Penalty rules for hospitals. Guilty without guilt? Fine for incorrect registration of a medical policy
Stolyarova E. A., Head of the Legal Department of the State Budgetary Institution “GP No. 3 DZM”, Moscow
Keywords: fines, insurance companies, quality of medical care
Based on the Federal Law of November 29, 2010 No. 326-FZ “On Compulsory Health Insurance in the Russian Federation,” insurance companies monitor the volume, timing, quality and conditions of medical care provided by medical organizations within the framework of compulsory health insurance programs.
Thus, insurance companies in the compulsory medical insurance system are the operator of budget funds, that is, they are given budget money, and they decide whether to give it to medical institutions or not, assessing the quality of medical care. In other words, insurance companies receive money from the state, look at how medical institutions provide assistance or provide medical services in each specific case, and decide whether to pay in full for the case, withdraw some part of the payment for violations, or not completely pay for the case for gross violations. violations.
This law determined the grounds for the application of sanctions, but the document did not give any recommendations regarding the size of fines. In 2011, the Federal Compulsory Medical Insurance Fund issued a separate letter in which it fixed the recommended amounts of fines, while for some types of violations they reached up to 500% of the financial support standard for territorial state guarantee programs per one insured person per year. These recommendations caused a negative reaction in the medical community and the Federal Compulsory Medical Insurance Fund withdrew its letter.
Further, the authority to determine the amount of fines fell on the territorial tariff commissions in the constituent entities of the Federation. The fines, taken almost out of thin air, varied by region, many of which, in the absence of any methodological instructions, continued to be guided by the recommendations of the FFOMS letter that had become invalid.
An analysis of the structure of detected violations showed that 43% of them were due to incorrect execution of medical documentation, which does not directly affect the quality of medical care provided, for example, spelling, syntactic errors or unclear handwriting of the doctor. Moreover, as a result of the application of sanctions for such violations, over 30 billion rubles were recovered from medical organizations in 2015 alone.
Thus, almost half of the identified violations were related to the preparation of documents (medical histories, outpatient records and other medical documentation). Accordingly, the healthcare system lost billions of rubles because of this, which is a blatant injustice, since the preparation of documentation cannot in any way affect the quality of medical care.
But insurance companies are increasingly setting new requirements. For example, in the consent for surgical treatment, in addition to all other columns, there are the following: full name of the patient (I, so-and-so, know what kind of disease I have, such an operation is planned) and then - “I give my consent”, where necessary sign and indicate your full name. Always in the first case, patients were asked to put their full name, and below they were asked to sign with their last name and initials. But insurers at one point came up with the idea that you need to write your full name next to the signature, otherwise they will charge 10% of the cost of the case.
It is also noted that a significant percentage of sanctions are for violations of the quality of medical care, mainly for non-compliance with procedures and standards of medical care. But, as the Accounts Chamber of the Russian Federation has repeatedly noted, there are standards for only half of all diseases. In this regard, it is not clear how health insurance organizations identify violations in relation to diseases not covered by the standards. At the same time, the MHIF does not have information about the imposed sanctions, but only has data compiled by insurance medical organizations. The procedure and legality of the examinations are also not assessed in any way.
Therefore, the National Medical Chamber came to the defense of doctors and demanded that the Ministry of Health “relieve the medical community from the financial yoke” of insurers. As a result, the Federal Compulsory Medical Insurance Fund and the Ministry of Health issued an order designed to regulate the system of penalties.
FFOMS Order No. 130 dated July 21, 2015 “On introducing changes to the procedure for organizing and monitoring the volume, timing, quality and conditions of providing medical care under compulsory health insurance, approved by FFOMS Order No. 230 dated December 1, 2010” defined the grounds for full or partial refusal to pay for medical care. These include, for example:
- defects associated with violation of the conditions for the provision of medical care provided routinely to insured persons (identified by insurance medical organizations in the event of non-compliance by medical organizations with the provisions of the legislation of the Russian Federation, procedures for the provision of medical care, contracts for the provision and payment of medical care regulating these conditions (including including the timing and availability of planned care, routing if there are indications for hospitalization));
- defects associated with causing harm to the health of the insured persons (in case of deterioration of health, expressed in bodily injuries, diseases, pathological conditions resulting from the action of mechanical, physical, chemical, biological, mental and other environmental factors, as well as inaction in that case , if it caused a deterioration in health);
- cases of violation of medical ethics and deontology by employees of a medical organization, proven in accordance with the procedure established by the legislation of the Russian Federation, when they fail to comply with accepted ethical standards and principles of behavior of medical workers in the performance of their professional duties;
- failure to perform, untimely or improper performance of necessary or performance of unindicated, unjustified from a clinical point of view diagnostic and (or) therapeutic measures, surgical interventions in accordance with the procedures for the provision of medical care, standards of medical care and (or) clinical recommendations (treatment protocols) regarding the provision of medical care or premature, from a clinical point of view, termination of treatment measures in the absence of a clinical effect, is established in case of complete or partial non-compliance (either in the direction of decrease or excess) of the medical care provided to the insured person with the mandatory requirements provided for by the legislation of the Russian Federation, federal regulatory legal acts executive authorities, as well as those carried out without taking into account the patient’s health status (information about the presence of contraindications or individual indications, medical history data);
- violation due to the fault of a medical organization of continuity of treatment, unreasonable or non-core hospitalization of the insured person (identified by the insurance medical organization when the medical organization violates the procedures for providing medical care and the established criteria for hospitalization, including the absence of medical indications for the patient to stay in a 24-hour hospital for therapeutic and diagnostic measures or hospitalization in a medical organization or department that does not have the appropriate license to provide this type of care (implementation of technology));
- development of an iatrogenic disease (detected when a person’s health status deteriorates or a new disease arises due to the adverse consequences of any medical influences);
- absence of objective reasons for the failure to provide primary medical documentation confirming the fact of providing medical care to the insured person in a medical organization (with the exception of: seizure of documentation by authorized bodies, the presence of an official request from the insured person (representative), issued in the manner established by the legislation of the Russian Federation);
- defects in the preparation of primary medical documentation that complicate work with documentation, impede the examination of the quality of medical care and create the impossibility of assessing the dynamics of the health status of the insured person, the volume, nature and conditions of the provision of medical care (identified by the medical insurance organization if the medical organization violates the rules for processing medical documentation
On October 2, 2016, the Ministry of Justice registered order No. 536n of the Ministry of Health of the Russian Federation, which regulates sanctions applied to medical institutions by insurance companies. Order No. 536n dated August 6, 2015 “On amendments to the Rules of Compulsory Medical Insurance, approved by Order of the Ministry of Health and Social Development of the Russian Federation dated February 28, 2011 N 158n” approved the methodology for calculating fines and incomplete payment of medical care costs.
The size of sanctions is now calculated using mathematical formulas with several parameters: the size of the tariff for payment of medical care, the value of the per capita funding standard and coefficients established in accordance with the list of grounds.
On average, new fines were lower than existing ones. For example,
- sanctions for failure to perform a mandatory pathological autopsy are 30% of the tariff cost;
- for treatment that led to a deterioration of the patient’s condition - 40%;
- for premature discharge of a patient leading to re-hospitalization - 50%;
- for non-core hospitalization - 60%.
However, the order that reduced the fines did not offer anything to eliminate the reasons for their unfair collection. As medical workers say, insurance company employees are not interested in the results of treatment; their bonuses and salaries depend only on the number of flaws they find in the documents filled out by doctors.
According to Federal Law No. 326 FZ, medical organizations are obliged to:
Provide medical care to insured persons within the framework of compulsory medical insurance programs free of charge. Keep individual records of information about medical care provided to insured persons in accordance with the current Federal Law. Medical organizations are required to provide insurance organizations and the territorial fund with information about the insured person. Provide information about the medical services provided to him, necessary for monitoring the volume, quality, timing and conditions of medical care. The duties also include the provision of reporting on activities in the field of compulsory health insurance, in the manner established by the Federal Fund and in the appropriate forms. Health care delivery organizations must appropriately utilize targeted programmatic funding. Use compulsory health insurance funds received for medical care provided in full compliance with compulsory health insurance programs. Organizations are obliged to inform the population about the procedures for providing medical care. Post on your official website on the Internet information about operating hours and types of medical care provided. Must provide insured persons, medical insurance organizations and the territorial fund with information about operating hours, types of medical care provided, indicators of accessibility and quality of medical care. Perform other duties in accordance with this Federal Law.<6>
Medical organizations enter into contracts for the provision and payment of medical care under compulsory health insurance. Providing medical care within the framework of compulsory medical insurance. Part 2 of Art. 39 of the Law on Compulsory Medical Insurance establishes that under an agreement for the provision and payment of medical care under compulsory health insurance, a medical organization undertakes to provide medical care to the insured person within the framework of the territorial compulsory health insurance program, and the insurance medical organization undertakes to pay for medical care provided in accordance with the territorial program compulsory health insurance.
Providing medical care of appropriate quality. Based on the provisions of Part 1 of Art. 16, paragraph 10, part 2, art. 38 and parts 8 of Art. 39 of the Law on Compulsory Medical Insurance, a medical organization is obliged to provide medical care of adequate quality, and only in this case is such care subject to payment.
The procedure for applying economic measures to medical institutions provides for penalties. The list of sanctions applied in a particular case of non-fulfillment or improper fulfillment of its obligations is developed by the Federal Fund as a supervisory control body. The amount of the penalty depends on the severity of the violation and its consequences. The composition of the violation is determined by conducting a medical and economic examination. After the expert has drawn up a report, the information is transferred to the Territorial Fund, where a decision is made on the application or non-application of the measure and its size. In some cases, penalties against an organization are accompanied by cases separated into separate criminal proceedings that provide for personal liability.
A methodology has been developed for determining the amount of penalties for medical organizations. The size of the financial support standard for the territorial compulsory health insurance program per one insured person in the current year is taken as a constant value.
- 1) The amount not subject to payment based on the results of medical and economic control, medical and economic examination, examination of the quality of medical care is withheld from the amount of funds provided for payment for medical care provided by medical organizations, or is subject to return to the medical insurance organization in accordance with the contract for the provision and payment of medical care under compulsory health insurance, a list of grounds for refusing to pay for medical care or reducing payment for medical care in accordance with the procedure for organizing and monitoring the volume, timing, quality and conditions of providing medical care.
- 2) Mutual obligations of medical organizations and medical insurance organizations, the consequence of which is the possibility of non-payment or incomplete payment of the costs of providing medical care, as well as payment by a medical organization of a fine for failure to provide, untimely provision or provision of medical care of inadequate quality, are provided for in the agreement concluded between them for the provision and payment for medical care under compulsory health insurance and the procedure for paying for medical care under compulsory health insurance established by the rules of compulsory health insurance.
- 3) Non-payment or incomplete payment for medical care, as well as payment by a medical organization of fines for failure to provide, untimely provision or provision of medical care of inadequate quality does not exempt the medical organization from compensating the insured person for harm caused through the fault of the medical organization, in the manner established by the legislation of the Russian Federation.
- 4) The provisions of the Law require a health care institution to spend compulsory medical insurance funds to pay for medical care for its intended purpose. For violation of these norms, the organization pays a fine in the amount of 10% of the amount of misuse of compulsory medical insurance funds and a penalty in the amount of 1/300 of the Bank of Russia refinancing rate in effect on the day the sanctions were imposed for each day of delay.
Few people know that a hospital or clinic that does not provide a patient with qualified care in a timely manner faces not only sanctions from the insurance company in the form of non-payment of bills, but also fines specifically provided for such cases. This method of monitoring doctors began to operate not so long ago, but has already caused a serious resonance in the medical environment.
It all started with the fact that at the end of 2010 the law “On compulsory health insurance in the Russian Federation” (dated November 29, 2010 No. 326-FZ) came into force. Article 41 of this law stipulates that medical organizations are subject to sanctions for violations identified during monitoring of the volume, timing, quality and conditions of medical care. In accordance with the law, a medical center can now be punished in three ways: the insurance company may not pay for the medical service provided, not pay for it in full, or impose a fine on the hospital or clinic.
Insurers punish...
The list of defects in the provision of medical care, for which punishment is provided in the form of non-payment or incomplete payment for medical services, is recorded in the order of the Federal Compulsory Medical Insurance Fund (dated December 1, 2010 No. 230). Defects that, if detected, may result in a fine for a medical organization, are listed in the Tariff Agreements. They, in turn, are signed by regional health authorities, territorial compulsory medical insurance funds, representatives of trade unions of medical workers, professional non-profit medical organizations or their associations, and medical insurance companies. For example, in the Nizhny Novgorod region in 2014, penalties can be imposed on medical organizations for 39 types of violations, in the Tyumen region - for 43 types of violations.
If we move on to the details, a clinic or hospital can be fined, for example, for an unreasonable refusal to provide free medical care to an insured person, for identified defects in medical care that led to a deterioration in the health of the insured person, his disability, or death. Fines can be imposed for falsification of medical documentation, for non-compliance by staff with medical ethics and deontology.
...doctors are indignant
Not long ago, a statement appeared on the official portal of the National Medical Chamber (NMC) that the medical community considers the adopted system of fines to be a “financial yoke” of insurance organizations and requires a review of the relationship in the compulsory medical insurance system. “It’s time to start a serious conversation about the effectiveness of the existing health insurance system, about the functions of health insurance companies in Russia, about the system of sanctions that are now applied to medical organizations,” Leonid Roshal, the president of the National Medical Chamber, bluntly states.
“The amount of sanctions for some types of violations reached up to 500% of the standard for financial support of territorial state guarantee programs per one insured person per year,” representatives of the NMP are indignant.
“Currently, medical organizations perceive penalties from insurance companies as excessively high, based on formal criteria and in no way affecting the quality of medical care. There is an opinion that insurers simply “make money” from medical organizations,” they declare on the NMP website. However, representatives of the National Medical Chamber nevertheless refused to personally comment on the situation, citing the incredible busyness of all the experts.
What is the strength? Really?
At the same time, insurers are confident that all complaints from the medical community that the imposed penalties are ruining medical organizations are exclusively populist in nature. At the same time, they refer to numbers, hinting that they are a stubborn thing! “There is data from the Federal Compulsory Compulsory Medical Insurance Fund. In 2012, the amount that medical organizations received less due to defects identified as a result of inspections amounted to 26.3 billion rubles. For comparison: in 2011 - 21.7 billion rubles. This is only 3.6% of the total amount of money sent to medical organizations for the assistance provided,” Nina Galanicheva, General Director of the ROSNO-MS company, cites data. - In addition, medical organizations paid 203.7 million rubles in fines, which is a meager 0.8% of the total amount of sanctions imposed. As can be seen from the presented figures, the amount of fines imposed on medical organizations is very small.”
As it turns out, not all doctors are so concerned about possible fines. On the contrary, some members of the medical community believe that insurers today play an important role in monitoring physicians. “If the hospital has not fully complied with the standards of medical care, then the insurance company may not pay for its services, and this is correct,” Evgeniy Achkasov, a professor at the Moscow Medical Academy, is confident in his point of view. THEM. Sechenov. - Today, the insurance company is one of the guarantors of the quality of medical services. It is clear that we need to talk about improving the examination of the quality of medical care. This is absolutely accurate."
The professor is sure that the only problem is that insurance company experts are often divorced from medical practice. “They lose their professional qualifications if they don’t work in a hospital. Now there is talk that insurance experts should simultaneously conduct practical medical activities,” says the professor.
Criterion of truth - practice
In practice, everything happens like this: both expert specialists from insurance companies and quality of medical care experts hired by insurers for this work are involved in identifying violations. The functions and scope of activity of these categories of experts are strictly delimited by the regulatory documents of the Federal Compulsory Medical Insurance Fund.
For example, in accordance with the current legislation, an examination of the quality of medical care can only be carried out by a quality expert of medical care, who is a medical specialist with a higher professional education, a certificate of accreditation of a specialist or a certificate of a specialist, and at least 10 years of work experience in the relevant medical specialty. He must also undergo training in expert activities in the field of compulsory medical insurance and be included in the territorial register of experts in the quality of medical care.
Today, the Unified Register of Medical Care Quality Experts includes more than 10,500 specialists, of which 9,126 have a qualification category, 2,988 doctors have an academic degree of candidate or doctor of medical sciences. Among them are 2,388 heads of departments, departments, heads (deputy heads) of medical organizations. “Knowing the composition and qualifications of the experts included in the register and attracted to conduct quality examinations, the repeated statements of individual health officials that the examination is carried out by doctors who do not have the necessary qualifications seem strange to us, to say the least,” complains Nina Galanicheva.
Let us remind you that all bills of hospitals and clinics that are received by the information and analytical department of the insurance company are processed by economists and financiers. After which they decide to pay 100% of the invoiced amount or apply financial sanctions.
“The bill arrived, we immediately check whether the patient for whom the bill was issued belongs to our insurance company,” says Lyudmila Ovsyannikova, director of the St. Petersburg branch of the Capital-Policy Medicine Insurance Company, about the decision-making procedure. - Since the patient, for example, could re-insure himself with another company two days before the insured event. In addition, the correctness of the invoice is monitored: whether all fields are filled out, the patient’s passport details, the date of service, the type of service. This is followed by a medical and economic examination with a visit to a medical organization. We check there whether the patient was actually in the hospital or went to the clinic, and whether there is a record of the medical care provided. We are checking medical documentation." According to the expert, there are cases when the insurance company is billed for seven days of hospital stay, but in fact the recording is interrupted on the fifth day. Two days of treatment go into the so-called registration. This is all revealed as a result of a medical and economic examination.
A medical organization can appeal the conclusion of the insurance company within 15 working days from the date of receipt of the report. The claim can be sent to the territorial compulsory medical insurance fund, which, within 30 working days from the date of receipt of the complaint, organizes its consideration and carries out the necessary checks. If you disagree with the conclusion of this department, you can always go to court.
At first glance, it may seem that all these unrest around the compulsory medical insurance system may negatively affect the process of private medical institutions entering the compulsory health insurance system. However, according to experts, this is not entirely true. “The possibility of private entrepreneurs coming from medicine is a desirable and necessary stage in the development of the medical services market in Russia,” says Nina Galanicheva. “The financial resources allocated by the state for the implementation of the state guarantee program for compulsory medical insurance are sufficient to motivate the business community to work in this system.” Lyudmila Ovsyannikova agrees with her: “Many private clinics want to enter the compulsory medical insurance system. It would seem that this is not profitable for them, because the level of requirements is very high compared to the injection of financial resources. It is believed that the tariffs are low, although in fact, today the level of tariffs is decent.” Compulsory medical insurance is a guaranteed source of financing medical care, experts say. “A private medical organization knows that, for example, it is guaranteed to receive 30% of its budget, even taking into account possible refusals; the receipt of funds from private sources does not guarantee the stability of the monthly budget,” summarizes Ovsyannikova.
The issue of private owners entering the compulsory medical insurance system is not decided by medical insurance organizations. There is a special commission that holds monthly meetings where a decision is made on who is included in the compulsory medical insurance system, on what basis and for what volume of medical care. Private entities want to enter the system, but local health authorities are more focused on urban medical institutions and strive to ensure that financial resources are distributed between them. This is understandable; we need to develop our healthcare system territorially.
In conclusion, we can say: it will be increasingly difficult for medical organizations to receive compulsory medical insurance funds without a serious level and degree of responsibility in the near future. This is demanded by both the social policy of the state and citizens. Medical organizations in general and doctors in particular will have to accept these realities of the times.
07.07.2017
It was decided to compensate for material damage associated with claims from medical insurance companies against the work of the Seversk Central District Hospital by withholding the lost amounts from the salaries of doctors. This was reported by Yugopolis with reference to the independent media outlet of the Seversky district, Narodnaya Gazeta.
As you know, Russia has a state system of compulsory health insurance (CHI). The free medical care that citizens receive in healthcare institutions is paid to hospitals and clinics by insurance organizations operating in the compulsory medical insurance system. But they have the right to control the work of medical institutions. And if they identify violations in the quality or execution of services provided to the patient, the insurance company can “punish” the hospital with penalties. The reasons for imposing penalties may be incorrect preparation of medical documentation (for example, spelling, syntax errors or unclear handwriting), non-compliance with procedures and standards of medical care. Insurers actively use this mechanism.
According to the document at the disposal of Narodnaya Gazeta (Minutes No. 7 of the meeting of the medical commission based on the results of internal control of the quality and safety of medical activities dated July 25, 2016, chaired by the head physician of the Seversk Central District Hospital M.A. Ananikov), the amount of fines of medical insurance companies in the amount RUR 2,595,414.02 It was decided to compensate at the expense of “doctors responsible for economic losses and causing material damage to the institution” - “in the form of deprivation of incentive payments, as well as other payments not provided for in the employees’ employment contracts until the material damage caused to the employer is fully repaid.”
The list of those “at fault” includes 58 doctors. Two gynecologists at the Seversk Central District Hospital must pay more than 26 thousand rubles each; two local therapists - 62 and 71 thousand rubles; three more local therapists - 232, 223 and 188 thousand rubles. respectively.
According to the newspaper, the head physician of the Seversk Central District Hospital and his deputies, who are responsible for the work of doctors and the quality of medical services they provide, are not on the list of employees from whose salaries are subject to deduction.
According to the “fined” doctors, no one at the Central District Hospital notified them about the “sanctions”, and many found out about them only when they signed their payroll. Those who became indignant were told: remain silent or you will never receive any bonuses at all.
Seversky lawyer Sergei Bogdanov considers deductions from doctors’ salaries illegal.
At the request of Narodnaya Gazeta, Nikolai Chernyshuk, head of the regional public organization Right to Health, commented on the situation with the deprivation of payments to doctors in the Seversk Central District Hospital:
Different medical institutions deal with fines differently. Someone is trying to reach an agreement with the insurance company, someone is introducing an internal review of medical records, someone is defending illegal fines in court. But if sanctions do occur, the administration often resolves the issue at the expense of its employees. You need to understand that the total amount of money received by a doctor consists of several components - salary, tariff rate, additional incentives and compensation payments. The first two parameters are quite difficult to change, and they are fixed. Compensation payments, according to the law, are also difficult to change - this is only possible if working conditions change. Another thing is incentive payments, which, in essence, are the good will of the employer, the so-called bonuses; by law they are at least 30%. The hospital budget has a certain amount of money for incentive payments, which is distributed among all team members depending on a joint decision, with the participation of the administration, representatives of the trade union, and representatives of the workforce. In practice, the manager usually personally decides who gets extra pay and how much, and who doesn’t, which is a mechanism of influence on doctors.
According to Nikolai Chernyshuk, the “punished” medical workers of the Seversk Central District Hospital have every reason to appeal the actions of the hospital management.
The editors of Narodnaya Gazeta announced their intention to transfer the documents at its disposal, indicating the “punishments” of doctors of the Seversk Central District Hospital, to the prosecutor’s office with a request to conduct an investigation.
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According to the results of inspections in 2013, it turned out that insurance companies withheld about 50 billion rubles from medical organizations - almost 4% of the annual budget of the federal compulsory medical insurance fund. A significant part of these funds “settled” in the companies themselves. In the coming years, the amounts that insurers will be able to keep for themselves “to conduct business” will become even greater, experts warn: due to the transition to single-channel financing, the bulk of the money will go to healthcare through territorial compulsory medical insurance funds and insurance companies. At the same time, insurers do not defend the rights of patients in any way, but are focused “on identifying paper flaws in the work of doctors.”
Where does the profit come from?
Experts from the Independent Monitoring Foundation “Health” have calculated what share of the budget for compulsory health insurance “settles” in insurance companies. “According to our experts, up to 4% of these funds remain in medical insurance organizations in the form of deductions, write-offs, and fines from medical institutions. This is about 50 billion rubles,” said Eduard Gavrilov, director of the Health Foundation. He recalled that, according to the law, medical insurance organizations in the field of compulsory medical insurance not only receive a budget for conducting business, but also make a profit. It consists of money that hospitals and clinics “unreasonably presented for payment” (insurers receive up to 30% of these amounts), fines for medical care not provided or provided late, as well as medical care of inadequate quality (insurance companies take up to half of these fines) and “ savings" (from which insurers receive 10%).
According to Gavrilov, all control measures, as well as assessment of the quality of medical care, should be carried out only by government agencies, and not by commercial organizations “living off the funds allocated for free medicine for citizens.” Moreover, already next year, due to the transition to single-channel financing, the bulk of funds will begin to flow into healthcare through territorial compulsory medical insurance funds and insurance companies. And if in 2013 the total budget of the Compulsory Medical Insurance Fund was about 1 trillion rubles, then in 2015 it will grow to 1.4 trillion rubles.
“Today, a huge flow of money has flowed into healthcare through territorial compulsory medical insurance funds and medical insurance organizations, and the amounts that insurers, by law, can keep for themselves “to conduct business” are becoming gigantic,” Gavrilov believes. Moreover, these “cases” sometimes look very peculiar: one of the insurance organizations last year purchased 22 tennis tables, and also paid its employees for the services of a massage therapist using unconventional methods of treatment.
The Federal Compulsory Medical Insurance Fund, in response to a request from Mednovosti, clarified that insurance companies did not have all the money withheld from hospitals, but only a part. “Based on the results of inspections in 2013, medical insurance organizations withheld about 50 billion rubles from medical organizations. At the same time, according to the law, 1.7 billion rubles were allocated for the formation of own funds from funds unreasonably presented for payment by medical organizations, identified during an examination of the quality of medical care, and funds received as a result of payment of fines by medical organizations for the provision of medical care of inadequate quality. The remaining funds in the amount of 48.3 billion rubles were returned to the territorial compulsory medical insurance funds and were again used to pay for medical care in medical organizations,” the FFOMS reported.
For comparison, 1.7 billion rubles is a quarter of the budget of the territorial compulsory medical insurance fund of a small Russian region (for example, in the Kaluga region in 2013 it was 7.5 billion rubles). And we are talking only about “premium” ones. According to the Health Foundation, Russian medical insurance organizations (61 in total) received 24 billion rubles from the budget in 2013 directly for business management.
No patients needed
At the same time, as doctors say, insurance company employees are not interested in the results of treatment. Premiums and salaries of insurers depend only on the number of flaws they find in the documents filled out by doctors. “Insurers especially like to come with checks in the spring, before the summer - in order to receive good bonuses for the holidays,” said a doctor at one of the clinics in Lipetsk. - The believers take a few cards selectively and start digging. Either the analysis is not confirmed, or after the analysis there is no description and treatment is prescribed without taking this analysis into account. It's just written illegibly. But when there’s a huge line of patients outside the door and a bunch of paperwork needs to be filled out, there’s no time for calligraphy. And you can’t prove that you looked at this analysis.”
“Everyone is afraid to contact insurance companies; it is absolutely impossible to challenge their sanctions,” adds a local pediatrician from the Moscow region. - I had a case when a mother brought her child for an examination after visiting the dentist. On the same day they had an appointment with an ophthalmologist. As a result, the inspectors left the service only to the dentist, the ophthalmologist and I were crossed out, and even fined, accusing us of making additions. Even the intervention of this child’s mother did not help.” According to her, the situation is no better in hospitals, where doctors are fined for “overexposure” of patients. As a result, patients are not left in the department a single day longer than expected, even if they get worse. Moreover, as the doctor explained, doctors urgently remove patients from a dangerous state and then discharge them. “If a person becomes ill on the day of discharge, he will be taken out of this state and discharged anyway,” said MedNews’ interlocutor. “I witnessed the scene when relatives came to pick up my grandmother from the hospital and waited until the evening while they cleaned her up. The patient experienced a glycemic coma, but the manager. department (by the way, a very competent endocrinologist) categorically refused to leave her until the morning, fearing fines.”
According to the consultant of the Open Institute of Population Health, professor at the Higher School of Economics, Doctor of Medical Sciences. Kirill Danishevsky, there is nothing surprising in the behavior of insurance companies, because the goal of any commercial organization is to make a profit. And the audits carried out in hospitals are legal: the insurance company has the right to know what it paid for. What’s worse is that fines from medical institutions become an end in themselves, and no one thinks about the interests of the patient. “Patients don’t even know that they received actually defective medical care,” the expert explained to Mednovosti. -- The insurance company, based on the documentation remaining after treatment, concludes that the patient received poor-quality care, fines the hospital, and does not consider it necessary to inform the patient about this. It’s not like we should compensate him for something or give him additional examination and treatment.”
“At the moment, experts from insurance companies check (on paper) the compliance of medical care with approved standards, as well as the justification for the provision of a particular service,” says Danishevsky. - Simply put, the medical documentation should show the compliance of the treatment with the data of the examination. But filling out documentation is not a medical service, and the quality of its completion is not the quality of treatment. Moreover, as you know, a third, or even half, of the doctor’s appointment time is spent on paperwork.” According to the expert, the Russian health insurance system itself “is artificial.” “By their nature, insurers must compete with each other, choose medical institutions, and negotiate with them,” he says. “We don’t have anything like that, and therefore there is no opportunity to boost the quality of work of institutions.”
The President of the Society of Evidence-Based Medicine, Vasily Vlasov, also does not consider the activities of Russian insurance companies to be real insurance. “These companies do not raise money and do not pay insurance claims,” the expert explained to Mednovosti. - They receive money from the territorial compulsory medical insurance fund and pay for the work of medical organizations, while keeping part of the funds. That is, the state uses a private intermediary to transfer public money to public hospitals. Many people do not understand this system. Therefore, some say that insurance organizations should be made state-owned, while others say that they are not needed at all. I am one of those who believe that these companies should be abolished and the work of government agencies should be paid for without intermediaries.”
However, according to the president of the non-profit foundation “Supporting the welfare and health of the nation “Assistance””, Doctor of Law. Vsevolod Sazonov, the situation could be corrected using less radical methods, by establishing real control over the activities of the insurance organizations themselves. According to him, although the Rules of Compulsory Medical Insurance establish a procedure for insurance organizations to disclose information about the financial results of their activities, this is no longer enough. “It is necessary to establish clear controls and supervision over this activity at the legislative level,” says Sazonov.
But despite the difference in approaches, all experts agree on one thing: the current operating system of insurance companies is no good. It “eats up” a considerable part of the budget, but at the same time it complicates the lives of doctors and does not help patients in any way.
Irina Reznik
Comments (25)
27.11.2014 11:42
DoctorNorth
Before the New Year, they will again go to hospitals to collect for Thailand
27.11.2014 12:29
It’s time to put an end to these insurance companies making money out of thin air (actually stealing the country and medicine, in particular). Tighten penalties for corruption, as in China (for the conspiracy of a group of people to harm the state by stealing funds, ultimately causing harm to the health of the people as a result of curtailing programs (ex. oncology). This is the so-called planned mortality due to failure to provide medical care (no drugs , childbirth in SP cars due to the destruction of unprofitable maternity hospitals (sanitary aviation does not fly for childbirth).According to Lenin - red terror to white terror, otherwise we will lose our country and people!
27.11.2014 13:20
Doctor
Alas, that's all true!!! I don’t want to work in a hospital because of this nonsense!
27.11.2014 14:22
Doctor A.S.
“According to the results of inspections in 2013, it turned out” - somehow “suddenly” it turned out... I have known this since the 90s.
27.11.2014 15:11
Man from compulsory medical insurance
Custom-made material for the purpose of discrediting insurers.
27.11.2014 16:02
Ivan
It is necessary to eliminate commercial insurance organizations and switch to non-profit ones, as in Germany. So that the money goes not to shareholders, but back to the healthcare sector. And what needs to be checked is not how the doctor fills out the paperwork, but the quality of the medical care provided.
27.11.2014 17:39
Guest
What is insurance? When you buy compulsory motor liability insurance, you get the opportunity to compensate for your losses for a certain amount. Not a penny more! I took CASCO insurance - the amount is different, the conditions are different. What is the point of health insurance? No one finds out how much you actually contributed to the insurance fund, and whether you contributed at all. Help is provided according to standards. This is a simple money distribution system. And weaning too. Isn’t it easier to distribute them “personally” or some other way? We would be better off in terms of the number of square kilometers in the region. And return to clear and transparent “rates” for health workers. Without any incentives or anything.
27.11.2014 20:31
Lonelyowl
Insurers demand treatment and examination “according to standards,” and they did not care about the words of our minister that “standards are not for treatment, but for planning.” There are simply no standards as such, as a result, these “great doctors” in insurance companies, who have never even cured anyone’s runny nose in their lives, have invented a bunch of their own standards, which they demand compliance with. From what point these “standards” are based, no one knows. Complete nonsense; but if you don’t do it, they’ll fuck you. These farriers have no idea about an individual approach.
28.11.2014 00:05
Reader
Where can I get acquainted with these standards for 2014-2015?
28.11.2014 00:08
Guest
Why these intermediaries at all?
A lot of money is spent on offices, employees, profits, etc.
Those who work there are often those who were asked to come from medicine, because they are not good as doctors.
But they felt like bosses, whom everyone was afraid of, otherwise they would kill them.
What is the point of their work? Cut up the state ones, i.e. our money?
Voluntary insurance is clear here.
What about the state one? What is the raison d'être for these companies?
28.11.2014 06:35
Endosurgeon
Guest
They have been robbing us for 20 years, and you just have a question - why are they needed? This is obvious, they were immediately invented to steal. “Insurance is theft,” this is the rhyme of the former Minister of Health Shevchenko, after which he quietly disappeared from the horizon.
28.11.2014 07:18
Doctor
To the reader
Officials of various stripes are very fond of talking about standards and protocols, but no one has ever seen them in real life and who knows where you will find them.
28.11.2014 17:26
Ivan
@Guest
28.11.2014 17:27
Ivan
@Guest
We don’t know why we have them. In a working system, insurance companies check the quality of care provided and help the patient receive compensation for damage if any was caused to the patient. He also advises the patient about the possibility of receiving medical care (Where, what kind, possibilities of rehabilitation, spa treatment). Dedicated to promoting a healthy lifestyle.
- Penalty rules for hospitals
- Where and how to change the compulsory medical insurance policy when changing your last name: features, requirements and recommendations
- Medical policies: types of policies and validity period How long is a health insurance policy valid?
- Normalized safety stock of the territorial compulsory medical insurance fund inspection