Major Directions of Medical Insurance Development Under Health Care Reform in the Far East of Russia
A.I. Vyalkov - president of the Far East association, MD
Respectful colleagues!
The reform of the health care system in Russia and establishment of health care insurance sharply pointed out numerous problems of the health care system, which need to be understood and solved.
It is not necessary to underline all the complexity of the transition of health care to a market based economic system. Problems of financing medical facilities were aggravated by the growing budget deficit and the increase in price of health care inputs - supplies, equipment and personnel; difficulties with material-technical supply; deterioration of the quality of medical services because of the excessive expense of medical equipment, drugs, and food - these are the conditions, the background which define the economic environment for health care reform in the Far East and all of Russia.
During three years, we in the Far East Medical Association have discussed aspects of health care reform many times, considered the economic, social, political and other conditions of the region, and have calculated the best strategy for joint actions. We have gathered a wide circle of specialist of the region, specialists of other sectors of national economy, and specialist from foreign countries to identify solutions for our problems. Evaluating the results of our cooperation, we have concluded that the Association has passed the examination of time, because by thoughtful examination some of the painful effects of problems associated with health care reform and not solved by the Central Government have been reduced.
The Far East is a special part of Russia, remote from the center; with complex social, economic and climatic conditions; and an economic orientation of extractive and defense industries. With the effort of administrative agencies, institutions of medical care, and the Mandatory Medical Insurance Fund the state guarantee of health care protection to the population has been maintained.
The first steps of health care reform demonstrated the health care system did not need an immediate revolutionary reconstruction, but rather it was in need of a planned evolutionary development, proceeding from the changing conditions which resulted from the introduction of a market economy and other changes taking place in all spheres of social interrelationship.
Major socio-economic indices of the Far East area testify to the deterioration of the quality of life for most of the population. During the period of 1991-1994 the level of real income of the population declined by more than 30% in 1995-1996 these processes intensified and most of the population earned less income than required for a living wage. Comparative expenditures on medical care from 1991 to 1995 declined by more than 50%. The outflow of population from some of the Far East region continues to increase, as it does from the Extreme North regions
With above conditions and disruption of "normal" vacation schedules, growing social stratification of the population of the Far East, less than satisfactory housing and working conditions for many, and general social instability -- all are conditions that produce chronic stress for most of the population and thus reduce the environmental supports necessary for a healthy population.
During the recent past, the "natural decline of the population" [death rate?] in the Far East has increased from 1.9 to 4.8 per 1,000 population. During the last 10 years the birthrate has declined by more than 50%. The life expectancy continues to decline and for men it is approaching 57 years. The number of people first qualified as handicapped has grown from 28.7 per 10,000 in 1985 to 51.6 per 10,000 in 1994. The number of infectious diseases is growing (syphilis, diphtheria, hepatitis B).
During the 1990's more than half of the labor losses among the population in the Far East region was due to mortality from trauma and poisoning and this tend continues today. Losses due to circulatory disease were less than losses due to trauma by almost 2-2.5 times. Third, there are diseases of the prenatal period. These are diseases which caused most infant deaths. Cancer is the fourth leading cause of death, fifth is respiratory diseases, sixth is losses due to congenital abnormalities in development, and seventh is infectious and parasitic diseases. These causes accounted for approximately 95% of losses of working potential of the population in the region.
Health condition of the population in the Far East region must be judged as unsatisfactory. Deterioration of the health status of the population is further supported by the growth of alcoholism and use of drugs and other toxic substances by youth. The socio-economic crisis has been the principal factor which has changed the general health care picture: tuberculosis, venereal diseases, psychic disorders, alcoholism, addiction, murder and suicides have become the health care problems we need to be concerned about first.
Today the efforts of health care personnel in the Far East are directed at stabilizing the health status of the population and attempting to initiate activities that will result in g positive health care outcomes for population during this period of dynamic change. Some positive beginnings already measurable. The declining birthrate has been significantly slowed. Infant mortality measures, except the European autonomous district, are the same as those of Middle Russia. There is also, a stabilization of the indices for mortality and morbidity.
Transition to the market economy brought serious changes to the work of the health care system: in planning, administration, financing, in the organization of medical services to the public all of which required adequate decisions at all levels. In addition, implementing a whole line of conflicting legislative acts, not just in the field of health care, further contributed to the changes in the structure of financing, administration, and organizing the health care system. When the law was enacted for basics local self-management of the health care, a sharp turn was made from a centralized system to a decentralized and fragmental system. The effective and efficient definition of duties and coordination of activities in the prior authoritarian structure failed. Failure to enact appropriate and timely legislation about state, municipal and private health care is aggravating an already stressed situation. A sharply increased differentiation in the quality and quantity of health care services delivered by federal institutions exists even in the a single territory.
With tendencies in the health care delivery system being more clearly defined, we can point out some problems:
Today we see, that there is a need to take the following steps to address the mentioned problems:
In the national economic structure the health care system continues to have a low priority among the major consumers of the budget's financial resources on one side. On the other side, the health care system continues to carry the responsibility of a tremendous number of social functions placed on it in the past. During the last years, the social structure of the society has changed considerably. The system of social security of the population is being reorganized, but there has been no significant change in the structure of the social functions assigned to health care. At the same time financing of these programs continues to be accomplished by methods used in the prior system, such as the residual principle of budgeting for health care.
Major treatment and preventive facilities fall in decay, they are not maintained in working conditions, medical equipment is not renewed. The solution of these problems falls to the health care management and insurance entities. Search for the necessary financial resources for adequate payment to sustain medical services becomes a major topic of discussion at meetings about health care at all levels.
Our systematic analysis of the health care in the Khabarovsk Krai for the last years shows that to increase management effectiveness, we need to concentrate on the searching within the health care system to identify methods for saving resources and institute changes in the structure of the health care delivery system, but attempt to provide for maintaining the quality and security of medical services and keeping the level of social guarantees to the population. It is difficult for the management of the health care system at all levels to realize this objective.
Achievement of acceptable results or outcomes of health care management is possible only with adequate training of personnel in management structures and methods, and with an appropriate readiness to recognize the changed roles of all medical personnel. The solution for training the personnel at all levels of the health care system requires the collective efforts based on a concerted plan between and among: a) the mandatory insurance fund, including their personnel training centers and health care management, b) the medical universities and academies, and c) the academies of economy and law. What is realized in this region due in part to methodical support of: a) the Scientific Manufacturing Association ["Medsoceconominform" (professor U.M.Mikhailova)], b) the program of partnership under the auspices of AUPHA between the University of Kentucky, USA (Thomas Robinson, Joel Lee, Thomas Samuel and others) and the Far East State Medical University, and c) the considerable material and moral support of the Director of the Federal Fund of the Department of Material Provision V.V.Grishin. During the past three years, we have been able to prepare several hundred specialists, in management and issues of health care reform, for the health care system and medical insurance in the Far East region by using the Far East Center of Training Specialists and the Department of Management and Organization of Health Care at the Far East State Medical University.
During the last five years, the Far East region specialists and scientists have accomplished research on questions of pricing of medical services, contractual relationship in health care, information about the process of providing medical services to the population, and licensing and accreditation of medical activities. The work has generated more than 100 publications and have been discussed at four scientific- practical conferences held in Khabarovsk, Vladivostok and Birobidjun. This has assisted in the timely preparation of the necessary methodology for implementing the medical insurance legislation.
Medical insurance in the Far East, as in the whole Russia, has taken its first steps and the importance of those steps are multi-meaningful, reaching beyond simply their direct implications for health care. On one side at the beginning of 90's the governmental budget system began to fail and resources provided for health care began failing to keep pace with the increasing cost of providing health care services. What is the more important, there were no laws, defining the rights of all social groups of the population (refugees, adolescents, women, mothers, children, and older people) to health care services. Even more important were the rights of sick people, including patients of psychiatric clinics and patients with AIDs, venereal diseases, tuberculosis and others. The basic principles of the rights of these individuals were considered for the first time during the discussion of legislation about the health protection of the citizens of the Russian Federation. Unfortunately, the law about medical insurance for the citizens of Russian Federation was passed prior to the legislation about the health protection of the citizens in the Russian Federation. The result was problems at the point of implementation of the medical insurance legislation.
The medical insurance problems for the Far East region are primarily focused in: a) the weak economic condition of the enterprises, facilities and individuals; b) a large deficit in the territory budget; c) difference in basic programs of the Department of Material Provision (DMP) in the regions of the territory , which caused sharp difficulties in the inter-payment between Territorial Funds of the DMP and some others. (This is typical for the whole Russia.)
In our opinion, the geographical, economic, social situation of the Far East Federal institutions differ considerably from others in the Russian Federation.
Nevertheless, medical insurance today won its own positions, established stable structures both for the Mandatory Medical Insurance Fund and medical insurance organizations. The majority of the population of the region has medical insurance polices, all territories work according to the DMP program, the inter-territorial inter-payment has been started. The investment of funds grew significantly in the DMP territorial funds general accounts for health care. In Khabarovsk Krai, for example, in 1995 the DMP constituted 43% of all resources available to the health care system. Several steps have been taken increase the payment made by the territorial administration for the unemployed population, which enables us to maintain some optimism. Mechanisms of examining the quality of medical services to each particular insured person are being developed, considerably increasing the level of quality and effectiveness of medical service to the population. In addition, the methods for filing malpractice claims and pre-court trial procedures of such claim made against Treatment Preventive Institution are being developed.
With the implementation of the Law " about medical insurance of the citizens of the Russian Federation" the psychology of many managers of medical facilities, physicians, and middle medical personnel began to change. The physician becomes a central figure of the process of accomplishing the function of medical institutions.
Implementation of the Law " about medical insurance of the citizens of Russian Federation" for specialized regional medical centers turned out to be a particularly complicated situation. The flow of patients there visibly reduced, there are objective reasons for this, and at the same time a problem occurred with financing the treatment of individuals from other territories of the region, since most of them are financed by the territorial DMP budget and means, but these specialized regional centers are not directly a part of the DMP budget. It is our opinion, under existing conditions, the specialized regional medical centers should accept the target program at the federal level to support their functions, since this should stabilize their financial position and thus their functions within the larger health care system.
A rather mixed picture is drawn of the amount of financial resources for health care in the territory from 1995 data. (See the table - not included this presentation) Observing the formation of financial provision on the Far East territory, it should be pointed out that the situation is even enough in the most populated regions, but in each territory the structure of financial provision is different, in some places the budget support is dominant, and the part of DMP support is low; in other places it is vise a versa. In this regard an exchange of experience is needed within the framework of the Far East association, because in each territory there are some developed directions that are better than in their neighbors'.
Nevertheless, today it is possible to say that in the Far East a search continues for a new economic mechanism, based on the principles of self-financing, self-regulating, and intra-system self-control of cost in health care.
In Khabarovsk Krai the legislative base of medical insurance continues improving with the active participation of the krai administration and Duma. Just in 1996 such krai laws as "About Krai DMP Fund", "About the budget of the DMP fund for 1996" were enacted. It was the first time when the payments for the unemployed population was legislatively fixed and the financial DMP program of the Krai was financially approved. They continue working on accepting the DMP fund budget for 1997, simultaneouslyaccepting the krai and local budgets.
The process of formation of the Far East insurance market started more than 6 years ago, when alternative insurance companies appeared as part of a powerful state insurance system. Currently in the territory of Khabarovsk Krai, Amur, Magadan, Chita districts, Chucotsk autonomous okrug (district) there are 53 insurance medical organizations, 16 provide voluntary medical insurance and 10 provide mandatory medical insurance. Most of the insurance companies are small and middle size for Russia and they have a charter capital of around 200 mln rubles and private means of around 400 mln rubles.
Currently voluntary medical insurance agents work: a) in Khabarovsk Krai -10 companies, b) in Amur district - 3 companies, c) in Chita district - 3 companies. In Khabarovsk by January of 1996 there were 2900 active contracts of voluntary medical insurance, they insured 29 thousand people. The volume of voluntary medical insurance is not big, but the growth is noticeable in 1996. Certainly, insurance companies involvement in mandatory insurance so far occupies a modest position in the region, but nevertheless last years insurance companies had a positive experience.
The formation of the medical insurance in the region continues. The DMP funds reinforced their positions as financial-credit institutions, but they obviously cannot manage the role of medical insurance organizations where their function is delegated to the DMP fund branches. First of all - this is a provision of medical service to an insured population in a guaranteed volume and quality. If the problem of medical services volumes guaranteed by the basic DMP is forcefully focused on and controlled by insurance agencies, then the issue of quality is reduced in importance due to time and resource limitations, despite significant expertise in quality by the insurance agencies.
Protection of the right of the consumers/patient to get medical services according to the DMP program is on the consumer/patient. The territorial fund is to pay for a provided service only if the service provided meets a specified level or standard of quality. Unfortunately, practice shows that the consumer/patient pays for medical service when quality standards are not met. Today the insured citizen has been put into the center of the interrelationship scheme between insurance agent, insured person and the medical institution. He is now at the periphery of the relationship system of DMP institutions. The situation is that society still has not comprehended the concept of medical insurance and considers it as somebody else's business - medical personnel's, the state's, etc., but not their own. Many people don't like the current model of mandatory medical insurance. The challenge is to devise a new one, a more modern one, satisfying the majority. As medical personnel, our job is to meet society's needs according to the requirements of a contemporary society for its health care needs.
In regard to the relationship with medical personnel, a difficult task is ahead of us to prepare collectives in treatment -preventive institutions to work on a contract basis in the framework of the DMP. In the formation of the relationship between insurance and medical workers, there will be some problems in the near future with the implementation of mechanism for limiting the seemingly endless growth of expenses at the treatment-preventative institutions and the introduction of resource saving mechanisms.
Reforms of the health care system does not leave consumers/patients or producers/providers uninvolved, in the changing conditions, they have to reevaluate their functions and objectives. With this background, there is a pressing need for changing all forms of activities of health care organizations and institutions according to the requirements of the market economy. It is difficult to identify the kind of organization-management problems facing the health care system. Even foreign specialists experienced in management under market conditions cannot offer a single solution. This requires us to use our own and foreign experience in evolutionary solutions to existing situation.
According to the opinion of many health care leaders, all reforms look naive and useless until the system has sufficient resources to meet the existing needs:
a) increase the portion of health care in the budget of the territory by 4-8 %, b) increase the DMP assignment from 3.6 to 6%, c) steadily increase of receipt from the voluntary medical insurance, and d) increase the payments made by the population for the "direct" charged medical services. There is logic in such reasoning, but if we really look at the existing situation, then we are dealing with the following questions:
There are more questions and the most important of them is why the society and medical personnel don't like the current system of health care in Russia and how do we need to reform it?
At first glance the question seems simple from the position of the average man. It needs to be done this way: a) the patient should be seen by a physician without a line, b) the patient should be seen free of charge, c) the patient should not be required to bring medicine and food with him to the hospital, and d) the patient would be treated politely by the medical personnel.
About 10 years ago, the government also defined the problem this way and did accomplished a series of measures in this direction. With the purpose of increasing access: a) we increased a number of beds up to 140-150 per 10,000 of the population, b) increased the power of policlinics up to 200 visits a shift per 10,000 of the population, c) increased the number of physicians up to 55 per 10,000 of the population. But nothing positive came out of it. Up to 40% of beds were not used, people were forced to come and see a doctor, and it didn't add any politeness to the manner of the medical personnel. The solution was not found.
At the end of the 80's experiments, new economic mechanisms began affecting medical personnel. Couldn't medical personnel be paid not for the time they spent at work, but for the particular work and the quality of the work accomplished. More specifically, legislation was passed which allowed salary not spent for vacant positions to be used for the salary of existing according to their participation in the health care organization (coefficient of participation in work). With the increased volumes of activity everything turned out to be just "excellent", especially in the hospital, where all patients were sent, but up to 40-50 % were not in need of inpatient care. Beds started were fully utilized, despite up to 60 % of them being located in substandard buildings without the elementary conditions necessary for providing real hospital care. The wage of all medical personnel went up.
Some of the generals of health care were in a hurry to announce: "Here is a reform. We'll add the means of medical insurance, reinforce the lever of economic influence on medical personnel (or institutions) through standards of quality. Through constant expertise enforcing quality and with economic sanctions, reform will be accomplished." But it didn't happen, it was thwarted.
Because of the economic crisis there suddenly wasn't enough resources to maintain the existing hospitals and polyclinics, even with the involvement of insurance fees from compulsory medical insurance. What is the solution? What else can be done?
Two years ago ideas appeared about a new concept of health care development in Russia, the basis of which was the same expense mechanism of functioning medical institutions. Due to the efforts of the current administration in the Ministry of Health Care DMP of Russia this concept is being reevaluated. Our research of the last two years tells of our unhappiness with medical care. It is not only because of lack of financial and other resources, but the effective usage of those resources. We discovered they are not used as effectively and efficiently as possible. According to these studies we have spent up to 7% of the resources of policlinics for test results which were never requested by doctors. More and more resources were held in hospitals for unnecessary and uncontrolled therapy and repeated expensive examinations. Even after increasing the wages, we managed to pay the specialists within a given category more without considering the difference in the results of their work compared to physicians and the nurses within the category or those without the category.
All this makes us say that the basic health care system changes to provide a functioning medical services system is based on a "physician-patient system". In such a system the doctor, along with the high knowledge of the clinic, has to be able to manage the process of choosing an optimal decision from many standard and nonstandard situations, in order to achieve a positive treatment outcome within a short period of time. It's clear that to further change the process, we must change the existing structure and the system of management of the medical institutions.
Using this doctrine, looking first at two years ago we came to the conclusion, that the restructuring of the process was possible only by establishing standards and by providing "secure" medical care. From that point the cost of providing "secure" health care can be calculated. The first two questions - how many resources do we need to provide such "secure" health care and what kind of care is it possible to provide for the resources provided by society. This process permits establishing a more or less realist federal program budget and, on the basis of the federal program, a regional program for providing medical care to the population can be established. With this, the kinds of care provided to the population can be documented, at a stated level of insurance fees and a given level of budgeted funds. Also, the level of payment the consumer/patient can expect to pay for directly from personal funds out of his own pocket can be estimated.
We are convinced that this kind of program worked out by the universal method first of all will eliminate the questions of equalizing resource between and among the territories, will raise the responsibility of local legislative and executive organizations for health care and will enable active involvement of the population in maintaining and managing their own health.
Just from these positions with the participation of scientists, practitioners of health care, and economists, we managed in Khabarovsk Krai to form the main directions of the health care development for the period until 2005. According to these directions the purpose of health care reforming in the Krai is reduction of morbidity and mortality of the population by conducting a complex of measures for the protection of health of the population, increasing the quality and effectiveness of medical services, which means first of all stopping the increase of preventable losses of health, then, on the background of a stabilized socio-economic situations in the Krai to achieve stabilization and improvement of health indices in the future. [See this plan elsewhere on this web page.]
A list of objectives is formed on the basis of priority ratings in gradual realization of the "Main directions of health care development". The considerable increase in the indices of medical prevention was chosen as the main objective. It can be accepted by the majority as preferable based on the high return for a small expenditure and given the significant financial and other resources deficit currently present in the Krai. But while analyzing the health care system, the following was revealed:
In such a situation despite the significant reduction in the bed network in the Krai in recent years, 25% of the bed fund is left unused or occupied by the patients having an ambulatory profile.
Hence, even in an under funded health care system there are resources available for stabilizing and developing preventive activity by:
According to the rating the next objective is: "To provide accessible quality and secure medical care for the population" on the basis of the minimum social standard approved at the federal level. The decision of this objection is concentrated first of all on reorganization of the family practice program, on expanding the home health care, day care hospitalization, centers of ambulatory surgery, continuing reorganization of the system of ambulance and emergency medical care, reorganization of hospital medical care. Providing access to medical care is a complex objective for the health care system and for the system of mandatory medical insurance. Unfortunately, we must admit that for the last 1 - 2 years access to some kinds of medical services declined (dentistry, rehabilitation, some kinds of surgical aid and others) not only because of lack of means but because of formation of "black" market of charged medical services. No one wants to acknowledge the existence of the "black" market in health care services, but research and study of this new phenomena for the Far East region is necessary.
The objective is: Improving of management along with the
complex of objectives in planning, financing, innovation and
personnel policy. Improvement in management is not simply a way
for professional personnel to get the leading positions; not
simply a way for elimination structural problems in the system,
not simply for improvement in planning and standardizing the
treatment outcomes of the system, but a method of providing
incentives for managing the processes of quality and of
effectiveness of the medical institutions. Workers of all levels
should be involved in the process of making decisions and
discussing the activities of the organization. It is necessary to
provide a real opportunity to all workers to have a role in the
results of the collective work. As we can see from a world
practice and experience of our colleagues in USA (University of
Kentucky Medical Center) active participation of the personnel in
the process of making decisions increases the personal
responsibility of the individual, thus establishing a creative
attitude towards work which ultimately leads to significant
quality and effectiveness of medical care provided to the
population. In other words each member of the collective of the
medical institution should have a guaranteed level of incentives
for the results of their work, based on their occupation and the
full realization of their potential contribution to the health
care outcomes of the patients.
Respectful colleagues!
There are some conclusions and situations on conducting the
reform in the Far East and in Russia stated in my presentation
that may a quarrelsome character. But health conditions of the
Far Easterners today is such it makes us do more active searching
for decision, enabling our health care not only to survive in
such difficult economic conditions, but also to gradually
improve. Thank you for your attention!