How much do we pay for "free" medicine and why we can't choose where to get treatment

Victoria Pavlova

With any of the cardinal methods of reshaping the system, we will be left without public health care at all. So what can be done to bring our medicine to a qualitatively new level?

A lot of things, because at the state level now there is a movement in the opposite direction - away from that very competition. The health care system is again concentrated in the hands of budgetary institutions. Private traders are now completely disconnected from the compulsory medical insurance system, says Ali Mudunov, head of the department of head and neck tumors at the Lapino-2 CG:

- They began to exclude private players from the system, in particular, if we are talking about oncology. I am talking now about small and medium-sized clinics - large ones still participate in the system, although there are already delays in payment. But the crux of the matter is that the fund has begun to cut off small and medium-sized clinics from payments for KSG (clinical and statistical groups), from payments for compulsory medical insurance. In general, they began to disconnect from the system.

Dead end? However, in the opinion of Aleksey Serebryany, board member of the Association of Private Clinics, there is a way out, and it is too early to put an end to the development of competition:

- For the development of competition, a simple way is needed - to allow a patient with a compulsory medical insurance policy to choose the medical organization where he wants to be treated on his own. And the second is to allow co-financing. This means that if, according to the compulsory medical insurance policy, treatment costs 100 rubles, and in a private clinic it costs, say, 110 or 120, then the patient should have the right to pay these 10 rubles to the private clinic, and the private clinic should have the right to accept them. At the same time, it is necessary to leave in state medical institutions the conditions for treating a patient under the compulsory medical insurance policy without charging any additional money, free of charge. Then we will have competition, then patients with a compulsory medical insurance policy will go to be treated where they see fit, and state medical institutions will indeed then compete for the patient.

Taking into account the fact that 35% of all health care costs in a country with “free” medicine are paid by people themselves, additional medical care at their own expense will not be a novelty. Maybe it will also save money. The state is not very generous with medicine. This is also noted by the first vice-rector of the Higher School of Health Organization and Management Nikolay Prokhorenko.

- The main thing is how much money is allocated for health care from all sources. We see that we have total spending on health care - both public and private - about 5% of GDP. State-owned - about 3%, and this is very small compared to other countries. Even if we do not take the USA, where these costs are 18-19%, then the young members of the European Union such as Poland, Hungary, Slovakia spend 6-7% of GDP on health care. We are exactly 2 times underfunded at the expense of the state. But on the other hand, we have 2, 3 or more times more spending from our pockets.

There is not enough money for everything, but the country is big. In addition to large cities, almost every region has remote villages, practically cut off from civilization. There is immense Siberia with Yakutia, the sparsely populated Far East. And everywhere people need to be provided with medical assistance. If you set an economically justified tariff in such areas, then no one will go to the doctor - plantain with activated carbon will also come off.

- Participants in the healthcare system of large cities like to talk about competition, but for some reason no one wants to talk about competition in Yamal, Chukotka, in villages where you can't lure a doctor with a roll. Therefore, we must understand where the zones of this possible competition are. The zone is possible only in large settlements, which more than overlap the need for medical care in high-margin areas, says Prokhorenko.

Experts propose to solve the problem by eliminating the multichannel financing system - all money should go through the MHI Fund. “ Perhaps the estimated funding that goes to state polyclinics and hospitals should be shifted, it should be passed through the CHI tariffs and the CHI tariffs should be adjusted so that they would meet at least some kind of economy. We need to put everyone in the same conditions - both private and public clinics. At the very least, allow private clinics, if they have earned money by serving clients under compulsory medical insurance, to spend this money as they see fit, ”explains Alexei Serebryany .

But then a problem arises with medical insurance organizations, which distribute MHIF funds directly to medical institutions. They also have an important function - protecting the interests of patients and monitoring the quality of services provided. Only often it is implemented in a rather specific way: everything results in multiple fines to doctors for formal violations of filling out a pile of papers. Private traders are unlikely to want to work on such conditions. According to Aleksey Serebryany, you shouldn't stand on ceremony with the CMO for a long time:

- I adhere to the radical point of view that under the existing system, medical insurance organizations are not needed at all in the CHI - they simply take money from the CHI fund, after that they are kept for some time, and then they are transferred in a smaller amount to medical organizations. Their role - the redistribution of this money, payment of bills - from my point of view, it is not needed, this may well be done by the CHI fund with the help of modern payment technologies, and in fact all this is not necessary - a lot of money is spent on service, and in my understanding , the protection of patients by medical insurance organizations does not occur.

It turns out that there are ways to increase competition, and their implementation is quite realistic. So why, then, are they still not implemented? Here, expert opinions are divided. Nikolay Prokhorenko emphasizes that when choosing the European path of development with competing private clinics, in order to maintain the quality of medicine, it will be necessary to introduce a corresponding very strict regulation of tariffs and standards of services. And you should not forget about remote regions, where private traders will never go. But in the opinion of Alexei Serebryany, the main problem is a conflict of interest.

- To increase competition, of course, it is necessary to change the law on compulsory medical insurance and remove the distribution of funds by territorial commissions, and so on. But none of the officials goes to this, because the Ministry of Health of the region is responsible for state hospitals and polyclinics. And how will they let a competitor into this clearing? They don't want to do this. If we look at this situation from the point of view of the results, we will see that the state simply has a conflict of interests. The state is a large owner and, in fact, a monopolist in the market of medical services, plus it acts as a customer for treatment under compulsory medical insurance policies, plus it regulates the industry, and it is also a legislator. It is necessary to separate all this so that there is no conflict of interest.

As always, the personal interests of officials and unwillingness to change something are at the forefront. After all, if the relevant minister agrees on the initiative and promotes its passage in parliament (and the State Duma, as we know, adopts laws literally blindly, if they come from the government), then he will have to be responsible for the results of the reform. And unnecessary responsibility can negatively affect his career: the more burden he takes on himself, the higher the likelihood of making mistakes and failing the task.

In general, until there are people who are ready to take responsibility for the decisions made, then you will have to choose - either go to a state clinic, hustle in queues and get an unpredictable result, or go to a private clinic and get an unpredictable bill.