Conservation law: why "covid" hospitals do not pay extra for the doctors

So why do the medical staff still complain that there are no additional payments?

Ivan Petrovsky

"Coronavirus" allowances for doctors, paramedics, nurses and ambulance workers were extended for another two months - for July and August. Such an order was recently voiced by Vladimir Putin. In general, after several meetings of the president with ministers and other officials, the topic of “coronavirus” additional payments to doctors faded into the background: there were no more loud scandals, the prosecutor’s office took over the management of hospitals, and the allocation of additional funds or at least the publication of news about them was put on stream. But the network continues to periodically receive messages about the dissatisfaction of doctors: when calculating "coronavirus" allowances, the previous incentive payments and other allowances are cut.

Novye Izvestia decided to figure out how the system of “covid” payments to health workers works, and why scandals around them still do not subside.

There is work, but no money

The largest stream of complaints was observed in April. Doctors of the Botkin hospital, one of the buildings of which was redesigned for "covid", complained about a decrease in income by 10% -15%, a similar situation was in the Kamensk interdistrict hospital in the Penza region, there were problems with incentive payments for the partially redesigned autonomous public health care institution of Moscow region GAUZ MO Central city clinical hospital of the city of Reutov. At the Samara City Clinical Hospital No. 8, doctors complained that they did not receive any allowances at all for working with covid patients. There were questions from the nursing staff, who are entitled to a bonus of 50 thousand rubles (and in Moscow, another 43 thousand from Sobyanin). It even went as far as mass layoffs in the famous and "titular" Kommunarka. But where does the discontent come from after May 15, when Putin made a splash for doctors' surcharges calculated by the hour?

Zugzwang for the chief physicians

Let's start with the salaries. They usually consist of a salary and various incentive payments. Like almost all state employees, the salary itself is quite small - no more than 10 thousand rubles. For example, according to one of the nurses who works in the FNKTs FMBA of Russia, redesigned for "covid", the salary is only 7874 rubles. As we were told by sources close to the Ministry of Health, this obligatory amount is formed by paying for services from the MHIF according to established standards, while quite often there is not enough money from the state budget, and even these small amounts of hospitals often have to find in their own budget. And in the case of the FSCC, the hospital itself paid the incentive surcharges of 56,000 rubles, which were before the pandemic, from its own funds - profits from the provision of paid services and within the framework of the state order. As a result, the nurses had quite a decent salary - more than 60 thousand rubles. For comparison: in Penza, for example, nurses receive from 11,280 rubles. And you can't jump higher, because the average doctor's income there is 38 thousand rubles. In addition, the standard schedule of a nurse is not 40 working hours a week, as in other ordinary organizations, where they work from 9 to 18 hours from Monday to Friday, but less.

What happened after the epidemic, and how is it that “covid” payments became not an addition, but a replacement for the previous incentive payments? The first thing that comes to mind is the possible machinations of chief doctors trying to cash in on the situation. However, having plunged into the intricacies of the topic, we found out that everything is much more complicated. Hospital managers are often held hostage by the system and are convenient scapegoats. First, the redesigned clinics completely lost their income from the provision of paid services - all efforts were devoted to providing the same affordable care for all victims. And it is right. But in the end, the chief doctors were forced to find funds by any means to provide employees with at least some acceptable level of income and to those who are entitled to additional payments for working in the “red zone”, and to those who, according to the law, are not allowed to work in the “green” zone. nothing is relied on, as well as those who have gone on forced leave.

As a result, hospitals found themselves in a rather strange and unpleasant situation: “Putin's” and “Sobyanin's” payments to those who worked in the “red zone” were paid in full, but allowances that are paid regardless of epidemics, in addition to scanty salaries, are now taken nowhere. People who save lives need to make good money. But, alas, in Russian reality this is fantastic. Everyone has to pay, and the "covid" grants allocated to hospitals do not reach the previous income of hospitals.

Why hospitals have nothing to pay employees during an epidemic

As we wrote earlier, Russia has a complex multistage healthcare financing system. Part of the money for some medical institutions comes from the federal budget, for others - from regional budgets, part of the money goes through the MHI Fund, part of the money is earned by hospitals themselves, and ambulance stations are generally financed from meager municipal budgets. And there are many problems with funding at the regional level. And there is no single center for financing that could control and coordinate all cash transfers. Paradoxes grow out of this: money for copayments has been allocated and even brought to doctors in full, but incomes do not always grow the way doctors and nurses want.

Legally, the green zone surcharges are not formalized in any way. They simply do not exist in the laws. And all incentive payments, which accounted for the lion's share of income in the dock era, to doctors, as noted by the co-chairman of the interregional trade union of health workers Action, Andrei Konoval, are not guaranteed by the state. They are paid by the hospitals themselves, subject to the availability of funds. And if there is no money, then there is nothing to count on.

Of course, there are some healthcare facilities where employees do not have to deal with declining income. But this is not happening because the management by some miracle was able to find money, but because the "obligatory" part of salaries in some Moscow institutions may not be 7,000, but 50,000 rubles. Much depends on the level of subordination of the hospital, on its specialization and the range of paid services. And here again the question arises of the need to increase funding for health care from the state in terms of employee salaries. After all, if the chief physician does not have to think about where and how to make money, then more time will be devoted to medicine itself.

You can complain to the prosecutor's office about the chief doctors, perhaps this will help increase incomes even in the short term: some heads of medical institutions, in order to get rid of the pressure of supervisory authorities, may go to increase the debt of a medical institution to banks in order to keep all payments to doctors in full, but in the future everything you will also have to face savings. With money, as with the law of conservation of energy - they do not come out of nowhere. And the key problem lies at a much higher level than just the reluctance of chief doctors to cut staff salaries.

Health Minister Mikhail Murashko himself raised the topic of increasing the transparency of the compulsory medical insurance system in May, but this is just a drop in the ocean. Reconsidering the relationship with insurance companies, which act as intermediaries between people and doctors, clearly cannot solve the problem. You can at least transfer all the chief doctors of all hospitals, but if the salaries of medical workers continue to add up from the meager salaries and allowances that depend on the earnings of hospitals, guarantees of income stability will not be added one iota.

It is long overdue to revise the system of remuneration of medical personnel at the legislative level. Now there is no rationing that would allow guaranteeing the amount of payments. The same infectious diseases hospital in Kommunarka is located in the department of Moscow, does not provide a wide range of paid services and, accordingly, has a different funding structure, receiving money from the city, not the federal budget. Plus, in Russia there is a system for dividing funding by groups of diseases - not all specializations are equally valued. This problem, at least partially, should have been solved by legislative establishment of the share of salary in the salary of at least 50%, with guaranteed money being brought to the hospital, otherwise it would again turn into a problem for chief doctors. But the adoption of the law was delayed and the health workers met the pandemic with the same conditions as before.