a decade of the system's functioning, have encountered a number of structural and financial problems, including uneven regional financing, the budget-insurance model of ensuring healthcare institutions, and insufficient motivation of insurers for the efficient use of resources. The research examines theoretical and practical aspects of the optimization of interaction between IMOs and HPIs, analyzes the experience of different territories and foreign countries, and develops proposals for improving the mechanisms of cooperation between the parties in order to raise the quality of medical care for the insured population.

A decade of the operation of the OMS system is characterized by undeniable successes, among which, first and foremost, should be counted the formation and development of a stable system of healthcare financing. Despite the fact that the implementation of the OMS system took place during years of economic crisis, its establishment was accompanied by macroeconomic instability, the 1998 default, a difficult period of emergence from a systemic crisis; the structure of compulsory medical insurance not only withstood but also developed, increasing the number of all categories of insured population and ensuring financing of the system through improved accounting of policyholders—payers of OMS insurance premiums.

Over this period, the methodological and organizational base of OMS was substantially enriched:

- a significant number of territories operate according to schemes that meet the requirements of the insurance system, with the participation of all OMS subjects, including insurance medical organizations;

- many TFOMS, when distributing OMS insurance funds among insurers, use per capita indicators as the financing norm;

- the majority of territorial OMS programs are implemented using licensed software complexes, which made it possible to systematize the system of financial calculations between territorial OMS funds;

- systems of off-budget control over the quality of medical care provided and the protection of the rights of insured persons were significantly improved;

- the methodological base for the formation of tariffs on medical services and the procedure for their indexation has been developed and is constantly being refined.

At the same time, within the system of compulsory medical insurance, a number of problems are noted, associated both with the general economic situation in the country and with the specific features of the implementation of the OMS program itself.

Among the problems caused by the situation in the country's economy, the following should be noted:

- a low level of economic development and, as a consequence, a low level of financial provision for the entire healthcare system, including OMS (according to estimates by various authors, financial provision of the Program of State Guarantees of Free Medical Care for the Citizens of the Russian Federation does not exceed in most territories 35–65%);

- uneven regional development, which gives rise to high differentiation of OMS insurance premiums across different territories;

- a tax system that diverts a significant portion of wage payments into the shadow economy, reducing the volume of collected OMS insurance premiums.

Among the main problems of OMS, the following should be highlighted, first, the problem of making OMS insurance contributions by the non-working population. The "Law on Medical Insurance of Citizens in the Russian Federation" does not specify the amounts and does not establish the procedure for making contributions by executive authorities for OMS for the non-working population, which gave rise to a variety of forms and sizes of contributions: from complete non-payment of insurance premiums to significant differentiation of their amounts not only among the subjects of the Russian Federation but also within one region (krai, republic). What is common to all territories of the country is only that everywhere payments to OMS by the non-working population, which is the main consumer of medical care, significantly lag behind in size the insurance premiums of employers for OMS for the working population.

The next problem was engendered by the creation of the budget-insurance model of financing curative and preventive care for the population. The realization of precisely this model does not allow the full formation of the market of medical services. The multi-channel financing of healthcare and preventive institutions, or rather not the sources of financing themselves, but the different method of payment for the work of healthcare institutions from these sources, became an obstacle to healthcare reform. Indeed, if OMS funds are received by institutions as payment for the volume of work performed—the provision of medical services to the insured population—then budgetary funds continue to be allocated for the maintenance of institutions according to resource (network) indicators: in the calculation per bed, visit, number of positions, heads conducting ambulatory reception. And since medical organizations have the status of institutions and are under the departmental subordination of local administrations, they have a limited level of independence both in the disposal of all types of resources and in the planning of the volumes and character of their activities. In fact, if a significant portion of financing is allocated according to expenditure budget articles, then control over the expenditure of these funds should logically also be conducted according to budgets. The division of spheres of responsibility for financial provision of the curative-diagnostic process between budgets of all levels and the OMS system according to expenditure budget articles led to the fact that control over the targeted use of OMS funds at both the sectoral and intersectoral (Ministry of Finance of the Russian Federation, Accounts Chamber of the Russian Federation) levels is also conducted according to expenditure budgets. Thus, market relations, whose creation in the sector was supposed to be ensured by the introduction of the OMS system, have still not been created in the main sector of the system—the sector of production and realization of medical services. Rigid regulation of the use of financial resources, accompanied in many regions by centralized procurement of medical and other types of equipment, medications, reagents, and dressing materials, the monopoly of food product suppliers, the impossibility, and indeed the absence of motivation for the leadership of healthcare institutions to change the organizational and staffing structure of the institution became the basis for the conservation of the budget system in the healthcare sector.

Moreover, it can be considered that the budgetary method of financing the healthcare system was strengthened with the introduction of OMS. This is related to the fact that often heads of local administrations, making contributions for the insurance of the non-working population, set a condition for the use of these funds within their own municipal formation. Thus, if in the Soviet period of healthcare development, planning (and, accordingly, financing) of the need for medical care was carried out within and with account of the potential of all healthcare institutions of the region (krai, republic), then today it is often confined to the district level. At the same time, changes in the principles of organization of medical care and the structure of the network of healthcare institutions did not occur over this period: as before, for residents of rural districts, and indeed the entire population of the periphery of the region, with the exception of major cities, the stage-by-step provision of medical care is preserved. In this situation, the desire of local authorities to finance "their own" network of healthcare institutions creates disproportions in the levels of provision of medical care to the population of different districts of one subject of the Federation and leaves without financial provision the medical care of the population of the periphery of the region at higher stages of its provision. In addition, this violates the principles of insurance and the rights of citizens to receive medical care at the expense of OMS funds in any healthcare institution of their choice.

Thus, despite the fact that the OMS system fulfilled the most important task of ensuring, during the difficult period of conducting economic reforms in the country, the preservation of accessibility of free medical care for the population, the problems laid down at its development and truly realized during its implementation became an obstacle to the development of the OMS system and make it inconsistent with the requirements of the changed economic environment in the country. Therefore, today the conduct of reforms in healthcare is associated, first and foremost, with the deepening of the system of compulsory medical insurance. The OMS system itself should become the lever that ensures the transition of the entire healthcare system to a new level of development.

What has been stated above allows us to state that the development of healthcare reform lies in changing the principles of its financing, in the transition from the maintenance of healthcare institutions to the acquisition (purchase) of medical services from them. This will entail a change in the entire system of legal and economic relations, both in the structure of compulsory medical insurance and in the sector as a whole. Above all, the reform should affect the relationships between sellers and buyers of medical services, in which, within the system of compulsory medical insurance, healthcare institutions and insurance medical organizations act.

Despite the fact that in recent years many aspects of the activity of the OMS system have been the subject of numerous studies by such well-known specialists as Shchedin O.P., Starodubov V.I., Lisitsyn Yu.P., Shishkin S.V., Lindenbraten A.L., Sheyman I.M., Taranov A.M., Andreeva O.V., Chesnokov P.E., Vishnyakov N.I., Reshetnikov A.V., the questions of relationships between the main subjects of OMS (insurance medical organizations and healthcare institutions) have not found sufficiently full reflection in the available literature.

The "Law on Medical Insurance of Citizens in the Russian Federation" and normative documents on OMS provide a wider range of obligations for healthcare institutions than for insurance medical organizations, along with a narrower range of rights. Thus, within the framework of the existing standard contracts for the provision of curative and preventive assistance to the insured population, healthcare institutions have the right only to the provision of additional volumes of medical care beyond those provided by the contract and the possibility of unilateral termination of these contracts. At the same time, insurance medical organizations have the right to choose healthcare institutions, may participate in their accreditation, bring claims against healthcare institutions in judicial proceedings, and control the volumes and quality of the medical care they provide. That is, healthcare institutions are a party in the OMS system with an undetermined volume and conditions of fulfillment of obligations.

The sizes of tariffs for services of healthcare institutions are largely determined by the volume of collected insurance premiums and payments for OMS and often do not reflect the real costs of institutions for the provision of certain types of medical care.

Moreover, within the OMS system, sufficiently powerful incentives for the interest of insurance medical organizations in the efficient use of OMS resources have not been created, which leads to a passive attitude of insurers toward the choice of institutions for providing medical care to the insured and insufficient influence on ensuring the provision of medical care to them in the necessary volume at a high quality level. It is sufficient to say that the main violations identified during the conduct by insurance medical organizations of expert examinations of the volumes and quality of medical care provided to the insured population are: inadequate quality of medical care—35.5%, overstatement of volumes of medical care—25.1%, actions impeding the assessment of the quality of medical care—19.6% (reference-analytical collection "OMS in 2002", Moscow, 2003).

For the forthcoming reform of the system of compulsory medical insurance, a Concept for the Modernization of the OMS System in the Russian Federation has been prepared and agreed with the FOMS by the relevant ministries. One of the main directions of the upcoming reform should be the raising of requirements for insurance medical organizations, including the fulfillment of obligations to ensure equal accessibility of citizens to medical care within the basic program of OMS, the presence of an operational plan of activity, the assurance of transparency of financial flows, accessibility of information, and rational use of OMS system resources. The solution of these tasks will require a substantial revision of relationships within the OMS system, and first of all, the mechanisms of interaction between insurance medical organizations and medical institutions within the OMS system.

The goal of the research: scientific substantiation and development of a mechanism of interaction between insurance medical organizations and healthcare and preventive institutions within the OMS system.

In order to achieve the stated goal, the following tasks were formulated and solved in the research:

- to study and generalize domestic and foreign experience in the optimization of interaction between insurance medical organizations and medical institutions;

- to conduct a comparative analysis of the parameters of territorial programs of state guarantees for the provision of free medical care to citizens of the Russian Federation, developed and implemented in the territories selected for research;

- to study and conduct a comparative characterization of existing models of OMS financing based on the analysis of normative and methodological documents regulating the activity of insurance medical organizations and healthcare institutions in the implementation of territorial OMS programs, and to determine their influence on the effectiveness of medical care provision in different subjects of the Russian Federation;

- to conduct a sociological research to assess by the subjects of OMS the state and prospects of development of the OMS system;

- to develop proposals for the improvement of interaction between healthcare institutions and insurance medical organizations in order to raise the quality of medical care for the insured population.

The objects of research were territorial systems of compulsory medical insurance.

The subjects of research were the problems of relationships between healthcare and preventive institutions and insurance medical organizations in the implementation of territorial OMS programs.

Research methods. In accordance with the set tasks, a complex methodology was used in the research, including the following methods: observation, comparison, measurement, content analysis, analytical, statistical. The use of sociological research methods made it possible to conduct a population survey and an expert assessment of problems of regional healthcare, as well as to determine the directions of development of relationships between healthcare institutions and insurance medical organizations based on the methodology and with the application of the statistical apparatus of the Delphi method.

The research was conducted in the Moscow, Perm, and Tula Oblasts and the Republic of Chuvashia. The base of the research was the network of medical institutions, indicators of the activity of healthcare and preventive institutions, parameters of planning and implementation of territorial programs of state guarantees, their financial provision, as well as documents regulating the activity of healthcare institutions and insurance medical organizations in providing medical care to the insured population of the selected territories in 1995–2002.

Scientific novelty of the research. In the course of the work, the experience was generalized and the features of relationships between insurers and medical institutions in the implementation of insurance programs in Russia and foreign countries were identified. A comprehensive analysis of the development of the OMS system in four subjects of the Russian Federation with different levels of healthcare development, using different models of construction of the OMS system, was conducted. The main normative and methodological documents regulating the activity and system of relationships between healthcare institutions and insurance medical organizations in the implementation of OMS programs in the territories were analyzed. The dynamics of formation and features of implementation of programs of state guarantees for the provision of free medical care to citizens of the Russian Federation in each territory, as well as the volumes of medical care actually provided to the insured population and the costs of its provision, were studied. A sociological research was conducted with the aim of studying the opinion of the population, physicians, and heads of insurance medical organizations and territorial OMS funds about the prospects of development of medical care for the population, the role and place of insurance medical organizations in this system of compulsory medical insurance, and the improvement of interaction between healthcare institutions and insurance medical organizations.

Practical significance. The information obtained in the course of the multifaceted scientific research made it possible to develop and substantiate proposals for the improvement of interaction between healthcare institutions and insurance medical organizations in order to raise the level of medical service for the insured population.

The results obtained were introduced into the practice of the work of territorial OMS funds of the Moscow, Perm, and Tula Oblasts and the Republic of Chuvashia, are used by insurance medical organizations and leading healthcare institutions of the indicated Oblasts when concluding contracts for the provision of curative and preventive assistance to the insured population, as well as in the educational and pedagogical process at the Department of Commercial Law of the Faculty of Law of Saint Petersburg State University and in cycles of advanced training for workers of territorial OMS funds, insurance medical organizations, and healthcare and preventive institutions operating within the OMS system.

The materials of the research were reported and discussed at various all-Russian and regional scientific-practical conferences and meetings.

Based on the results of the research, 10 works were published.

The main provisions to be defended:

- results of the analysis of the formation and implementation of territorial programs of state guarantees for the provision of free medical care to citizens of the Russian Federation;

- methodological approaches to conducting a comprehensive diagnosis of the system of territorial healthcare, based on the use of an expert survey by the Delphi method;

- proposals for the improvement of interaction between healthcare institutions and insurance medical organizations in order to raise the quality of medical care for the insured population.