SOME PECULIARITIES FEATURES
OF THE RUSSIAN MEDICAL
CARE INSURANCE
Julia Kachalova
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"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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