Application of clinical and economic analysis in medicine. Clinical and economic analysis in a medical organization (a practical guide for decision-makers)
After completing Chapter 11, the student should:
know
- the concept of clinical economic analysis(CEA);
- selection criteria and basic methods of CEA in medical practice;
- formulas for calculating the applied method of clinical and economic analysis;
be able to
- determine the appropriate method of clinical and economic analysis;
- make managerial decisions in order to improve the efficiency of medical care;
- generalize and balanced assessment of the results obtained by domestic and foreign researchers, identify promising areas, draw up a research program in the field of clinical and economic analysis;
own
- the ability to independently master new methods of clinical and economic analysis, to change the scientific and scientific-production profile of their professional activities;
- criteria for choosing a method and its area of application in clinical trials;
- skills of public and scientific speech, formed, inter alia, on the basis of the results of an independently conducted clinical and economic research.
Factors that determine the effectiveness of medical care. Method of calculating the cost of illness
One of the basics national security- the health of the population, therefore, the quality of medical care is the principle of the development of health care in the Russian Federation. "The customer is central to the key aspects of the quality system of any organization that produces products or services, and his assessment is the ultimate measure of the quality of the service or service and the effectiveness of the system as a whole." In health care, only that which has a good clinical effect is economically effective. Thus, "each process is evaluated primarily from the standpoint of its result and is considered as a continuous increase in 'value' from the beginning of the process to its completion."
The effectiveness of medical care is the degree of the achieved level of the patient's health at the optimal level of material, labor, financial costs... In the analysis of effectiveness, the result is understood as a medical effect, characterized as the degree of achievement of the set goal in the field of prevention, diagnosis and treatment.
The World Health Organization (WHO) has identified effective health as one of the main strategic directions of its policies related to social issues, economics and the environment. In this regard, the main subject of the health care system is considered a citizen, on whose state of health economic efficiency depends and, as an end result, the economic well-being of society. "Each patient obviously requires an individual set medical services, which are based on a variety of medical technologies, and it is natural that it is this set of services that should be provided to him and that they, and not something in between, should be paid for by the insurance organization. For this, the compulsory medical insurance system, the priority of which is the fulfillment of obligations to the multimillion contingent of insured persons in relation to the range and quality of medical services provided, i.e. claiming a sufficiently high level of socio-economic efficiency, should be focused on optimal system management supported by modern technology. "
For the implementation of priority programs for the protection of public health with the constantly growing cost of medical care, an optimality criterion is needed as a quantitative indicator expressing the marginal measure of the economic effect of a decision made for a comparative assessment of possible solutions (alternatives) and choosing the best one.
The criteria for the socio-economic efficiency of financial resources management, assessment of the activities of various subjects of the CHI system are based on the principle of dominance of the interests of end users - the insured. The same criterion is the basis for evaluating the effectiveness of various medical technologies.
Economic evaluation involves the analysis of medical alternatives, for each of which it is necessary to compare the estimated benefits (results) and costs in one way or another. "The basis for the alignment of interests should be a focus on the final results of activities." This applies to all subjects of the health care system, including a medical worker, health care organizer, manager, who need practical skills and knowledge in the field of clinical and economic analysis in order to carry out their professional activities in order to make more rational use of the available resources of the health care organization and ensure quality medical help.
Thus, the clinical and economic analysis is a comparative analysis of various methods of diagnosis, prevention, drug and non-drug treatment, rehabilitation, surgical intervention methods used in medical practice, carried out in order to determine the most clinically effective and economically feasible from the set of considered methods.
Analysis (from the Greek. analysis - decomposition) - a method of scientific research (cognition) of phenomena and processes, which is based on the study component parts, elements of the system under study (for example, a system for providing quality medical care).
Analysis of the total cost of illness (economic burden of illness, cost of illness - COI) - This is a type of economic analysis, which determines all the costs (total cost) incurred by society, a specific health care institution, family in connection with the implementation of all therapeutic and diagnostic measures during the treatment of a disease of any nosological form. This type of analysis does not imply the calculation and determination of the effectiveness of the medical care provided. But when analyzing the "total cost of the disease", it is possible to identify the disease for which the largest amount of financial resources is spent, and to determine the greatest economic damage caused to society, family, individual in connection with the morbidity of the population. The analysis allows you to make a managerial decision on the optimal distribution of financial resources in a separate subdivision of a healthcare organization, as a whole for a given organization (polyclinic, day hospital, round-the-clock hospital), as well as identify costs at the level of the family and society as a whole.
The analysis of the total cost of illness (total disease burden) is done using the formula
where C01 - indicator of the cost of illness; OS - direct costs (costs); 1C - indirect (non-medical and indirect, alternative) costs (costs).
The grouping of costs depends on what kind of problem is solved with the help of economic analysis.
Direct costs (OS)- these are expenses of a healthcare institution that are directly related to the treatment process. The types of direct costs primarily include:
- salaries of medical personnel (basic and additional);
- salary accruals for medical personnel;
- the costs of a healthcare institution for medicines, soft equipment, patient nutrition (in a hospital);
- depreciation of medical equipment (i.e. the amount of depreciation of medical equipment expressed in monetary terms).
Indirect (indirect, alternative and non-medical) costs (1C) - these are expenses that are not directly related to the treatment process, but create conditions for it. Also, indirect costs include opportunity cost, which are otherwise called opportunity cost, or imputed costs. In the English-language literature, the term is used for opportunity costs "indirect costs" (IC). It is permissible to combine the overhead costs of a healthcare institution and the so-called indirect costs (or, in other words, opportunity costs, opportunity costs) into indirect costs (costs 1C).
Different groupings of health care costs should serve specific purposes of economic analysis. Since in the interpretation of economic theory, direct costs include those that are directly related (involved) with the production of a product (goods, works, services), in this case, direct costs are associated with the provision of medical care at all its stages - diagnosis, direct treatment and rehabilitation. ... Such costs are denoted as DC.
Indirect costs (or costs, costs) include those that are not directly involved in the production of a product, but without which this product cannot be produced either. Indirect costs (or in the interpretation accounting- overhead costs) make up, as a rule, most of the costs of a healthcare organization, however, they are not at all directly related to the treatment process. Anyone, not only a medical organization, has such costs, therefore it is proposed to designate them as "indirect non-medical costs". Also, the provision of medical care is associated with such concepts as disability, disability, underproduction of GDP due to loss of health by the working population, "implicit" costs family budget, i.e. the costs of society as a whole in connection with morbidity and premature mortality, and all these are also indirect costs.
All listed costs are objectively social in nature and are considered social costs. In practice, it is often necessary to know which costs dominate in order to take effective measures to reduce them. In this case, for the completeness of the clinical and economic analysis, it is necessary to divide the costs into groups, within which the costs are united by common features. Thus, to DC we attribute direct costs, and to 1C - indirect costs as the sum of “indirect non-medical costs of the health care facility” (or overhead costs) and “indirect costs”, to which the term “opportunity costs” also applies. Opportunity cost
In the case of indirect non-medical costs of the health care institution (or overhead costs) to 1C relate:
- costs of wages (basic and additional) of administrative and economic personnel;
- salary accruals for administrative personnel;
- costs of utility bills, detergents;
- transport costs;
- current repair of buildings and premises;
- costs of personnel training at the expense of the health care institution;
- travel expenses;
- advertising costs;
- loan payment (for LUZ);
- hospitality expenses;
- office expenses;
- communication services costs;
- other expenses for the household needs of UZ, etc.
In the case of indirect (imputed) costs to 1C additionally include the costs associated with temporary disability, permanent disability, death due to illness. The following aspects are meant.
Clinical and economic analysis is a methodology for comparative assessment of two or more medical technologies (methods of diagnosis, prevention, treatment, rehabilitation) based on a complex interrelated accounting of the results of their application and the costs of their implementation. The methodology of clinical and economic analysis is described in the OST “Clinical and economic research. General Provisions"(Approved by the order of the Ministry of Health of the Russian
these from 05/27/02? 163). The term “pharmacoeconomic analysis” is often used in relation to the drug component.
Clinical and economic analysis is a tool for choosing the most appropriate of several technologies that can be used in the same situation, based on a comparative assessment of their effectiveness and cost. The results of clinical and economic analysis are used in the formation of standards of medical care, formulary lists of drugs, determination of priority areas for health care development. The purpose of using clinical and economic analysis is the rational use of health care resources: to obtain the best result within a known (fixed) budget.
Allocate basic (basic) and helper methods clinical and economic analysis. The main methods are reduced to calculating the ratio between costs and results. The results reflect the dynamics of clinical symptoms, demographics, patient or community preferences, including those expressed in terms of money.
Analysis cost-effectiveness(eng. cost-effectiveness analysis- CEA) - a type of clinical and economic analysis, in which a comparative assessment of the ratio of costs and effect (result) is made for 2 or more medical technologies, the effectiveness of which is different, but the results are measured in the same units (indicators of clinical effectiveness or life expectancy as a result of the application of technology).
When conducting the analysis for each medical technology, the cost-effectiveness ratio is calculated using the formula:
Where CER (cost-effectiveness ratio) is the cost-effectiveness ratio (shows the costs per unit of effectiveness, for example, how much it costs to reduce blood pressure by 1 mm Hg); DC - direct costs; IC - indirect costs; Ef is the efficiency of medical technology application.
When analyzing cost efficiency increments difference between costs 2 alternative options treatment is divided by the difference in their effectiveness:
Where: CER incr - an indicator of an increase in cost effectiveness (an incremental or marginal indicator of the ratio of costs and effectiveness, in fact, demonstrates what additional investments are required to achieve 1 additional unit of efficiency when using a more efficient technology); DC 1 - direct costs when using technology 1; IC 1 - indirect costs when using technology 1; DC 2 and IC 2 - respectively, direct and indirect costs for technology 2; Ef 1 and Ef 2 - respectively, the effects of treatment when using technologies 1 and 2.
The cost increment analysis is only necessary if technology 1 is more efficient than technology 2, but its costs are higher. If technology 1 is more efficient than technology 2 and costs are lower, then technology 1 is dominant.
Analysis minimizing costs(cost-minimization analysis - CMA)- a special case of cost-effectiveness analysis, in which two or more technologies are compared that have identical effectiveness and safety, but different costs. It is recommended to use cost minimization analysis when comparing the use of different dosage forms or different conditions for the use of the same drug or the same medical technology (for example, the use of the same treatment regimen in inpatient and outpatient settings). This methodology is unacceptable when comparing generic analogs of drugs, as they are often not equivalent in therapeutic effect.
Analysis cost-utility (utility)(cost-utility analysis - CUA)- a variant of cost-effectiveness analysis, in which the results are evaluated in units of "utility" from the point of view of the consumer of medical care. As an indirect criterion of usefulness, the patient's quality of life is most often used and the indicator "years of life saved, adjusted for quality of life" (eng. quality-adjusted life-years- QALY).
The calculation of the cost-utility (utility) ratio is carried out using a formula similar to the cost-effectiveness analysis, but instead of the efficiency values, the utility value is substituted:
Where CUR is an indicator of the cost per unit of utility (utility), the cost-utility ratio (i.e. the cost of a utility unit, for example, 1 year of quality life); CUR incr - an indicator of the increment in costs per unit of utility when comparing 2 technologies (utilitarian), cost-utility ratio (i.e. the added value of an additional unit of utility, for example, 1 year of quality life); DC 1 and IC 1 - direct and indirect costs for technology 1; DC 2 and IC 2 - direct and indirect costs for technology 2; Ut 1 and Ut 2 - utility for technology 1 and 2.
To assess utility, QALY indicators are most often used.
Analysis cost-benefit(cost-benefit analysis- CBA), in contrast to the previous options, assumes an assessment of both costs and effectiveness (benefits, benefits) in monetary terms. This is the only true economic analysis - "in its purest form." It is recommended to present the results of the cost-benefit analysis as an indicator of the ratio of benefits and costs:
BCR = B / C (8.5)
or the absolute difference between costs and benefits in monetary terms:
CBD = C - B, (8.6)
where BCR (benefit-cost ratio)- cost-benefit ratio; B - benefit (in monetary terms); C - costs; CBD (cost-benefit difference) is the absolute difference between costs and benefits in monetary terms.
Several approaches are used to determine the monetary expression of the “benefit” from the use of medical technologies: the “human capital” methodology, the assessment of “revealed preferences” and the assessment of “willingness to pay”.
The auxiliary types of clinical and economic analysis include, first of all, analysis "Cost of illness"(cost of illness - COI) - a method that involves the calculation of all costs associated with the management of patients with a certain disease at a certain stage (period of time) or at all stages of medical care. This analysis does not imply a comparison of the effectiveness of medical technologies and is used to study the typical practice of managing patients with any disease. Historically, the first attempts at economic analysis in medicine were associated precisely with calculating the "cost of illness"; this analysis is widely used to solve certain problems, such as planning costs, determining tariffs for settlements between the subjects of the health care system and health insurance, etc. In some countries (eg the United States), a “cost of illness” has been calculated for most diseases, and these calculations have been used to justify a system of standards for diagnostic-related groups; in other countries (in Europe) the “cost of disease” has been studied for the most common diseases.
In the context of Russian healthcare, the calculation of the “cost of illness” is necessary due to the fact that the costs of providing medical care to patients with many diseases have not yet been determined. Huge data on the “cost of illness” have been accumulated by the health care organizations working in the compulsory medical insurance system, and especially in the voluntary medical insurance, but these data are not analyzed or published; it is likely that some of them have been irretrievably lost.
At the same time, if you have access to these data, you should keep in mind their unreliability - doctors, health care managers in non-state, and often in state medical organizations, are engaged in the registration of services and drugs in order to "master" the largest possible amount of financial resources, and insurance companies in most cases have no influence on this process. At the same time, the indicators of the volume of medical services and drugs are far from optimal.
ABC analysis- distribution (ranking) of individual medical technologies according to the share of costs for each of them in the overall structure of costs - from the most costly to the least costly with the allocation of 3 groups. Group A includes technologies that account for 80% of costs (naturally, the group includes 10-15% of all technologies used), group B includes technologies that require 15% of funds (up to 20-30% of the total), and group C - technologies, the implementation costs of which amounted to 5% of the costs (usually more than 50% of the assortment under study). The method is used to prioritize and determine the appropriateness of spending based on a retrospective estimate of real costs.
Frequency analysis- a retrospective assessment of the frequency of application of a particular technology, which, combined with the cost of each type of service
gi or drugs allows you to determine which types of assistance spend the bulk of the cost - massive and cheap or rarely used but expensive.
VEN analysis- distribution of medical technologies according to their degree of importance: V (vital) - vital, E (essential) - important, N (non-essential) - minor (unimportant, insignificant).
All 3 analyzes complement each other and, as a rule, are carried out simultaneously. ABC and VEN analyzes were initially recommended for use at the health facility level to assess cost structures and identify cases of inefficient allocation of funds. For example, the predominance of minor drugs (N) in group A is considered irrational. Based on the results of ABC, frequency and VEN analysis, recommendations can be developed for the compilation and further improvement of the formulary of a medical organization or a list of preferential dispensing of drugs.
Modeling- a method of studying various objects, processes and phenomena based on the use of mathematical (logical) models, which are a formalized description of the object under study (patient, disease, epidemiological situation) and its dynamics when using medical technologies.
Discounting- the introduction of a correction factor when calculating costs (and sometimes efficiency) taking into account the influence of the time factor: the costs to be incurred in the future are less significant than those incurred today, and, on the contrary, the benefits gained today are more valuable than the ones coming in the future.
Sensitivity analysis establishes the extent to which the study results will change when the initial parameters change (for example, fluctuations in drug prices, changes in the frequency of side effects, etc.).
All of the techniques described above are not specific to clinical and economic analysis and are widely used in various types of epidemiological, economic and management studies.
Research using basic methods of clinical and economic analysis is carried out mainly by research organizations and the Society for Pharmacoeconomic Research. In medical organizations, specialists more often use auxiliary methods: calculating the "cost of illness", ABC, frequency and VEN analyzes of the cost structure. In addition, in medical organizations it is necessary to be able to interpret the results of clinical and economic studies in order to use them for the formation of standards and forms.
Clinical and economic analysis is a relatively new area of research, the need for which is determined by:
- the rapid growth in the cost of treating the most common diseases and the general rise in the cost of medical services;
- the emergence of alternative methods of treatment (but not cure) of the same disease, the choice of which has to take into account not only their clinical effectiveness, but also the cost;
- the existing in all countries lagging behind the pace of their creation in financing high-tech and expensive methods of treatment.
This analysis makes it possible to assess the clinical effectiveness of treatment in terms of the cost of treatment for society, health care institutions, in the context of clinic departments and individual patients. The analysis focuses on addressing the cost to the patient, the healthcare facility and / or the community for the desired outcome of the treatment. Methods for obtaining information for clinical and economic analysis: clinical trials, computer modeling, retrospective analysis of databases, or a combination of these.
In our country, there is an industry standard "Clinical and economic research. General provisions" (OST 91500.14.0001-2002), approved. by order of the Ministry of Health of Russia dated May 27, 2002 No. 163.
A clinical economic analysis evaluates an intervention or technology based on a comparison of the effects of the following criteria:
- Measured in natural units:
- the frequency of deaths, life-threatening and disabling complications, the frequency of readmission, etc .;
- duration of treatment;
- survival, mortality, etc.
- Measured in conventional units of "utility":
- equivalent years of health (HYEs - healthy year equivalents),
- years of returned working capacity (DALYs - disability adjusted life years),
- returned years of full-fledged life (QULYs - quality adjusted life years), correlated with indicators in monetary terms.
In world practice, 5 main methods of clinical and economic analysis are used (Drummond M.E. et al, 1999, Gray J.A.M., 1977, Jefferson T. et al, 2000, Principles of Phamacoeconomics, 1996):
- Cost minimization analysis
- Cost (cost) - efficiency analysis
- Cost (cost) - benefit (benefit) analysis
- Cost (cost) - utility (utility) analysis
- Economic Modeling Methods - Markov Model, Decision Tree
In Russia, there are four methods of clinical and economic analysis, the main of which is formally the "cost-effectiveness" analysis, which simultaneously analyzes the cost and effectiveness. The rest of the methods are its special cases.
- Cost (cost) - efficiency analysis(cost effectiveness analysis) - a type of economic analysis in which a comparative assessment of the costs of two or more interventions is made, the result of which is measured in the same units (years of life saved, survival, the number of complications averted, etc.).
- Cost minimization analysis(cost miniminization analysis) - a type of economic analysis that compares the cost of two or more interventions with identical clinical outcome. These studies take into account all types of medical services related to each method of treatment and determine the costs of them. In medical socio-economic systems, this type of analysis is rarely used, since more often both types of treatment differ in both cost and clinical outcomes.
- Cost (cost) - benefit (benefit) analysis(cost benefit analysis) - a type of economic analysis in which both cost and benefit are presented in monetary terms, which makes it possible to compare the cost-effectiveness of different interventions with different results. From the point of view of economic evaluation, this is the most accurate type of analysis. Unfortunately, it is not always possible to apply this type of analysis in medical systems.
- Cost (cost) - utility (utility) analysis(cost utility analysis) - a type of economic analysis in which the results of interventions are estimated in units of "utility", of which quality-standardized years of life are more often used.
Utility - the utility (preference) of the state. In a broad sense, in economics, utility is understood as the level of satisfaction received by an individual from a product or service when the characteristics of a product or service are defined. Utility in a narrow special meaning, considered in health economics, is a numerical value, measured in a state of uncertainty, and reflects the measure of a patient's preference or desire for a given health condition or a given outcome (in the course of the disease).
Table 1 summarizes the features of all four methods of clinical and economic analysis.
Basic methods of clinical and economic analysis
Analysis type | Cost estimation | Assessment of clinical results |
"Cost minimization" - (cost miniminization analysis) | Monetary expression of direct and indirect effects | Treatment outcomes are not measured because treatment outcomes are equivalent |
Cost Effectiveness Analysis | -//- | Assessment of true clinical outcomes based on actuarial prediction |
Cost utility analysis | -//- | Standardized characteristics of "usefulness" (for example, the criterion of the ratio of the number of years of extended life to its quality (QALY - quality adjusted life years) |
Cost benefit analysis | -//- | Monetary value of treatment outcomes |
In addition to the main ones, auxiliary methods of clinical and economic analysis are distinguished:
- Discounting- bringing future cash flows to the current period, taking into account the change in the value of money over time
- Cost of Disease Analysis("all costs") - represents the basic economic assessment of the disease required to accept management decisions on the distribution of health care resources, which calculates the full cost (the so-called "economic burden") of a specific disease, taking into account various types of costs (medical and non-medical, direct, indirect).
- Sensitivity analysis- an analysis that allows you to establish the extent to which the results obtained will change when the initial parameters change (for example, fluctuations in drug prices, changes in the frequency of side effects, etc.).
Methods such as ABC and VEN analysis are considered separately in foreign literature. In Russia, due to their wide distribution in the formulary system, these methods are often indicated together with the main methods of clinical and economic analysis or pharmaco-epidemiological analysis.
The main stages of clinical and economic analysis
I | Analysis plan development and analysis programs |
formulation of the goals and objectives of the analysis |
selection of an alternative intervention for comparison | ||
selection of criteria for assessing the effectiveness and safety of the investigated medical interventions | ||
II | Choice of methodology for economic research | the choice of the main method of clinical and economic analysis depends on the purpose of the study |
III | Cost estimation
Direct costs are easier to identify, so only these are usually estimated. Indirect costs, as a rule, do not change for a certain period (they are a certain constant), therefore, when performing a clinical and economic analysis, they can be neglected. |
|
IV | Cost-effectiveness of compared interventions | It is considered economically more efficient if:
|
The use of methods of clinical and economic analysis
The methods of clinical and economic analysis can be used to prepare information materials for the choice of management decisions and funding priorities. However, the methodological complexity of this approach prevents its widespread adoption. Quite often, there is simply no or little evidence for such an analysis. In addition, the information obtained on the basis of clinical and economic analysis does not fully describe the system of organizing medical care. Costs that arise outside the health sector may usually not be included in clinical and economic analyzes, but can significantly affect the social value of treatment.
For example, today a patient's payment for travel from regions remote from a specialized clinic or co-payment for treatment (expensive imported consumables - stents, prostheses, pacemakers, medicines, etc.) may exceed the cost of the operation itself. This reduces the burden on the health care budget, reduces the costs of the medical institution, but such cost shifting turns out to be ineffective from a social point of view. Both on the part of patients and on the part of the development of domestic import-substituting technologies. The latter is of particular importance for the state, since the money for paying for the treatment of Russian patients goes to the further development of foreign manufacturing companies. Consequently, factors such as access to expensive diagnostic equipment, existing principles and traditions of patient management can significantly affect the decision-making process on the choice of medical intervention.
In addition, the results obtained in the process of performing the clinical and economic analysis based on the data different countries and different clinics may differ. The length of hospital stay, the incidence of complications, medical infrastructure, payment mechanisms for care can have a significant impact on the ratio of the cost of treatment by different methods and, therefore, lead to the formation of a particular clinical practice.
Table 2 clearly shows the differences in the cost of treatment with the same method according to the data of studies carried out in different clinics and different countries.
Table 2. Comparative cost of CABG and SCA treatment (ART, ERACI-II, SoS)
Index | SKA, USD | CABG, USD | R |
The cost of procedures is average In selected studies |
9522 ± 2400 (7668,8921, 10 369) |
13 107 ± 808 (12517, 13067, 13 689) |
< 0,001 |
The cost of "bed-days" is average In selected studies |
2288 ± 2649 (865, 865, 2562) |
7468 ± 5 130 (5369, 6234, 7964) |
< 0,001 |
Total hospital cost - average In selected studies |
11 810 ± 3765 (9087, 10718, 13 328) |
20 574 ± 5230 (18081,19616, 21 157) |
< 0,001 |
Total cost over two years - average In selected studies |
17 634 ± 12 065 (10073, 13385, 21 726) |
24 288 ± 12 260 (18376,20449, 26 225) |
< 0,001 |
In the Russian Federation, in contrast to the countries of Europe and the USA, the cost of coronary artery stenting already with the initial intervention is practically equal to the cost of CABG, despite the long duration of inpatient treatment for CABG (due to the disproportion in the cost of imported consumables and wages medical personnel). Consequently, given the need for repeated revascularizations, stenting in the current practice turns out to be an economically ineffective technology. Differences in the results of clinical and economic analysis are one of the reasons why new technologies cannot be transferred from one country to another only on the basis of publications, without assessing country or even regional acceptability.
Arustamyan G.N.
Clinical and economic analysis and its role in quality management
medical care
In the last third of the 20th century, large-scale changes took place in the management of national economic systems and, first of all, in its social sector. The emergence of new forms of reproduction of fixed capital, the acceleration of innovation processes and the growth of the accumulation of intangible capital have radically changed the vector of investment policy development. The goal of global investments was the concentration of human and material resources on the reproduction of human capital and the accumulation of national wealth, which underlies the satisfaction of the needs of society. Thus, a global economic system socially oriented type, based on investing in human capital, accelerating innovation, forming a new structure of reproducible wealth.
The formation of a new infrastructure of society determined the need to solve social problems, which prompted the governments of many countries to reconsider their views on the management of the health care system, which is a system-forming element of the modern structure of society.
It is generally recognized that the health of an individual, as well as the health of the entire population, is a factor in the growth of the country's economic potential. In view of this, the improvement of the quality management system of medical care is undoubtedly becoming one of the most important strategic goals of national security.
Nevertheless, despite numerous attempts to bring the reform process closer domestic health care to the true understanding and essence of modernization, the issue of the quality of medicine in Russia remains unresolved. The main problem is the fragmentation of the reforms carried out in this area. It is important to understand that the task of the state is mainly to provide conditions for the achievement of high efficiency of treatment and prevention activities, taking into account the limits of state funding for health care. In this regard, the need to use economic methods of regulation and improve the quality of medical care comes to the fore.
Clinical and economic analysis in health care management. History of the issue. Basic concepts and methodology. The possibility of using economic regulation instruments in health care has been discussed for more than half a century. Nevertheless, the first who made a breakthrough in this area was the English statistician and economist W. Petty, who estimated the cost of a human life in the range of 60-90 pounds sterling1. According to Petty, the value of human capital should be estimated by the capitalization of earnings, which acts as a life annuity, taking into account the market interest rate.
The British demographer William Farr developed Petty's theory by calculating the present value of an individual's future earnings minus the personal cost of living. In addition, Farr calculated the economic benefits of health care to workers during epidemics based on an analysis of financial losses from underproduction.
1 LaPorte R., Omenn G., Serageldin I. Introduction to Health Economics.
Http://www.pitt.edu/~super1/lecture/lec0092/010.htm (01.10.2011).
However, until the middle of the XX century. no systematic economic analysis has been used in medicine. Only in the 1950s. American scientists K. Arrow and M. Friedman conducted research that proved the possibility of practical use of economic methods in health care. On the one hand, it became possible to use economic analysis as a information resource when making decisions on financing and allocation of resources, on the other hand, it made it possible to significantly “accelerate” the implementation of social reforms.
The unceasing rise in prices for medical services and medicines in the 60s and 70s led decision-makers to think about the need to develop price control mechanisms. The problems of reducing the cost of providing medical care began to be discussed, which led researchers to determine the role and place in it of the concept of "economic efficiency".
The urgent need to organize a systematic analysis of the economic benefits of various medical technologies was formed as a result of the emergence of state mechanisms in the field of public health protection. As a result, in the mid 50s and 70s. XX century Such methods of economic analysis as "cost-benefit", "cost-effectiveness" and "cost-utility" were developed. The authors of the first examples of economic analysis, called cost of illness analysis, were the American economist, Professor D.P. Rice (Dorothy P. Rice), who for the first time in 1963 calculated the cost of the "burden of disease" for the American society, thereby laying the foundation for further research in this direction (coefficients DALY (disability-adjusted life years) and QALY - adjusted on the quality of life).
The active development of clinical epidemiology in parallel with the improvement of tools for assessing the effectiveness and safety of medical interventions contributed to the emergence and implementation of the concept of evidence-based medicine in clinical practice.
The founder of the concept of evidence-based medicine is the British epidemiologist A. Cochran. He was the first to draw attention to the need to assess the effectiveness of treatment technologies by analytical generalization of the results of clinical trials2. The use of the concept of medicine based on evidence allows the use of objective criteria of medical efficiency in the economic assessment of alternative options for action to achieve a specific result and, as a consequence, improve the quality of services provided.
The key provisions of evidence-based medicine formed the basis for the formation and introduction into everyday medical practice of tools for clinical and economic analysis of medical institutions.
Clinical and economic analysis is currently the most important link in the quality management system of medical care. Its main task in the management of CMP is to rationalize the choice of medical technologies based on an integral assessment of clinical and economic efficiency. Currently, clinical and economic analysis is the main method for conducting a comprehensive assessment of the clinical and economic efficiency of medical technologies (interventions) in the process of choosing certain methods of treating patients. Nevertheless, in domestic and foreign literature there are many
2 Shah H.M., Chung K.C. Archie Cochrane and his vision for evidence-based medicine.
Http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2746659/?tool=pubmed (02.10.2011).
alternative terms, which, of course, complicates the search and development of uniform approaches to conducting a comprehensive medical and economic research.
The main problem is the shift in emphasis in conducting such research into the area of drug provision, which is often identified with the term “pharmacoeconomics”. According to the doctor of medical sciences, professor A.S. Spiegel, “pharmacoeconomics is a comprehensive clinical and economic analysis of the results of the use of medical interventions in the field of drug provision” 3. Nevertheless, the methods of pharmacoeconomic analysis can and are actively applied to all types of medical interventions. At the same time, aspects of pharmacology itself are not affected in the course of CEA.
Clinical and economic analysis, in essence, is a comparative analysis of two or more medical technologies (diagnostics, prevention, treatment and rehabilitation) based on a complex interrelated accounting of the result of medical interventions and the costs of their implementation4.
The main goal of CEA is to achieve the best result within the limited amount of allocated funds, that is, rational use of resources while maintaining the high quality of medical care.
In healthcare, the main expected result is health, which is difficult to quantify; therefore, there are different approaches to assessing the results of medical interventions during CEA.
The development of the CEA methodology and the introduction of its results into medical practice has become an important step towards improving the management of the quality of medical care (hereinafter referred to as CMP) and the health care system as a whole in a number of foreign countries. The greatest development of clinical and economic research has received in the economic developed countries who identified this method as a key one in achieving a balance in the provision of quality health care and limited health financing resources.
Conducting CEA implies the use of two criteria that the study must meet:
1. Comparative design, i.e. inclusion of at least two treatments in the analysis.
2. Cost and benefit analysis (clinical efficacy and safety) of each treatment method included in the study.
It is customary to distinguish between the main (basic) and auxiliary methods of FEA:
The main methods are devoted to calculating the ratio between costs and results obtained:
1. Cost-effectiveness analysis (CEA).
This method is a cost-benefit comparison technique for two or more medical technologies that have different efficacy, but the results are measured in the same units. According to Professor N.G. Shamshurina, this method is especially relevant for health care facilities in conditions of limited resources5.
3 Shpigel A.S. Clinical and economic analysis and development of a formulary system based on evidence-based medicine: expanding opportunities for antihomotoxic pharmacotherapy // Biological medicine. No. 1. 2004. S. 3-4.
4 Management and economics of health care / Ed. acad. RAMS A.I. Vyalkova. M .: GEOTAR-MEDIA, 2009.S. 513.
5 Shamshurina N.G. Indicators of socio-economic efficiency in health care. M: MCFER, 2005.S. 320.
The cost-effectiveness method consists of the following stages:
1. Analysis of various methods of treating a specific disease;
2. Determination of the average and (or) maximum costs per patient;
3. Calculations of cost-benefit ratios for each treatment option;
4. Comparison of cost-benefit ratios for each treatment option.
The results of the cost-effectiveness assessment can be calculated using this formula:
CER = DC + IC Ef,
Where CER (cost-effectiveness ratio) is the cost-effectiveness ratio per one cured patient (in%)
DC - direct costs
IC - indirect costs
Ef - treatment efficiency (percentage of patients cured)
In order to make a choice in favor of a particular treatment technology, it is necessary to analyze the incremental cost-effectiveness, in other words, the so-called incremental approach, i.e. comparing the costs and benefits of one method versus another.
CERincr = (DC1 + IC1) - (DC2 + IC2) Ef1- Ef2
CERincr is a measure of the incremental cost efficiency, i.e. cost of achieving each additional unit of efficiency
DC1 - direct costs when using technology 1
IC1 - indirect costs when using technology 1
DC2 - direct costs when using technology 2
IC2 - indirect costs when using technology 2
Ef1 and Ef2 - indicators of the effectiveness of treatment when using technology 1 and 2.
2. Cost minimization analysis (CMA)
In the course of using this CEA method, two or more treatment options (technologies) are compared, which are identical in their effectiveness, but different in cost. The methodology for calculating cost minimization is based on the following indicators:
The structure of health care financing by sources (budgetary funds, compulsory medical insurance, extrabudgetary sources, etc.);
Financing structure by type of medical care (inpatient, outpatient, etc.);
Degree of deterioration of equipment and fixed assets of health care;
The volume of medical care by types of medical care provided to the population.
At the national level, this method is practically not used, due to the impossibility of agreeing on the public level of the entire set of medical and economic parameters. At the regional level, the cost minimization method is advisable and possible to apply in order to develop various kinds of sectoral programs, for example, programs for the introduction of inpatient replacement technologies instead of expensive patient treatment directly in healthcare facilities. At the same time, it should be borne in mind that the reduction in the number of beds and the redistribution of resources in favor of outpatient treatment should not lead to a decrease in the health indicators of the population in comparison with the normative indicators.
3. Cost-utility analysis (CUA)
This method is a form of cost-benefit analysis in which results are assessed in terms of “usefulness” for individuals or society as a whole. This method is used if it is impossible to assess the effectiveness in monetary terms. The calculation of the coefficient by the cost-utility method is similar to the formula presented in the cost-effectiveness analysis method, with the only difference that the utility indicator is used instead of efficiency.
To calculate the utility coefficient, the QALY (Quality-Adjusted Life Years) indicator is most often used. The QALY indicator reflects the years of life, taking into account its quality. It became especially popular in the 70s. XX century to assess the losses of the population due to the deterioration of their physical and social status. The QALY coefficient is calculated by multiplying the expected number of years won by a utility coefficient in the range from 0.0 to 1.0, which reflects the quality of life for a given period of time.
Despite the versatility this approach and its popularity in the international practice of calculating indicators of the effectiveness of health care systems, the main disadvantage of the cost-utility method is the inaccuracy of measuring the utility coefficients, which significantly limits the scope of this analysis.
4. Cost-benefit analysis
Unlike previous types of clinical and economic analysis, the cost-benefit method evaluates costs and effectiveness (benefits, benefits) in purely monetary terms. Being the simplest version of economic assessment, this methodology is most relevant in the course of comparing costs and benefits at the macro level. A striking example of this is the organization of preventive programs, in which the costs of vaccination lead to savings in subsequent costs for the treatment of infectious diseases.
Among the auxiliary methods for assessing the effectiveness of health care, the following are worth noting:
1. Cost of illness (COI)
A method that involves the calculation of all costs arising both at a certain stage of treatment, and at all stages of medical care in general. Disease costing is mainly used to develop a system of standards for diagnosis-related groups.
2. ABC analysis is a method of ranking individual medical technologies by the share of costs for each of them in the total cost structure - from the most costly to the least costly, with the allocation of 3 groups.
Group A - technologies, the costs of which account for 80% of total costs;
Group B - technologies, the costs of which account for 15% of total costs;
Group C - technologies, the cost of which is 5% of total costs.
The results of the ABC analysis are the basis for the development
programs of corrective measures to improve the quality of medical care, the introduction of advanced training programs for medical workers with the allocation of priority groups of diseases. ABC analysis, as a rule, is complemented by frequency analysis, so that it is possible to determine which types of services spend the bulk of the costs - often used and cheap, or vice versa.
Rare but expensive.
3. The effectiveness of the ABC analysis can be increased by combining it with the VEN analysis. VEN analysis makes it possible to assess the rationality of medical technology costs. For this, all treatment technologies are divided into three categories: V - vital (English vital), E - necessary (English essential), N (English non-essential, unimportant).
ABC / VEN analysis and countrywide results provide a clear picture of implementation effectiveness. government programs... By identifying the range of the most costly (category A in ABC / analysis) medical technologies, but not effective (category N in the VEN analysis), it will be possible to identify scientifically supported recommendations for their use or non-use in medical practice.
According to the order of the Ministry of Health of Russia dated October 22, 2003 No. 494, the duty of clinical pharmacologists is to regularly conduct ABC and VEN analyzes of drug consumption6. However, it still cannot be argued that these methods have become a management tool used in daily medical practice, although they are simple and extremely useful for understanding the situation with spending funds.
4. Modeling is a method for studying processes or phenomena based on the implementation of a formalized model for assessing and calculating the dynamics of the use of medical technologies. As a rule, there are computer, mathematical, analytical, statistical, simulation and other types of modeling.
According to the form of presentation (design), the most frequently encountered in FEA models can be divided into the Markov model and the “decision tree”.
Decision tree is a diagram that allows you to illustrate all possible outcomes in relation to a specific situation. This model is commonly used to describe the process of treating an acute illness. The use of this model implies the presence of several alternatives with different probability of outcomes. The Markov model allows you to describe several discrete states and transitions between them over time. Markov models, as a rule, are more often used in pharmacoeconomics due to their more flexible structure than the “decision tree” structure.
6 Legal Russia. Internet library LawRu.Info. Order of the Ministry of Health of the Russian Federation of October 22, 2003 No. 494 On improving the activities of doctors and clinical pharmacologists.
Modeling in pharmacoeconomic studies is effective in cases where the clinical data are insufficient to carry out a comprehensive comparative analysis.
5. Discounting is the introduction of a correction factor when calculating costs, taking into account the influence of the time factor. The costs that need to be incurred today are more important than those that are planned in the future; nor is the benefit gained today is more important than what is expected in the future.
6. Sensitivity analysis is a method for assessing the influence of various parameters (changes in the frequency of side effects of treatment, fluctuations in the price of medicines, etc.) on the end result of a particular medical process (recovery / deterioration of the patient's condition).
The choice in favor of one or another method for conducting CEA depends on a number of factors, namely, on the purpose of the study, the availability of data and the medical case (disease) under consideration. Nevertheless, the most important, especially in the conditions of Russian reality, is not so much the implementation of clinical and economic research, but the introduction of the ideology of CEA into medical activity, i.e. awareness of the importance of this analysis by all members of the medical community and the management of the health care system. Moreover, when deciding on the purchase of equipment, procurement of drugs and consumables, managers should comprehensively assess the expected costs and results, not focusing only on cost savings and not considering that all new technologies are a priori better than old ones and will certainly bring additional benefits.
A rational combination of various types of clinical and economic analysis will significantly increase the efficiency of medical activities at all levels of healthcare organization. Thus, the cost-benefit method, as a rule, should be carried out in conjunction with the cost-benefit analysis, which ultimately will make it possible to obtain more accurate information about the result and the correctness of the chosen treatment alternative. The cost-effectiveness method should be combined with a cost-minimization analysis, which will help determine the most effective treatment options with an optimal funding structure.
Application of clinical and economic analysis in the healthcare system of Russia. Assessing the experience of using clinical and economic analysis in the Russian health care system, it is worth noting its extreme fragmentation and contradiction. Nevertheless, it cannot be argued that in the domestic health care system there was no economic assessment of medical technologies in principle. In the late 70s - 80s. XX century In the Soviet medical literature, works appeared in which the assessment of the social and economic efficiency of state programs for the provision of medical care was carried out. at the same time, the very concept of efficiency was studied in isolation from three positions: medical, economic or social efficiency, which, of course, deprived managers medical institutions on the one hand, and medical workers - on the other, understanding the complexity of this issue.
Over the past 20 years, economic problems in the domestic health care system have escalated to the limit. Over the years, there has been a sharp imbalance between the prices of medical services; the data of domestic statistics indicate an extremely low efficiency of the use of beds, medical equipment, the quality of distribution of working hours
specialists 7. In the late 90s. in the domestic literature, there is an increase in interest in the search and development of economic mechanisms for regulating health care issues. It became clear that the growth in financing of medical services and the growth in the level of its quality are not directly dependent on each other. Thus, there is a need and expediency of introducing a comprehensive medical and economic assessment of effectiveness, which ultimately led to the creation of the industry standard “Clinical and economic research. General provisions "(OST 91500.14.0001-2002). In accordance with paragraph 2, this industry standard is a set of rules for the conduct and use of clinical and economic research results, as well as the documentation and presentation of their results8. Observing the rules specified in the OST, a doctor or a medical institution as a whole provides guarantees of the reliability of the results of clinical and economic studies, their safety, protection of the rights and health of subjects and researchers.
In addition, the specificity of this standard is its "openness" and the possibility of adjustment in the context of rapidly changing and improving methods for assessing economic efficiency.
In addition to the aforementioned industry standard, a very important role in the formation of the regulatory framework for conducting CEA in the Russian Federation is played by:
OST “Protocols for the management of patients. General requirements "(Order No. 303 dated 03.08.1999), and
OST "The procedure for organizing work on the formation of the" Rules for the formation of the List of vital and essential medicines "(EDL) (Order of the Ministry of Health of the Russian Federation No. 321 dated October 21, 2002).
Speaking directly about the practice of introducing the methodology and tools of CEA in Russian medicine, the main one, as a rule, is the cost-effectiveness analysis, which combines the analysis of cost and effectiveness. The rest of the methods of clinical and economic research are its special cases.
To date, clinical and economic analysis in medical institutions of the Russian Federation consists of the following stages:
Tab. No. 1. Stages of conducting a CEA in Russia
I Development of a plan and program for conducting clinical and economic analysis, formulation of goals and objectives of the analysis, selection of alternative interventions for comparison, selection of criteria for assessing the effectiveness and safety of the investigated medical interventions
II Determination of the methodology for conducting a clinical and economic study Selection of the main method of FEA analysis, determined by the objectives of the study
III Cost Estimate Direct costs - direct medical costs - all costs incurred by the system
7 Vyalkov A.I., Karpeev A.A., Kuzin V.F. Problems and prospects for the development of the standardization system in the health care of the Russian Federation // Probl.standard in health care. 2000. No. 2. S. 3-10.
8 Order of May 27, 2002 N 163 On the approval of the industry standard “Clinical and economic research. General Provisions ". - http://docs.kodeks.ru/document/901823470 (10/29/2011).
health care - direct non-medical costs - overhead costs Indirect indirect (alternative) costs (lost opportunity costs) Intangible (intangible) costs
IV Cost-effectiveness of compared interventions Medical technology is considered the most effective in terms of the feasibility of its use if it: requires less costs for its implementation in comparison with other alternatives, but at the same time is not inferior to them in terms of medical efficiency; is more efficient, but more expensive and its additional benefits justify the additional costs; is less effective but less expensive, and the added benefits of competing interventions do not justify the additional costs.
Despite the presence and constant growth of doctors' interest in the development and active implementation of CEA methods in medical practice, clinical and economic research has not yet become an integral part of the quality management of medical care, which is often explained by health officials by a lack of funding. Describing the current stage in the development of clinical and economic research in Russian healthcare, professor P.A. Vorobyov noted that the slogan "to do things right" was replaced by another - "to do the right thing." In most economically developed countries, clinical and economic analysis, used in conjunction with the concept of evidence-based medicine, is the basis for decision-making on the use of medical technologies in practice and the corresponding consolidation of these decisions in national standards.
Foreign experience in the implementation of clinical and economic analysis (on the example of France). The main task of conducting clinical and economic analysis is to form an objective assessment of the process and results of medical care, which, in fact, is the key to managing the quality of medical care. Until recently, the only method for assessing the adequacy of the choice of a particular technology was expert opinion. However, the inevitability of the influence of the "human factor" deprives the expert method of objectivity. In view of this, many Western countries have come to the need to rationalize the methods of integral assessment of effectiveness based on a balanced combination of evidence-based medicine and clinical and economic analysis. In this regard, it is worth noting the positive experience of a number of foreign countries that have introduced the so-called national guidelines for the economic assessment of medical technologies. The purpose and objectives of developing national guidelines depend on the specifics of health care functioning in a particular country. In most cases, they regulate the sphere of drug supply in the country, less often they serve as the basis for justifying recommendations on the use of a number of medical technologies in the health care system or clinical guidelines for the treatment of patients.
The experience of using economic methods of regulation in the quality management system of medical care in France is noteworthy. In its current form, the French model of healthcare organization took shape at the end of World War II. Originally formed on the basis of budgetary and insurance principles, in the process of creation national system health care, a system of social security funds was formed, which laid a solid foundation for the implementation of the foundations of social democracy. The key factor that ensures the effectiveness of the French model of healthcare is a high level of quality of medical care, the main indicator of which is a high degree of satisfaction of the French population with the system of organization and functioning of healthcare.
According to the Eurobarometer Research Center, 98% of the French population is satisfied with the quality of medical services in their country and do not intend to use medical services in any other country. Overall for the EU-15 and EU-27 countries this indicator is 89% and 83% 9.
A very successful experience of using the tools of clinical economic analysis is demonstrated by the French model of the organization of the ILC. In 2008, the French High Commission for Health Affairs launched the "Project 2009-2011" (Le Projet HAS 2009-2011) program, the most important task of which was to improve the medical and economic analysis of the results of the activities of doctors and hospitals. According to the law on the financing of social insurance, adopted in 2008, the High Commission for Health Affairs was endowed with the function of conducting a medical and economic assessment of the quality of medical care in terms of its economic efficiency, and prioritizing diagnostic and therapeutic services provided in a particular case. Within the framework of the activities of the High Commission, these issues are dealt with by 2 structures - the Commission evaluation economique et de sante publique (CEESP) and the Service for the medical and economic evaluation of health care (Le service Evaluation medico-economique et sante publique (SEMESP) ).
The medical and economic analysis of the ILC in France is based on 3 principles:
1. Independence and impartiality
2. Accuracy and reliability of scientific data
3. Interdisciplinary approach, transversality
The mission of the Health Economic Assessment Commission is to organize and conduct medical and economic analysis, which, in turn, is divided into 3 stages:
1. Comparative analysis of two or more types of medical care (or drugs) for a specific disease in order to choose a more effective and less expensive type of treatment. At this stage, the actual economic assessment is not carried out, however, the results obtained make it possible to determine the amount of budgetary funds in favor of a particular type of medical service.
2. Analysis by the cost-benefit method, comparison of indicators of economic efficiency and degree of risk (patient tolerance of treatment, absence of complications, etc.).
Thus, during the organization of CEA, the effectiveness of using coronary stents with and without the use of a drug coating, it was found that the therapeutic benefit of the introduction of the first type is significantly less compared to
9 Flash Eurobarometer. No. 210. Cross-border health services in the EU. Analytical report. June 2007.
using uncoated stents. In the course of the analysis, it was found that drug-eluting stents are advisable to use in the treatment of only those types of diseases where their clinical advantages are more objective.
3. Conducting a full-scale clinical and economic study, which takes into account the medical efficiency and costs of a particular type of treatment, including the organizational and ethical aspects of the activity. The results of the final analysis are recorded in guidelines for organizing medical practice (for example, recommendations on strategies for detecting and combating HIV diseases) or in re-evaluating types of drug treatment.
The Organization for Medical and Economic Analysis of the Commission is being established with the assistance and cooperation of numerous services, in particular with the Service for the Medical and Economic Assessment of Health of the High Commission. Its main tasks are to carry out directly financial analysis and assessing the cost effectiveness of medical activities, including:
Grade economic impact a specific medical case or medical service (analysis according to the cost of illness method, the cost of treatment, budget expenditures etc.)
Making a decision in favor of a particular type of treatment (medicinal product, type of intervention), taking into account its economic feasibility (cost-effectiveness analysis, cost-minimization analysis)
According to the recommendations of the High Commission voiced during the Conference of Regional Departments in December 2010, the choice in favor of this or that method of economic assessment depends on the specific scope of consideration of a particular issue:
The cost minimization method is advisable in the case where the preliminary analysis revealed the identity of the results of two or more compared treatments.
The cost-benefit method should be applied when the health-related aspect of quality of life is considered and becomes the most important criterion in determining the health development strategy.
The cost-effectiveness method is applicable in all other cases. Typically, this method is complemented by cost-benefit analysis 10.
Clinical and economic analysis in France is extremely important and is seen as a fundamental mechanism for allocating resources in order to maximize the utility and minimize the risk of services provided to the population. CEA applies to all areas of medical activity (diagnostic procedures, prevention programs, methods of treating cancer, etc.), the results of which are further taken into account in the development and publication of guidelines with clinical recommendations. Nevertheless, the final decision in favor of a particular type of treatment or technology is carried out in conjunction with additional results obtained in the course of a systematic analysis of the efficacy and safety of a certain set of medical services, as well as an analysis of complementary factors (social, cultural, etc.) ).
In the context modern stage reforming health care in the Russian Federation, the relevance of the introduction of methods of socio-economic assessment is extremely high. According to leading domestic and foreign experts, clinical
10 Les Rencontres HAS 2010. 2 & 3 decembre 2010. Cite des Sciences et de l "Industrie, Paris-La Villette.
Http://www.has-sante.fr/portail/jcms/c_978353/rencontres-has-2010-2-3-decembre (08.08.2011).
economic analysis is a fundamental element in the development of standards and a system of indicators for the quality of medical services. As domestic and international practice has shown, prescribing drugs without taking into account the requirements of standards often leads to the leaching of funds from the system and irrational financing11.
Alas, in the current environment, even the most convincing results of the conducted economic assessment may ultimately be left out. In the context of constantly growing social, political and financial constraints, the choice can be made in favor of the far from the most economically profitable and effective option, which will inevitably cause regression in the process of reforming the health care quality system.
In the course of developing a step-by-step scheme for the transition to new principles of the functioning of the quality of medical care system, the heads of health authorities need to rely on the experience of foreign countries (including France) in the formation of a unified national policy for managing the quality of medical care. Having formed a single body responsible for the management of the ILC and including clinical and economic analysis as a prerequisite for the accreditation of medical institutions, it will be possible to solve the following tasks:
Establish methodological standards for conducting clinical and economic research to ensure a high level of their quality
Formulate mandatory requirements for the presentation of FEA results for state structures who make decisions on the control and regulation of prices, as well as reimbursement of costs for the provision of medical care;
According to Stanford University professor David M. Eddy, effective policy in the health care system must be based on the recognition that it is necessary to move from the principle of "doing everything that can be useful for the patient" to the principle of "doing what is most beneficial for him personally. and groups of patients and does not harm others ”12.
To solve the problems of the quality of domestic health care, systematic efforts are required, as well as regular monitoring of the implementation of the set goals. It is necessary to find a balance between quality and economy. Medical care that can be achieved on the basis of an interdisciplinary approach and interprofessional agreement on specific goals, objectives and measures for their implementation.
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