New funding rules: the Ministry of Health has taken another step towards paid medicine

Following the change in the rules of compulsory medical insurance, the Ministry of Health proposes to limit the provision of medical care: it will be paid to medical organizations only within the pre-allocated volumes, and the work of experts on the quality of treatment will be limited.

Irina Mishina

The Ministry of Health called these changes floridly: "harmonization of legislation in the field of health insurance, based on the need for optimization". The essence of the document is that healthcare institutions will be paid for medical care no more than a pre-planned amount. The document was published for public comment on the regulation.gov.ru portal. It will end on March 26th.

Treat or refuse?

Under the new rules, insurance organizations, Federal Compulsory Health Insurance Fund and territorial funds may refuse to pay the clinic for services that were provided to patients in excess of the previously allocated volumes. Also, the Compulsory Health Insurance rules are amended on medical and economic expertise. For heavy fines, clinics and doctors experts will be excluded from the register, that is, removed from office. And for life.

"Excessive volumes of medical care appear when a medical facility has accepted more patients than was planned for a year under a special tariff agreement. Frankly speaking, even before the procedure for paying for excess volumes was clarified, they were reluctant to pay for them. Now they want to legitimize this: if additional medical assistance is not justified and not approved by a special commission, the medical organization will not be paid for it", - explained the head of the Higher School of Healthcare Management, Doctor of Medical Sciences Guzel Ulumbekova.

"Over the plan" clinics receive and treat patients constantly. Subsequently, they are financially compensated for this. More precisely, compensated. Until recently, in matters of paying for additional medical care for patients, the courts most often sided with the doctors. Now the situation has changed. Recently, the Moscow Arbitration Court dismissed the FMBA clinical hospital No. 85 in a claim to recover the debt for medical care provided to insured patients in the amount of 40.4 million rubles. and penalties in the amount of about 1.6 million rubles to JSC Medical Joint Stock Insurance Company. According to the court, a medical organization has the right to refuse a citizen to provide free medical care and refer him to other clinics that provide similar assistance within the framework of the compulsory medical insurance.

“Patients, in fact, may be deprived of routine medical care. For example, a patient with acute cholecystitis needs emergency surgery. He comes to the hospital, and they tell him: “Come back in a month, now we can’t operate on you, we have finished funding. As a result, the patient will turn to the wrong clinic that he needs, in which there are competent specialists and about which there are good reviews, and because of this there are many patients. He will have to go to a clinic that may not have good experience in performing the operation he needs. Or be treated commercially. Thus, the new rules will support private clinics and medical organizations that work frankly poorly. In addition, it is completely unclear how these same volumes of medical care will be calculated. And where is the guarantee that the clinic will not deceive the patient, referring to the exhausted amount of assistance in order to force him to be treated on a commercial basis? Who will check it?", - Doctor of Medical Sciences, President of the National Agency for Patient Safety and Independent Medical Expertise, member of the Public Council for the Protection of Patients' Rights at Roszdravnadzor Alexey Starchenko told Novye Izvestia.

Indeed, the question arises: how will the Ministry of Health and the Federal Health Insurance Fund calculate the required volumes of medical assistance? Based on the average incidence over the decade? How to calculate it during a pandemic? And in general, what about federal legislation, which provides for the inadmissibility of refusal to provide medical care? Indeed, based on Article 4 of the Federal Law-323, the main principles of health protection are: observance of the rights of citizens in the field of health protection and ensuring the state guarantees associated with these rights; inadmissibility of refusal to provide medical care. The right to receive medical care and voluntary choice of a medical organization are also enshrined in Articles 11, paragraph 1; Art. 19, part 2 FZ-323 and the Russian Constitution.

But even if all this were not enshrined in law, it is difficult to imagine how the new rules on excess medical care would be implemented in the regions. Take, for example, a remote hospital in the Khanty-Mansiysk District. If a patient goes there in excess of a certain amount of medical care, where to send him to doctors? Looking for another hospital, which is located in another village 150 km away? And if there are many such patients? Of course, the clinic may in this case offer to use paid medical services. But where to get money for a person from rural areas, whose income does not exceed the subsistence level?

So what to do if a medical organization provided unplanned assistance?

“For example, during the epidemic, the hospital accepted more patients and cured them. In this case, the insurance organization must admit that the hospital did provide such assistance, and it was needed and justified. After that, the insurance company applies to the territorial insurance fund and asks for additional funding. - explains the head of the Higher School of Organization and Management of Healthcare (VSHOUZ), Doctor of Medical Sciences Guzel Ulumbekova. - But they may say: "Yes, we do not mind and are ready to pay." Usually funds are spent on this from the so-called "nest egg" - the rationed safety stock. And if there were more patients than money in the stash? This draft Order of the Ministry of Health says almost directly - "if there is no money, then the insurance medical organization, and, accordingly, the medical institution will not receive it".

It turns out that the institution will not be paid for the work done, and it will save on the salaries of doctors, nurses, and medicines for patients. And then, knowing that the clinic will not be paid for the excess volumes in the future, they will simply develop paid medical services, that is, they will shift all the costs onto the shoulders of sick people. In other words, if the flow of sick people is greater than there is money in the compulsory medical insurance system, then the costs of providing this assistance will be borne by the medical organizations or patients themselves. A prediction can be made: paid medical services will only grow. But will the population have enough money in the face of declining incomes? Anyway, in an election year, limiting free medical care is a rash decision”.

This decision also seems more than strange during a pandemic, when many medical facilities are redesigned to treat patients with coronavirus infection; when there are much more patients than before.

In addition to commercial services, the "denied" patient will most likely be offered to use Telemedicine, which our healthcare is so proud of now. With the mark "lightning priority", the editorial office receives messages: In Moscow, telemedicine center doctors have conducted more than 820 thousand consultations. Does this solve the problem? Personally, I have only encountered telemedicine once. After being discharged from the hospital with a diagnosis of viral pneumonia, a girl's voice called me and asked how I was feeling. I answered honestly that I feel very bad. “Well, then call the ambulance”, - the receiver advised. "And let us know about it". “And what this is for?”, - I asked. “To let us report on the case”, - confessed the representative of the Telemedicine. I think comments are superfluous here.