INFORMATION ON THE KHABAROVSK/RUSSIAN HEALTH CARE INSURANCE SYSTEM

The information was collected by the Khabarovsk Compulsory Medical Insurance Fund staff during the visit of the compiler of this report [Thomas w. Samuel] August 31 to September 13, 1996. The information has been translated both in Khabarovsk and Lexington, KY by individuals with some knowledge of the Compulsory Medical Insurance Fund. The source documents are in Russian and are technical, as a result of this the author cautions the use of this material without verification consultations with the Khabarovsk Compulsory Medical Insurance Fund. I do ,however, state that the data is presented in good faith and is reasonably accurate and usable as a beginning understanding of the Russian health care system.]

1. How many covered lives in the Khabarovsk Krai?

The number of the population of the Russian Federation insured (millions of people) by the Compulsory Medical Insurance Funds: ***

*** There are approximately 56 million Russians with medical coverage paid directly by the military, police, fire, prisons. This coverage is financed under the authority of their own ministry.

Financing ratio of the Regional Compulsory Medical Insurance programs by medical institutions providing insurance and Regional funds [Russia total]:

** These "private insurance companies or agents" "sell" basic coverage under the Compulsory Medical Insurance Funds and for private insurance.

2. What is the median premium?

## The conversion rate is approximately 5,500 rubles/ $1 [dollar]

The structure of earnings and cash flows [revenue] of the Regional/Territorial Compulsory Medical Insurance Funds -- % contribution [Russia total]:

The structure of expenditures of the Regional/Territorial Compulsory Medical Insurance Funds -- % expenditures [Russia total]:

3. What is the actual MLR (Medical Loss Ratio, a % of premiums spent on actual health care cost)?

Best information is for all of Russia and is based on a chat headed: "Percentage of expenditures of financing territorial programs of Compulsory Medical Insurance -- Amount of expenditures allocated to health care in the Regions".

Percent of Regional/Territorial Compulsory Medical Insurance Funds not distributed during the period [Russia total]:

4. How many days in the hospital does the Krai average per 1,000 population?

5. How many primary care physicians in the Krai? (Family Medicine, Internal Medicine or General Practitioners)

No answer.

6. How many specialist physicians? Please, provide a breakdown by speciality.

No answer.

7. What is the geographic area covered?

Khabarovsk Krai - The area is 788.6 sq km and is 4.5 % of Russia's total territory. It is 1,800 Kilometers from North to South and 750 from East to West. The number of inhabitants per sq km ranges from 16 people/ sq km in Khabarovsk City to 0.03/ sq km in more remote regions. The population of Khabarovsk City is 620,000, Komsomolsk-on-Amur is 300,000, there are 5 other cities of 20,000 plus. The total population of the Krai is 1.6 million. The average age of the population is 31.2 years and 14% of the population is over 60 years of age.

8. How many hospitals and hospital beds in the Krai?

1993-136 hospitals

1994-136 hospitals

1995-131 hospitals

9. What, if any, outpatient facilities are operated in the Krai?

Medical ambulatory, polyclinics, female consulting centers, dispenser, medical attendant-obstetrics post.

10. What is the demographic breakdown by age and gender of covered lives in the Krai?

Compulsory Medical Insurance Fund:

Working and age classification:

Sex classification:

Number of insurance companies having a license to provide medical insurance. [I believe this includes agent licensed to sell private insurance.] 13 companies

11. From whom, how much, and how often do you get your medical supplies?

Each facility has its own authority , standard policy as to required supplies up to a given amount of rubles. After that amount is reached then added authority is required. The Khabarovsh Krai is in the process of establishing a group purchasing contract.

12. From whom, how much and how often do you get your pharmaceuticals?

See #11.

13. How are primary care physicians paid?

See answer after #14.

14. How are specialty care physicians paid?

Payment to the medical personnel of the medical-preventive facilities is conducted according to the tariff of the United tariff net and granting the qualification committee the rank of payment matching the category and occupied position.

Payment of physician-specialists of the surgical profile is one rank higher than physicians of other profiles. Head physicians of the emergency (ambulance) response and mountain rescue parts is one rank higher than physician-specialists of surgical profile.

For new physicians (physician-patron) payment is two ranks lower than a physician-specialist seeing ambulatory patients, and is getting one rank higher when the new physician moves to the physician-intern]. The range of physician-specialist levels depends on granted qualification category. The higher the category, the higher payment of his work.

15. Are there any economic incentives for either primary care or speciality physicians? If yes, please describe them.

If provide more services, then the physician will be paid more.

There are three categories to determine compensation:

• A federal standard specifying the number of patients or volume of services by speciality.
• All will be paid standard salary, regardless of the number of patients or volume of services.
• There is a factor called "Labor Contribution" and if contribution is above a set amount then the physician is eligible for a bonus.

Salaries/compensation paid to physicians is a matter of administrative authority of the facility where the physician works and NOT of the Compulsory Medical Insurance Fund.

16. Is supply purchasing cooperative?

See 11 and 12.

17. Draw an organizational chart of a large hospital's staff.

The Structure of a Large Multispeciality Hospital in the Khabarovsk Krai

18. Draw an organization chart of the compulsory medical insurance fund.

19. Draw a flow chart showing how supplies (both material and pharmaceutical) are distributed.

See #'s 11 and 12.

20. Breakdown on a graph the administrative expenses of both the compulsory fund and hospital and clinics by percentage of total administrative budget.

The percent of the [?] spent on "Standard Administrative Costs" by the Regional Compulsory Insurance Funds [Russia total]:

21. What is the average hospital length of stay?

22. What are the admission requirements?

Acute inflectional and noninfectioinal diseases in moderate and severe conditions; aggravation of chronic disease, which need intensive treatment and observation, trauma and poisoning which ask for immediate help, and labor and delivery.

23. What are the discharge requirements?

Movement to the stage of rehabilitation

24. Describe the use of case management as a distinct activity of the health care delivery system.

There is no use of case management as a distinct activity, however see the answer to #'s 25 and 26.

25. Describe the use of home health care as a distinct activity of the health care delivery system.

Currently in the home-health care we lack legislative mechanisms of managing the patient. We can speak only about subjective mechanisms, based only on individual approach of the physician to the patient (the art of deontology).

For the purpose of increasing the level of managing the patient in the home-health care in the health care system as a whole, we need mutual interest of both the physician and the patient in maintaining the health of the latter.

For this purpose, the creation of the institute of family practitioner may help. In the future we need to work out legislation and documents related to the economy, stimulating the public to a healthy way of living.

The home-health system includes :

• hospital at home
• observation of patients at home, both healthy and sick, by the physician and medical personnel at mid level.

In the case of organizing the hospital at home, the patients gets examination, treatment and recommendations by a physician at the home, during the period of time when the patient is not ambulatory.

According to the order of Minzdravmedprom, the following category of people are eligible to receive home treatment:

Newborn children during 1 month after leaving the maternity house.

1. Children up to 3 years of age with acute illness.
2. People with acute illness, who are not ambulatory because of their health condition.
3. People with chronic diseases, not ambulatory because of their health condition.

Physician visits to the patient are:

• Initial visit
• Follow-up visits (active)
• patronage

Initial visits are to acute sick patients on the first call.

Follow-up or active visits to sick people who need to be observed for progression.

Patronage - is a visit made by a physician to see a healthy patient at home ( for example new born children) or sick people with chronic disease out of aggravated stage for a routine examination.

26. Detail the use of physician assistants, nurse midwives, nurse practitioners, and other clinical support staff.

I did not receive specific answers to these question, but I was told that there are 2,000 unemployed physicians in Khabarovsk City.

27. Detail the number and training of each of the disciplines described in # 26.

I did not receive specific answers but did have a meeting at the Far East Medical University which discussed the training of health care professionals:

The budget is set by the Federal Ministry of Health for training most health care professionals. The Regional Minister allocates the funds to train nurses.

The number of admissions to the University is now about 250 individuals rather than the previous number of 650 individuals. [Not clear if this is physicians or all students.]

Physician training requires six (6) years of training. Pharmacist and dentist require 5 years.

Physicians must complete a one (1) year internship and require 140 to 150 additional training to be a specialist in a given area. The training consist of lectures, problem solving and "techniques".

Every five (5) years continuing education is required. The Far East Medical University has special faculty for continuing education.

Approximately 50% of dental students have contracts with the territory and their education expenses are paid by the territory.

Nurse training takes three (3) years and as previously stated is funded by the Regional Minister of Health. There is a standard of 2.5 nurses per physician. [I am not clear if this was for inpatient, as a health systems delivery goal, or a training goal.]

28. What percent of the health care cost does the payment to these professional represent of the total health care system?

No answer.

29. Detail the use of automation - both hardware and software.

I suggest that individuals follow very carefully the discussion surrounding President Yeltsin's heart problems. I particularly suggest articles in the New York Times and Washington Post from September 24.

30. Give a brief description of your goals for the Krai's health care system.

This document will not be translated until September 28, 1996. It is a 20 page document and was completed on September 12, 1996.

31. What are your objectives for the conference?

Goal and objectives

The main purpose of the conference is the discussion of the most important problems of formation and development of a medical insurance in the Far East and Russian Federation and in a number of foreign countries also.

The main objectives of the conference are: Analysis of the first practical steps of implementation of medical mandatory insurance in different subjects of the Russian Federation; discussion of methodical organizational questions and problems, which need to be further learned and developed; experience exchange and discussion of questions of international cooperation in the affair of training personnel and ways of improving the delivery of medical service to the public.

At the conference it is suggested to discuss the following questions:

• the role and the place of the voluntary medical insurance in the system of public health protection;
• reform of health care and mandatory medical insurance;
• management of finance resources in conditions of medical insurance, financial risk and its management;
• assessment to medical assistantship in condition of medical insurance, relationship between a physician and a patient;
• medical-preventive facilities in the system of mandatory medical insurance;
• economical effectiveness of improving the quality of medical-preventive assistantship;
• planning and realization of activities on improving the effectiveness of using medical -preventive facilities' resources;
• standards and expertise in the system of mandatory medical insurance;
• marketing of medical service and strategy of pricing;
• the role of state management agencies in the system of mandatory medical insurance;
• allocation of the work payment fund in medical facilities, working in the system of mandatory medical insurance;
• social non-budget funds as a form of managing the finance resources;
• training of personal for the system of mandatory medical insurance; business undertaking in health care;health care in rural regions;
• foreign insurance companies in Russia and their possible role.

As the result of the conference, there must be the total document, which will define the ways of further development of a mandatory health insurance system, including the list of the most pressing problems and possible ways of solution.

[ Table of Contents | Program | Invitation | Goals | Khabarovsk/Russian Health Care Information | Khabarovsk/KRAI Health Care System Goals | Questions of Participants | Proceedings | Links ]

This site is hosted on the University of Kentucky WWW server.

Many hyper-links follow off campus/site links.

Main URL: http://www.uky.edu/OtherOrgs/khabarovsk/

email: tsamuel@pop.uky.edu