SOME PECULIARITIES FEATURES
OF THE RUSSIAN MEDICAL
CARE INSURANCE

Julia Kachalova

"According to the data of sociological surveys of public health problems held by the All-Russian Center of public opinion investigations, Institute of social technologies, sociological service "Megatek" and some other sociological centers, "every third Moskovite being polled regard the system of the compulsory medical care insurence (CMCI) as one of the usual far-fetched experiments in the field of the public health. The citizens have a very faint idea of the compulsory medical care insurance . Only 22% of them roughly understand what CMCI is, 39% know but a little bit and about 40% of Moskovites have declared that they know nothing about CMCI. For many of them receiving a medical care policy is nothing but a formality, and a half of those being polled told that they don't see any changes in medical service after receiving a policy. What is more some of the Moskovites (5%) are scared by the facts when patients were refused medical care because they had not an insurance policy." (From the book "City, reforms, life. Moscow in figures. 1992-1995").

All of us pay taxes. At least those who work officially. Enterprises withhold from our salaries 3.4% to the City Fund of the Compulsory Medical Insurance and 0.2% to the Federal Medical Insurance. We used to it. But we have not accustomed yet to a rosy paper known as "Insurance polycy" given in your local polyclinic and urgently demanded in every medical institution. Let us investigate this document carefully.
The line above reads: "Moscow (for residents of Moscow) City Foundation of Compulsory Medical Care Insurance". Further the paper declares that an owner of the policy "has the right to get medical care under the program of compulsory medical insurance in any medical institution operating within CMCI."
Your signature concludes the sentence "The conditions are known". If you think you'll find the conditions of insurance on the back of the paper you're wrong. It would be quite reasonable but this document does not contain any conditions. Your signature is likely supposed to testify that you might read a list of conditions while getting your policy and you should have remembered them by heart for life remained. Well, forget about them, these conditions. Then follows "a name of insurance organisation, issued the policy (Zip Code, legal address, phone)." A stamp of an insurance company is put on this interesting place. Your district is under the authority of this very company. For example, a stamp on my policy is of "Medstrakh" ("Medical care insurance") stock company.
So an insurance policy links together: You. The Foundation of Compulsory Medical Care Insurance, a medical institution, and an insurance company.
It's You who open and close the circuit: At the input you pay taxes and at the output get medical care.
Medical care insurance fund is an intermediate party between state collecting taxes and a body of a taxpayer which might need a repair.
And what about insurance company, what has it got to do with it?
Again you look at your policy in the hope to see any obligations of your company. Alas! Then you make up your mind to go according to the address mentioned at the stamp (if you got it). When you approach the office of the insurance company you smell a strong scent that can not be confused with anything else. A smell of money! You are absolutely right: insurance companies are engaged in pumping money through oneselves. What money? The same one: your taxes withheld into the City Foundation of the Compulsary Medical Care Insurance.
Insurance companies in this country are purely financial institutions. They get money from the Foundation of the Compulsary Medical Care Insurance for settling with medical institutions for those medical services they render to population. Insurance companies cope with the first part of their task quite successively. As far the second part is concerned - I mean payments the case is much more worse. The fact is that insurance companies are not at all eager to let money go out of their hands. That's the reason why payments to medical institutions are regularly delayed.
Most of commercial companies live according to the principal: "Money beforehand!" And how are doing medical institutions?
Surely you guess that treatment costs money. Cost of treatment includes wages of medical personnel, drugs, employment of medical equipment and stock. When you come to a hospital the number of your policy is reported to the insurance company which transfers money to this medical institution according to your diagnosis and medical and economic standards. If you have no insurance policy and a hospital nevertheless assents to treat you (by the way in many cases a medical institution has no right to deny medical care to you by law, a hospital incurs losses because neither an insurance company, nor anybody else won't pay for your treatment.
One more point.There are a lot of insurance companies in Moscow, and they divide the territoty of the capital between themselves. For instance an insurance policy is given to you according to your place of residence by an insurance company X. A medical institution that treats you, report about it to its insurance company. Now let us suppose that you happened to come to a medical institution situated in another district which is allotted to an insurance company Y. A medical institution, which treats you, report it to its insurance company. An insurance company Y get in touch with an insuranse company X and waits when the former would transfer money to it. And only after this a company Y would pay for your treatment, as a result a medical institution get money with a delay of 3-5 months. And if you were treated in some other town, in this case it is better for it just to forget about its money.
Reasonably you might ask: And what I am to do to it? One minute! Now you'll understand everything. We almost have come to the end of our description of the circulation of money in nature accompanied by their dissipation on the accounts of insurance companies. But this scheme lacks something. Do you remember, we mentioned so called "medical and economic standards" (MES)? In compliance with them disease treatment cost is determined if the treatment was in accordance with your diagnosis.
Suppose you need laparoscopia. This operation may be performed in a district hospital as well as in a clinic of the highest category. The only difference is that in the former case you'll get a stitch from shoulder to groin and keep your bed in a hospital a month or so, and in the latter one you'll get off with a point incision and will be able to run after not more than the third day. And not because surgeons in a clinic are better than those in a district hospital. The reason is that a clinic has the latest equipment at its disposal and one doctor deals with twice or thrice as less patients than a doctor in a local hospital. Extra money is needed to acquire equipment and keep personnel. Surely your treatment in a clinic of the highest category is more expensive than in a district hospital, but the risk is also less. Nevertheless insurance company will pay for your treatment equal sum of money would both to a local hospital and a clinic of the highest category, according to MES.
We asked to comment on this situation a chief of planning and economic department of one of the leading medical institutions of Moscow.

How MES are estimated?

Treatment costs mentioned in MES are close to minimal. We do not know the basis they are calculated on, this information is supposed to be secret. We don't know even who do it. Insurance company, "Medstrakh", department, all of them allude to each other and nobody is ready to accept responsibility.
Annually we estimate our treatment charges on the basis of the data of statistics department. After transition to the MES system a big gap between the planned sum and those bills really payed by an insurance company (towards underpayment) keeps having place.

What's the reason of such situation?

First of all MES do not include at all many kinds of treatment we use and so they are not payed for. Secondly many patients are admitted to our traumatology department and burn center without any medical care insurance policy at all. Their treatment are very expensive, and nobody pays us for it.

How you manage to find a way out of the situation?

We try to cut our costs. Our doctors did not get their quarter bonus. We try to save money buying cheaper drugs, and it adversely affect our treatment. For instance we could buy very expencive and higly efficient medicine, as a result a patient would be getting better quickly. Using such a drug we we would secure a patient against complications. And we can't afford it, we are compelled to buy the cheapest drugs. We save on beds, beddings, mattresses...

Was the situation better under planned medicine?

I would not say so. Financing of public health was always made on the residual principal. The best situation was when accounts between insurance company and medical institution was based not on the MES but according to indivivual parameters. Then costs of treatment in different hospitals were different. When MES were introduced service costs became 1.7 less. We asked department to introduce appropriate coefficients, but we were refused, evidently in order not to create a precedent.

And what were hese MES introduced for?

It is a forced measure. It seems to be that means for treatment of not working part of the population - children, pensioners - are not transfered to the Fund of the compulsory medical care insurance...

So that's how things are! Considering that the amount of children and pensioners is as much as of the able-bodied population what a surprisingly insignificant role is assigned for social protection system among the other priorities of the government.
But let us recur to the beginning, I mean, to diseases. From the abovementioned we can conclude that clinics of the highest category would prefer to treat patients on the level of a rural hospital. Everything above determined by MES is a loss for a medical institution. And what is more a medical institution would rather exaggerate situation: it would rather take advantage and make more severe diagnosis, not corresponding to your real condition. Just for financial reasons. And if you think that more strong and expensive drugs are better, you're wrong: "overtreatment" could damage your body.
But how you can secure yourself against hyperdiagnostics? It's a high time to address your insurance company. If you lived in the West, I am sure, it would be exactly you would do. Insurance companies in the West really insure you against all sorts of abuses and negligence of medical institutions. If you suspect that a medical institution caused you a damage, pluck up your courage and take it into court. Experts of your insurance company do not lack professionalism and they will secure your interests. In our country you also can take it into court, but you'll fight alone. And you could hardly prove that you were treated for a wrong illness or in a wrong way, that necessary analysis were not made or on the contrary doctors were over zealous. This field is too specific, too professional and you would fail without special knowledge. And it is if no use to address your insurance company - bureaucratic insurance would be no help to you. May be the idea to create a medical care insurance system according to the Western patterns was inspired by a good intention to secure interests of a patient. But as a result one more mediator was created upon a thorny path which money follows by from consumer to provider of medical services. They tried their best but the result was as usual...
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