Five doctors told Novye Izvestia about how they are forced to falsify medical records.
Since March 2017, Moscow has seriously taken up the optimization of psychiatric medical facilities. After re-profiling, out of 17 psychiatric hospitals, there were actually 3 left in the entire capital (some were closed, others were merged, and others were reorganized into psycho-neurological boarding schools).
In the same period, the Psychoneurological Dispensary No. 19 (PND No. 19) was removed from the Psychiatric Clinical Hospital No. 15 and joined to the Psychiatric Clinical Hospital No. 4 named after Gannushkin (PCB No. 4). After four months of work under the wing of the new management, the employee remuneration system has undergone significant changes.
Before the reorganization, the load norm for a psychiatrist was calculated based on the population density in the area: one rate = 25,000 adults. For expanding the service area, doctors received allowances, which were indicated in the payroll documents as an increase in the amount of work. Since the spring of 2018, these allowances have been canceled by the hospital management, instead, a line about the so-called incentive payments . To receive them, every month the doctor had to fulfill the plan approved by the administration of the medical institution. In the documents issued by PKB # 4, this plan is referred to as a state order. For its implementation, the management receives bonuses, and the higher the indicator, the more funds are allocated to the hospital from the state budget.
Documented new standards were approved by order No. 208 dated 04/30/18 signed by the head physician of the PKB No. 4 Larisa Burygina. It follows from it that the psychiatrist of the dispensary must take 28 patients per shift.
Quantitative requirements for admission of patients by district psychiatrists were also confirmed in official reports on the fulfillment of the state task (2017), records of medical visits (2017), response of the Preobrazhenskaya interdistrict prosecutor's office of the Eastern Administrative District of Moscow (2018) Copies of documents are available at the disposal of Novye Izvestia.
According to doctors and representatives of the interregional trade union of medical workers "Action", the requirement of 28 patients per shift is absolutely unrealistic if you work conscientiously, in accordance with federal regulations and do not engage in falsifications. Even UMIAS - the unified electronic system operating in Moscow health care institutions allows making appointments with only 22 patients per shift. "It is not surprising that the result of the pursuit of shock indicators was the postscript on the number of admitted patients," the doctors comment.
- A budgetary healthcare institution (hospital) is obliged to fulfill the plan entrusted by the state, that is, the state order. If the institution does not fulfill the plan, then the head, who is also the head physician, is obliged to report to the manager of budgetary limits, specifically to the Department of Healthcare about the reasons for these shortcomings and return the unspent funds to the state. Next year, the budget allocation limit for this medical institution will be reduced (and the Moscow budget, accordingly, will be saved). The heads of medical institutions, however, prefer to act according to a different scheme: they hide from the founder - the Department of Healthcare the real situation with the number of patients who need help, imitate the fulfillment of the state assignment by adding non-existent patients, knock out budget money and receive bonuses for the effective fulfillment of the state assignment. The department, however, may be happy with such a situation: thanks to the shock indicators, the President's decrees are being implemented, and the salaries of doctors on paper “grow” - lawyers defending the “disgraced” doctors explain to NI .
At the same time, there is one interesting detail in the scheme with the distribution of budget money for Moscow psychiatry. The state assignment (state plan) is formed not by officials at all, but by the medical institutions themselves. From the Order of the Department of Health on the formation of a state assignment, it follows that the specific requirements for the number of patients for admission are set by the medical institution itself, the Department of Health only rewrites the data received from hospitals and, based on them, requests funding from the treasury, the lawyer adds.
"I learned about the appearance of the scheme in April 2018, when I returned from vacation. In the electronic records that the substitute doctor kept in my absence, I found that patients who used to come to see me once a month, or even less often, began to come almost every week. I asked one of these patients at the reception, they say, what happened to you, why did they start to apply so often? The patient replied that while I was on vacation, he did not contact anyone and that for the first time he hears the name of the doctor who made an entry in his medical record. Naturally, I reflected these data", - says doctor Mikhail Pervushin.
Later, the psychiatrist identified about two dozen such strange patients only in his area and appeared only in 3 weeks of his absence. After his report to his superiors about the alleged falsifications, the incriminating notes were cleared up in the electronic system by someone, however, Pervushin managed to print out part of the patient cards who went to dubious appointments in paper.
"The number of postscripts, apparently, has reached a certain critical limit, since absolutely monstrous overlaps began to appear. Patients, for example, were simultaneously in a hospital in the Moscow region and visited a doctor in Moscow. One of the cards contained a record: patient Zh*** came to the appointment, was dressed for the weather, had an even mood, and talked to the doctor. But at that time she was in a hospital in Khotkovo near Moscow, from which she received a request to PND No. 19. With all the desire to split, she could not", - the doctors say.
The psychiatrist's suspicions of deliberate falsifications only strengthened when, in the reports of his colleagues, he saw a sharply jumped indicator for admissions, namely: 30-60 people a day, while in reality no more than 10 patients come to the doctor per shift. “You go into a dispensary and see empty corridors, but on paper there are full houses, Stakhanov's 150%”, - the doctors say.
Mikhail Pervushin submitted a memo addressed to the head of the dispensary dated December 10, 1919, to which he attached copies of pages from the medical records of specific patients with records of invented appointments (the patients themselves confirm that they did not visit the substitute doctor). Tatiana Skriganova, head of the dispensary department No. 2 of PND No. 19, in turn brought this information to the management of PKB No. 4. In three statements addressed to the hospital's management, she, in addition, detailed the facts of financial violations in the entire dispensary known to her, suggesting that they could fall under the signs of a crime under Article 292 of the Criminal Code of the Russian Federation (official forgery).
- I have been working in the dispensary since April 2007, until 2013 I was the head physician of the dispensary, then the head of the dispensary department. In the past two years, I have constantly noticed financial violations in the IPA No. 19. As a leader, I saw that patients' medical records were massively recorded about fictitious appointments. Even in the children's wards, they did not disdain superscripts, although parents can certainly restore when and how many times they asked for help, and their words, unlike adult patients with psychiatric diagnoses, are more difficult to question. District doctors in this way tried to earn incentive payments, the volume of which can reach up to 40% of the total share of salaries. The very same medical institution in this way artificially fixes high indicators for the implementation of the state plan, on which the management premiums and, in general, receive annual tranches for the entire hospital depend. Many patients - a lot of budget money. From March 2017, in this way, an already impressive amount drawn can be recruited. I believe that in all nine dispensaries belonging to the structure of PKB No. 4, similar crimes occur. As a result of the so-called Moscow psychiatric reform, psychiatrists simply "drowned" in lawlessness", - told Novye Izvestia Tatiana Striganova.
The hospital management then wrote to the subordinate briefly: there is no forgery, all the patients you listed on the dates you specified were examined by a doctor. But how can you examine patients who did not come? - the doctor is perplexed. Instead of checking the signals of fraud, the leadership began to check Pervushin and Striganova themselves, they were charged with allegedly improper performance of their official duties and were hung with a bunch of disciplinarians.
When Mikhail Vasilyevich received his first salary after the vacation, he did not see an additional payment for expansion on the payroll, which is 35% of his salary. Then he turned to the management and asked to explain in writing the reason for the sharp decline in wages. Chief physician Larisa Burygina and her deputy for economic issues Alexander Music answered the employee that the psychiatrist, in their opinion, was not working at full capacity, and in April 2018, for example, he completed all 25.6% of the planned indicators - 255 patient visits instead of the prescribed 997!
The "ordered 997 appointments" per month, however, made the eyes of not only those who disagree. At first, doctors with genuine interest tried to find out from their superiors where to get so many psychiatric patients, when in reality there are 2-5 times less of them, depending on the area.
In addition, there are nuances of working with this category of patients - it is not so easy to fix even real people. “People don't go to psychiatry as much as, say, to therapists or surgeons. The difficulty is that the very nature of the disease suggests that patients do not consider themselves as such. Moreover, not all psychiatric care is compulsory, which means that it can be provided, like all other types of medical care, only with a voluntary written consent to medical intervention. Obtaining this consent even from those who have come to a psychiatrist is a separate long story, because not everyone is in a hurry to get into interesting lists”, - the doctors explain.
So how do you get the number of souls assigned by the state assignment? Instructions were given at general meetings, conferences within the walls of medical institutions subordinate to PKB No. 4. The doctors interviewed by "NI" recall the names of the ideological inspirers who suggested the way out: "Nikitin", "Shagarova", "Portnyagin", "Stepanova".
There were many inventions in this regard.
- Most often, it was proposed to take a patient who really was at the reception relatively recently (so as certainly not to get dead), and then unrestrainedly multiply him. Once he came for real, and later he allegedly walks to control the prescribed treatment. And now uninformative records appear on his card almost every week: he came with questions about the prescribed drugs, came the second time - he said that he had bought the drug at the pharmacy, came to the third - and reported that he had started taking it. In fact, of course, there were no return visits. In response to my remarks that this is a criminal offense, they simply made me understand that I was an undesirable element, instead of stimulating ones, I would receive disciplinary penalties, and then I would be fired, ”says Mikhail Pervushin.
- Another scheme is registration through a registration form. A patient is taken who takes, for example, azaleptin. The appointment of this potent drug is possible only with the permission of the medical commission: at least three people must sign in the register of the statement: the attending physician, the head of the dispensary department and the head of the branch. Thus, the patient comes for a prescription for azaleptin, does not go to any doctor, but according to the documents, a whole medical commission passes and seems to have visited all three doctors, '' says Tatyana Skriganova.
- It got to the point of ridiculousness - we have a person both lay in the hospital and went to outpatient appointments. We, as employees of the dispensary, provide outpatient care to patients. A person appears in the day hospital, the bosses tell us - go there, meet the patient, write him down as if he were at your examination, statistics take this into account, of course, as an outpatient examination. But a person cannot be simultaneously treated in a day hospital and in an outpatient clinic, this is absurd, mutually exclusive things, but thanks to such records, one patient gives a double load, double allocation of funds. We are talking about thousands of such postscripts, - the psychiatrist PND №19 is sure Alexey Fedotov. - There was also such a method: a psychiatrist sits on certificates in a paid department (talking about medical reports for work, real estate transactions, driver's licenses). The next day, the doctor goes to the budget department and rewrites all those who applied for paid certificates to a free appointment.
The exit of the scheme and beyond the limits of PKB No. 4 is confirmed by a former employee of the Psychoneurological Dispensary No. 18, located in the structure of the Psychiatric Clinical Hospital No. 1 Moscow (wished to remain confidential):
- I had to manage 4 sections per one bet. No time to go to the sick? They said - just call, ask: "Alive and healthy?" - And you're done! - This is supposedly called the control of therapy, it is entered into the medical record as a separate appointment. The patient's relatives came, you talked to him - also write that you had an appointment. Recommendations for recruiting the required number of patients were issued at general meetings by the heads of dispensaries, the deputy chief physician Mashoshin. Our salaries directly depended on these indicators, - said the psychiatrist.
The specialist was dismissed after refusing to serve 4 sites at one rate and deal with postscripts for receiving patients.
- The plans for the visits were unrealistic, everyone understood that one could not do without postscripts. Many different "tricks" have been suggested. Every call to the patient was recorded in the visit, any mention in vain of his outpatient card. Our patients regularly receive inquiries from the investigating authorities conducting inquiries, investigations, and courts. These certificates, extracts are prepared by the district doctor, so any mention of the patient's outpatient card in this regard was also entered into the card as a separate appointment. When this was not enough, the doctors simply took the medical cards from the shelves and entered an absolute lime tree there - they allegedly visited the patient at home or a relative of the patient came to the appointment with any question. In my dispensary, almost all doctors were engaged in this, and, as I know from colleagues, almost all dispensaries subordinated to Hospital 4 were engaged in falsifications, '' says the former head physician of the budgetary Psychoneurological dispensary in Moscow (asked not to disclose his name). He was fired after complaining about what was happening Chief Psychiatrist of the Moscow Department of Health Georgy Kostyuk.
- The worst is that this so-called optimization of psychiatry, all these state plans, which must be achieved at any cost, do not in any way affect the quality of medical care provided to the population, if not to say that they only harm patients. The words of one of our employees have already become an anecdote: "Oh, I just sat down to write a plan, and then the patients came!" Doctors do not have time to collect the required indicators on working days, come to work on Saturdays to get on the phone and give these numbers for fake appointments - tell me, but how can you even record appointments on a non-working day, on a weekend? All these falsifications are so overt that they are scary for colleagues, - says the doctor. Alexey Fedotov. - Medical records of patients turn into something incomprehensible. Because of the notes, the real picture of the treatment and condition of patients is distorted. It is not clear to what extent assistance was provided, when, it is not clear which techniques are real, which are fictional. You look at the map - the patient came three times, which means he is worse off. You ask him himself - the last time was a year ago.
Why did the doctors go and continue to go for forgery, even realizing that this is a criminal offense? Doctors who interviewed NI have a similar answer to this question.
Some paramedics believed that an order from the top management of the hospital could not be criminal. Many employees are enslaved by mortgages and other monthly obligations and are afraid of being unemployed. And under the monopolization of psychiatry in Moscow (in fact, one employer from the public sector - the Department of Health), being dismissed from a state medical institution under the article is like getting a wolf ticket. After that, most likely, it will not be possible to get a job in another budget hospital. The salaries of psychiatrists in private polyclinics are an order of magnitude lower: the flow of patients is unstable, labor contracts with psychiatrists, as a rule, are not concluded, employees of paid medicine work for a percentage, the doctors explain.
“Doctors, perhaps, understand that they are doing something illegal, but the fear that the employer has stirred up in connection with the need to fulfill the state plan is stronger. The fear of being fired here and now is stronger than some hypothetical criminal punishment”, - says psychiatrist Vadim Kumechko.
In September 2020, the doctors of the neuropsychiatric dispensary No. 19 sent a collective appeal to the Interregional Trade Union of Medical Workers Action. They asked for help to achieve a full-fledged check on the facts, which, from their point of view, violations of financial discipline and labor laws, - said the organizing secretary of the trade union Andrey Konoval.
Almost all psychiatrists who refused to engage in falsification of medical records and began to defend their rights are either fired or demoted, or still retain their place, but are already in the stage of litigation with the employer - they are challenging disciplinary sanctions, salary cuts , reprimands, etc.
Due to the policy of the new leadership of PCB No. 4, a highly qualified psychiatrist, healthcare organizer, candidate of medical sciences, chief physician of PND No. 5 is forced to leave his job Vadim Kumechko. Fired under article psychiatrist Mikhail Pervushin - a specialist with twenty years of experience, highly respected by patients, for the last 11 years he has worked in PND No. 19 - no complaints, no comments. Over the past five months before his dismissal, the administration has issued five disciplinary sanctions to him, including one for using the word "nonsense" in assessing the actions of the authorities (three disciplinary sanctions have already been contested, the doctor is trying to be reinstated in his position through the court).
Head of the dispensary Tatiana Skriganova “Demoted” to a military commissar psychiatrist. The Timiryazevsky Court of Moscow declared this transfer illegal and issued a writ of execution for the immediate restoration of the specialist in his previous position. But by the time the decision was made, the leadership of PCB No. 4 had merged two dispensary departments, and reduced the position of the head of dispensary No. 2, so that, according to the court, the head, reinstated to this position, now performs the functions of a doctor. Yuri Tyunev after three undeserved reprimands, he resigned of his own free will, realizing that he would not be allowed to work quietly anyway. Roman Zhuravlyov under administrative pressure, they were transferred to another division. The psychotherapist quit "of her own free will" Irina Follett. Psychiatrist gave notice Alexey Fedotov, who is currently in three lawsuits with an employer , - are summed up in the trade union.
According to Novye Izvestia, at present, according to signals about postscripts and falsifications in the medical records of patients of neuropsychiatric dispensaries subordinate to 4 PKB im. Gannushkin, the investigating authorities (OBEP and the Investigative Committee of the Russian Federation) initiated a check.