How to cure medicine?

The Ministry of Health proposes to "cure healthcare" by reforming funding, standardizing medical services and improving the quality of medical education. Doctors are skeptical: the main thing is the development of competition between medical institutions.

In December, the Ministry of Health and Social Development submitted to the government a concept for the development of healthcare until 2020, which has been discussed by experts and doctors for several years. The concept is published on the website created by the Ministry to organize discussions and prepare amendments to the document. The representative of the Ministry claims that some of the amendments proposed by the forum participants were included in the text submitted to the Cabinet of Ministers.

History of healthcare reformsOver the past twenty years, this is not the first attempt to improve the healthcare system in our country.

There were two main ones.In the late 1980s, medical institutions were transferred to the "new economic mechanism".

Its main idea is to turn the polyclinic into the central link of the entire system. All financial resources were transferred to her. Incentives for effective work for staff were introduced: if patients were sick less often, doctors were given a salary increase. This reform was stopped with the transition of the entire economy to market relations in the early 1990s.

Then the reform of the healthcare system began anew – by transferring it to insurance principles. Mandatory health insurance is deducted from employees' salaries (3.1% from salaries up to 280 000 rubles per year, 1.1% from amounts from 280 000 to 600 000 rubles, over – nothing). Since 2010, at the suggestion of the Ministry, insurance should increase to 5.1% from salaries to 415,000 rubles per year (over – nothing). Budgets pay for children and pensioners; funds are transferred to federal and regional health insurance funds that pay for medical treatment to medical institutions. The insurance mechanism allows medical institutions to pay not for the maintenance of beds, but for the work done.

However, the reform has not been completed, Igor Sheiman, Yaroslav Kuzminov, Anatoly Vishnevsky (Higher School of Economics) and other authors of the report "Russian Healthcare: how to get out of the crisis": "The old budget system was only partially replaced by an insurance one." Currently, about 40% of state financing of healthcare is concentrated in the compulsory medical insurance system (CHI): the remaining funds come from budgets of different levels, which "in the old way" pay doctors not for the work actually done, but for the maintenance of a network of institutions. As a result, it became even worse, the report says: "the eclectic combination of the budget and insurance systems has given rise to a new "disease" of the system — a declining level of responsibility for its financing."

Problems of the current stageIn principle, Russians are used to the current situation: despite the declaration of free medical care, there are practically no really free medical services – they have to pay extra for them.

Due to the low salaries of doctors (in October 2008 – 13,178 rubles, 25.3% lower than the average in the country), they have to go to shady earnings, demanding extra payments even for those procedures that they have to do for free. The quality of services, especially diagnostics, is low.

DemographicsThe demographic situation is gradually improving, but remains unfavorable.

The average life expectancy remains low – 12.5 years less than in developed European countries. The unavailability and inefficiency of medical services exacerbates this problem. The medical system is not ready for the surge in the birth rate, which has been outlined since the late 1990s – early 2000s.

FinanceThe availability of medical care varies greatly from region to region.

According to the Ministry of Health, the actual per capita standards of territorial programs of medical state guarantees are minimal in Ingushetia (1,723 rubles per year), and in Chukotka AO they reach 26,918 rubles. The average standard for the Russian Federation is 5,150 rubles. In 60 regions, health insurance budgets are in short supply.

More than half (in 2007 – 63.4%) of the funds of medical institutions receive from federal and regional budgets, the rest – from the medical insurance system. Budgetary (estimated) financing is considered by doctors not as payment for work, but as payment for the fact that they exist in principle, and clients can come to them.

The scale of the development of paid services is now largely determined by the vagueness of guarantees for the provision of free medical care, and the real activities of doctors are increasingly shifting to the sphere of paid services. In this situation, the nominal guarantee of free medical care, which all Russian citizens have, often turns out to be formal.

As a result, personal expenses of citizens reach 40-45% of the total cost of medical care, according to the report cited above. About 65% of patients have to make additional payments for dentistry, about 50% for treatment in hospitals, and 30% for outpatient care.

"Russian healthcare is mired in corruption. The free and accessible nature of our healthcare is empty words," Vladimir Matsenko, an anesthesiologist from Yaroslavl, writes on the Health 2020 website. Medicine cannot cope with the aging of the population, he notes: there are more and more patients, and the number of medical institutions is not growing.

Inefficient organization system It is necessary to recognize the disease at an early stage, and Russian doctors have to treat neglected diseases.

One of the reasons is the "wrong" ratio between outpatient and inpatient care. Instead of treating some patients on an outpatient basis, doctors often resort to placing patients in a hospital, which costs the state much more. One visit to a doctor in a polyclinic according to the standard of the Ministry of Health is 93.9 rubles, while the standard of costs for one bed-day in a hospital is 549.9 rubles.

Price and qualityOne of the reasons for the insufficient quality of medical services is the low salaries of doctors and their lack of motivation to improve the efficiency of their work.

Although recently the number of workers with salaries below the subsistence level in medicine has fallen to 8%.

The per capita standards increased annually by the Ministry of Health (for 2009 – 5,413 rubles per person per year, 8% higher than last year) do not keep pace with the growing cost of medical services. According to the Ministry of Health, it has increased by 30% over the past year.

The wear and tear of medical equipment in many regions has exceeded 60%, which is why doctors have to treat patients using methods that have long outlived their usefulness. In such a situation, innovative treatment technologies are being introduced very slowly. This situation can be changed only by the construction of new hospitals equipped with modern diagnostic and treatment devices, as well as by increasing the output of doctors of narrow specialization who will be able to use these devices, says anesthesiologist Vladimir Matsenko.

How to solve problems?The concept suggests changing the medical care system in several directions.

In terms of financing, the main task is to transfer the entire system to single–channel financing, when the share of funds received by doctors from the CHI system will grow significantly. This will make it possible to switch from paying for beds to paying for the work done and increase the effectiveness of monitoring the movement of funds, the Ministry of Health hopes. The share of government spending on medicine (now 3.5% of GDP), according to the department's plan, should reach 6-8%, as in developed countries.

Officials are going to increase the level of health in society through various preventive programs.

State guarantees will be specified and brought to a single standard. A set of services and medicines will be established for each disease, the provision of which is guaranteed by the state on a free basis. Accordingly, citizens will understand what they will have to pay extra for.

The state is also going to improve the quality of medical education and, most importantly, the motivation of doctors. The goal is that every doctor should be interested in the fact that there are as few patients as possible, and treatment is more effective.

The lack of highly qualified specialists is one of the main problems of Russian medicine, according to the chief physician of the central district hospital of Kolomna (Moscow region) Vladimir Yudaev. At the same time, the level of medical education is falling. It is necessary to distribute students to hospitals, at least for several years, he believes.

Medicine is approaching a personnel collapse, agrees Irina Semenova, chief physician of the Novgorod Regional Clinical Hospital. "There is no mandatory distribution, it is easier for young doctors to leave their specialty or go to pharmaceutical companies than to work in small district hospitals," Semenova believes.

OpinionsThe concept has caused a lot of discussions among health workers and ordinary citizens.

One of the key ideas of the concept is the transition to single–channel financing – a controversial position, says Evgeny Gontmacher, head of the Center for Social Policy at the Institute of Economics of the Russian Academy of Sciences. "The compulsory health insurance system has not justified itself during its existence," he writes in Rossiyskaya Gazeta. There are several reasons: the first is "the underdevelopment of a network of private companies that could be effective intermediaries between healthcare institutions and patients everywhere." The second is "the physical impossibility of creating a competitive environment in medium and small towns, and even more so in rural areas," writes Gontmacher, and the third is "chronic underfunding of healthcare with the actual impossibility of raising the social tax." In fact, the CHI has turned into just another source of financing for medicine along with budgets, it does not yet have a serious stimulating effect on the work of doctors.

The medical insurance system would have a motivating effect on the work of doctors if patients were completely "untied" from district polyclinics and district doctors to whom they are attached, believes Alexey Tikhomirov, editor-in-chief of the journal "Chief Physician: Economy and Law". It was possible to finance medical institutions when patients have such freedom of choice, for example, through payments from the patient's debit cards, to which his medical insurance had previously been transferred, Tikhomirov suggests. As the services are provided, funds will be debited from such a card.

Most of all, healthcare needs the development of competition between medical institutions, and this is not mentioned in the concept, he notes. Along with the growth of competition for the patient, the quality of services will increase, innovative programs will be introduced, and the demand for the best specialists will increase. The introduction of a single-channel financing scheme alone will not improve the quality of medical services, Tikhomirov believes.

On the website zdravo2020.ru the interested public (mainly doctors) expressed more than 500 detailed proposals and left about 2,000 comments on the concept.

Irina Eliseeva, Boris Grozovsky, "Open Economy" 

Portal "Eternal youth" www.vechnayamolodost.ru12.01.2009