Health care financing in the context of compulsory health insurance. Organization of compulsory health insurance at the present stage of healthcare development Funded by compulsory medical insurance

The procedure for financing the costs of health care facilities for the provision of inpatient and outpatient care to the population within the scope of the territorial compulsory medical insurance program for the year is approved by the territorial compulsory health insurance fund. (Appendix 4).

In accordance with it, payment for medical services is made for a completed case of hospitalization based on registers and a summary report, and can be carried out in three options:

1. at a tariff differentiated in accordance with the medical and economic standard (MES) or part thereof;

2. at the cost of one bed-day, in accordance with the standards for the purchase of medicines, consumables and food in the departments of health care facilities - in the absence of MES - for individual nosologies;

3. at the cost of one bed-day for the purchase of medicines and consumables in departments of health care facilities before calculating MES tariffs.

Financing of outpatient and inpatient care depends on the volume and level of quality of care provided. Expense items included in the tariff for medical services are determined by the tariff agreement for payment of medical services in the compulsory health insurance system. The tariff agreement is an interdepartmental document, the development and approval of which involves the Government of the Urals, the Ministry of Health of the Urals, the Ministry of Finance of the Urals, the Ministry of Economy of the Urals, the Price Committee under the SM of the URs, the territorial fund of compulsory medical insurance of the URs, as well as representatives of insurance companies and the association of doctors of the URs. In accordance with this document, health care facilities can spend funds from the territorial insurance fund only on food for patients, medicines and soft equipment, as well as on salaries and accruals.

When using funds from compulsory medical insurance, health care facilities are required to reimburse expenses under the heading “Medicines and dressings.” The remaining financial resources are used for other expense items listed above, determined by the tariff agreement.

By the decision of the conciliation commission on tariffs for medical services in the compulsory medical insurance system, standards for expenses for food, the purchase of medicines and consumables for departments of health care facilities are approved and indexed per bed-day. So, for example, by order of the Federal Compulsory Compulsory Compulsory Medical Insurance Fund No. 46 dated March 19, 1996, standards for food costs per 1 bed-day in various health care facilities and departments were approved from 1,407 rubles. (in departments for newborns) up to 39,061 rubles. (in departments - burns, neurosurgical, hematology). For the purchase of medicines and consumables, standards ranged from 6,646 rubles. in therapeutic, up to 33,205 rubles. in surgical purulent departments.

Compulsory medical insurance funding is not provided for:

1. payment for treatment of socially significant diseases;

2. payment for diseases caused by HIV infection;

3. payment for treatment of military personnel;

4. medical assistance classified as expensive (according to the relevant list of the Ministry of Health of the Russian Federation dated 04.03.95

Planned medical care for citizens of the Russian Federation insured outside the Russian Federation is paid if there is a referral from the health authorities of the territory of residence and a letter of guarantee from the territorial compulsory medical insurance fund for payment of medical services.

The essence of the compulsory medical insurance organization

Note 1

The fundamental purpose of compulsory health insurance is the collection and accumulation of insurance premiums, as well as the provision of medical care to all citizens using the accumulated funds on legally established conditions and in guaranteed volumes.

In this regard, the compulsory medical insurance system must be considered from two points of view. According to one opinion, this is an integral part of the system of social state protection of its own population, along with social and pension insurance. This is the social significance of compulsory health insurance. According to another opinion, compulsory medical insurance is a financial mechanism for attracting additional financial resources to budget allocations, allocated for subsidies to healthcare and medical services. This is the economic significance of compulsory medical insurance.

Note 2

In Russia, compulsory medical insurance covers only medical care for the population. Reimbursement of earnings that were lost during the period of illness is implemented within the boundaries of another state system - social insurance and is not recognized as a subject of compulsory medical insurance.

Principles of organization and financing of compulsory medical insurance

Compulsory health insurance is one of the most important elements of the healthcare system and the acquisition of necessary medical care in the event of a disease. In the Russian Federation, compulsory health insurance is organized and implemented by the state, and therefore has a universal character.

This means that the state, represented by its executive and legislative bodies, determines the main principles of organizing compulsory health insurance, establishes the tariffication of contributions, the composition of insurers, and creates specialized state funds for the accumulation of contributions for compulsory medical insurance. The universality of compulsory medical insurance lies in ensuring for all categories of citizens of the Russian Federation guaranteed equal opportunities to receive medicinal, medical and preventive care in the volumes established by the state programs for compulsory medical insurance.

The funds of the state system for compulsory medical insurance are made up of mandatory contributions from various categories of insurers. Compulsory medical insurance policyholders, that is, those entities that pay insurance premiums to provide health insurance to all citizens, are:

business entities;
local executive authorities.

All business entities, regardless of organizational and legal forms and forms of ownership of activities (individual entrepreneurs, employers, farms) are obliged to pay insurance premiums for the working population as part of the single social tax. Tariffication of insurance premiums is established on a regressive scale depending on the category of taxpayers.

Insurance contributions are paid on all payments accrued to employees in kind and in cash, excluding payments made from net profit, compensation payments, social benefits and some others. The amounts of accrued contributions are paid to the accounts of the Federal Treasury every month, no later than the fifteenth day of the following month.

Policyholders submit payment orders for the deduction of insurance premiums to the bank simultaneously with the provision of documentation for the issuance of funds for wages. The Federal Treasury authorities undertake to transfer the incoming amounts of contributions to the accounts of the corresponding compulsory medical insurance funds within 24 hours. Policyholders are responsible for the correct calculation and timely payment of insurance premiums. For violation of the procedure for paying insurance premiums, various financial sanctions are applied to them, which are provided for by the Tax Code of the Russian Federation.

For the non-working population, compulsory medical insurance premiums are obliged to be paid by the executive branch of government, taking into account the volume of territorial compulsory medical insurance programs within the limits of the funds provided for by the relevant health care budgets. The non-working population includes:

Children;
Students;
Disabled people;
Pensioners;
Unemployed.

Bodies of the executive branch of government undertake to transfer funds for compulsory medical insurance of the non-working population every month, no later than the twenty-fifth day, in an amount of no less than the quarterly amount of funds that are provided for these purposes.

The allocation of funds to territorial compulsory medical insurance funds must be implemented according to the standards for the non-working population, which are established based on the amounts of the territorial compulsory medical insurance program. But at the moment, the obligations of local administrations to pay such insurance payments are quite uncertain, since there are absolutely no regulations or legislative acts that regulate these issues. If for insurers who are business entities, tariffs are established by the Tax Code of the Russian Federation, then for the executive branch of government there is no regulatory documentation for calculating payments for compulsory medical insurance for the non-working population. The calculation of contributions is carried out on a residual basis based on standards that are independently established in each constituent entity of the Russian Federation. The methods for determining payments for the non-working population, proposed by the Federal Compulsory Medical Insurance Fund, when determining the standards of insurance payments for the non-working population in the region, propose to proceed from the difference between the amount of the territorial compulsory medical insurance program and the amount of its financing from contributions from business entities and other revenues.

According to the Law “On Medical Insurance of Citizens in the Russian Federation,” the management of funds in the compulsory medical insurance system is carried out by compulsory medical insurance funds and medical insurance organizations. They enter into contracts for the implementation of compulsory medical insurance, accumulate insurance premiums, and accumulate funds to pay for medical services. From the point of view of insurance theory, they are all insurers, but they have significant differences and have strictly demarcated powers to carry out certain insurance and financial transactions.

MHIF budget revenues - insurance premiums for compulsory medical insurance; arrears on contributions, tax payments; penalties and fines; federal budget funds transferred to the budget of the Federal Fund; income from the placement of temporarily available funds; other sources provided for by the legislation of the Russian Federation.

Mandates of the MHIF:

Participation in the development of the SGGP for the provision of free medical care to citizens;

Accumulation and management of compulsory health insurance funds, formation and use of reserves to ensure the financial stability of compulsory health insurance;

Publication of regulations and guidelines:

Monitoring compliance by subjects and participants of compulsory medical insurance with legislation. The Federal Fund provides subventions to the budgets of territorial

funds for financial support of powers; controls the payment of insurance premiums for compulsory health insurance of the non-working population, charges and collects from insurers arrears on insurance premiums for non-working citizens, penalties and fines; establishes a procedure for monitoring the volume, timing, quality and conditions of providing medical care under compulsory medical insurance to insured persons; monitors compliance with the legislation on compulsory medical insurance and the use of compulsory medical insurance funds.

The income of the budgets of territorial compulsory medical insurance funds consists of subventions from the budget of the Federal Fund; interbudgetary transfers transferred

from the budget of the Federal Fund; payments by constituent entities of the Russian Federation for additional financial support of the territorial compulsory medical insurance program within the framework of its basic program; income from the placement of temporarily available funds; interbudgetary transfers transferred from the budget of a constituent entity of the Russian Federation; penalties and fines; other sources provided by law.

Subventions from the budget of the Federal Fund to the budgets of territorial funds for the implementation of delegated powers are provided in an amount determined based on the number of insured persons. financial support standard for the basic compulsory medical insurance program and other indicators. The territorial fund is accountable to the highest executive body of state power of the constituent entity of the Russian Federation and the Federal Fund.

The main expenditure item of the budget of territorial funds is the financial support of territorial compulsory medical insurance programs. The territorial fund manages compulsory medical insurance funds on the territory of a constituent entity of the Russian Federation. intended to provide guarantees of free medical care to insured persons within the framework of the compulsory medical insurance program and to ensure the financial sustainability of compulsory medical insurance on the territory of a constituent entity of the Russian Federation.

Powers of the territorial compulsory medical insurance fund:

Participation in the development of a territorial SGG for the provision of free medical care to citizens, determination of tariffs for payment for medical care on the territory of a constituent entity of the Russian Federation;

Accumulation of compulsory medical insurance funds and their management, financial support of the territorial compulsory medical insurance program in a constituent entity of the Russian Federation. formation and use of reserves for the financial stability of compulsory health insurance;

Presentation of claims in the interests of the insured person to the policyholder, medical insurance organization and medical institution, including in court, related to the protection of his rights and legitimate interests in compulsory medical insurance;

Ensuring the rights of citizens in compulsory medical insurance, monitoring the volume, timing, quality and conditions of medical care, informing citizens about the procedure for ensuring and protecting their rights;

Filing a claim or lawsuits against a medical institution for compensation for property or moral damage caused to the insured person;

Filing a claim against legal entities or individuals responsible for causing harm to the health of the insured person for reimbursement of expenses within the amount spent on providing him with medical care;

Control over the use of compulsory medical insurance funds by medical insurance organizations and medical institutions, including inspections and audits.

The funds of the medical insurance organization are formed from funds received from the territorial fund for the financial support of compulsory medical insurance in accordance with the agreement; funds received from medical organizations as a result of the application of sanctions to them for violations; funds received from legal entities or individuals who caused harm to the health of the insured persons.

Medical institutions receive funds for medical care in accordance with the established tariffs for payment of medical care under compulsory medical insurance. Tariffs are determined in accordance with the methodology for their calculation and include cost items established by the territorial compulsory medical insurance program.

SYSTEM OF CONTRACTS IN THE FIELD OF COMPLIANT MHILIDA

The right of an insured citizen to free medical care under compulsory medical insurance is exercised on the basis of an agreement concluded between the parties to

financial support for compulsory medical insurance and contracts for the provision and payment of medical care.

Under the agreement on financial support for compulsory medical insurance, the medical insurance organization undertakes to pay for medical care provided to insured citizens at the expense of targeted funds. The contract contains the main obligations and rights of the medical insurance organization:

Registration, renewal and issuance of a compulsory medical insurance policy;

Registration of insured citizens, compulsory medical insurance policies issued to them, ensuring the recording and safety of information received from medical institutions in accordance with the procedure for maintaining personalized records;

Concluding agreements with medical institutions included in the register for the provision and payment of medical care under compulsory medical insurance;

Informing insured citizens about the types, quality and conditions of providing them with medical care by medical organizations, identified violations in the provision of medical care to them, the right to choose a medical organization, the need to apply for a compulsory medical insurance policy. responsibilities of insured persons;

Control of the volumes, timing, quality and conditions of providing medical care in medical organizations by conducting medical and economic control, medical and economic examination, examination of clinical medical care and providing a report on the results of such control;

Consideration of appeals and complaints from citizens, protection of the rights and legitimate interests of insured persons;

Participation in the formation of the territorial compulsory medical insurance program and the distribution of volumes of medical care through participation in the commission created in the constituent entity of the Russian Federation;

Participation in the coordination of tariffs for payment of medical care;

Involvement of KMP experts.

The agreement on financial support for compulsory medical insurance provides for the obligation of the territorial fund to provide targeted funds to the medical insurance organization upon application received from it within the volume determined based on the number of insured citizens in this medical insurance organization and differentiated per capita standards.

An agreement for the provision and payment of medical care under compulsory medical insurance is concluded between a medical organization and a medical insurance organization. According to it, the medical organization undertakes to provide medical care to the insured citizen within the framework of the territorial compulsory medical insurance program, and the medical insurance organization undertakes to pay for it.

The need to introduce health insurance in Russia during the transition to a market economy was largely predetermined by the search for new sources of healthcare financing.

Compared to the existing state healthcare system in Russia, financed from the budget, and on a residual basis, the health insurance system allows the use of additional sources of healthcare financing in order to create the most favorable conditions for the full realization of the rights of citizens to receive qualified medical care.

In connection with the introduction of the principles of health insurance in the country, the system of financing both the industry as a whole and individual medical institutions was practically revised.

The main sources of treatment, preventive, health and rehabilitation services are budgetary funds and insurance funds, formed through contributions from individuals and legal entities. The state budget performs a protective function in relation to socially vulnerable groups of the population (pensioners, disabled people, children) and workers in the spheres of education, culture, healthcare, and management. Contributions to the insurance funds of the working part of citizens are made through enterprises (institutions, organizations). These expenses are included in the cost of the enterprise's products (works or services).

Thus, insurance funds play the role of an intermediary between a health care institution (HCI) and the population. However, the maximum effect of the functioning of insurance medicine can be achieved only when the consumer enjoys the freedom of choice of both health care facilities and doctors, and those intermediaries who guarantee the patient (the policyholder) the protection of his interests. Otherwise, the monopoly of the intermediary gives rise to corporate interests that are contrary to the interests of the final consumer.

In accordance with Article 10 of the Law of the Russian Federation “On Health Insurance”, the sources of financial resources of the healthcare system are:

funds from the republican budget (of the Russian Federation), budgets of republics within the Russian Federation and local budgets;
funds of state and public organizations (associations), enterprises and other economic entities;
personal funds of citizens;
free and (or) charitable contributions and donations;
income from securities;
loans from banks and other lenders;
other sources not prohibited by law.

From these sources are formed:

financial resources of state and municipal health care systems;
financial resources of the state compulsory health insurance system.

Financial resources of the state system of compulsory health insurance are intended for the implementation of state policy in the field of compulsory health insurance and are formed through contributions from policyholders for compulsory health insurance. In most foreign countries with a developed compulsory health insurance system, there are three main sources of financing compulsory health insurance:

deductions from the budget;
entrepreneurs' funds;
personal funds of citizens.

In Russia, financial resources for the compulsory health insurance system are generated from two sources:

payments from the budget;
contributions of enterprises, organizations and other legal entities to the compulsory health insurance fund.

Funds are received through banks into compulsory health insurance funds from policyholders who are required to register with these funds as payers of insurance premiums. Financial resources of compulsory health insurance funds are state property, are not included in the budgets of other funds and are not subject to withdrawal for other purposes.

Voluntary health insurance is intended to finance medical care in excess of the social guaranteed volume determined by mandatory insurance programs. The financial resources of the voluntary health insurance system are formed through payments from policyholders, who in the case of collective insurance are enterprises, and in the case of individual insurance - citizens. Medical insurance companies pay at established rates for medical services provided by medical institutions within the framework of voluntary medical insurance programs. In accordance with the terms of the contract, part of the unspent funds may be returned to the policyholder (citizen).

The concentration of all financial resources in one hand - a territorial department (regional hospital) or local government authority - limits freedom of choice as the main principle of implementing an effective mechanism for providing citizens with treatment and preventive services. Therefore, a necessary condition for the development of the insurance medicine system is the freedom to conclude an insurance agreement by an interested group of persons (enterprise employees, individual citizens) with independent holders of insurance funds (independent medical insurance companies).

The formation and use of compulsory health insurance funds has its own characteristics. Conceived as insurance, they do not always comply with the principles of the formation and use of insurance funds. In their activities, the features of the budget approach are obvious: mandatory and normative contributions, planned expenditure of funds, lack of savings, etc. In terms of their economic essence, these funds are not insurance; in form, they belong to extra-budgetary funds. However, it should be noted that, along with compulsory state insurance, non-state - voluntary - are developing.

Health insurance rates

Tariffs for medical services in the compulsory health insurance system are determined by agreement between medical insurance organizations, government bodies at all levels, local administration and professional medical organizations. Tariffs must ensure the profitability of medical institutions and the modern level of medical care.

The insurance rate of contributions for compulsory health insurance for enterprises, organizations, institutions and other economic entities, regardless of the form of ownership, is established as a percentage of the accrued wages for all reasons in accordance with the instructions on the procedure for collecting and accounting for insurance premiums (payments), approved by the Government RF November 11, 1993

Insurance premiums are established as payment rates for compulsory health insurance in amounts that ensure the implementation of health insurance programs and the activities of medical insurance organizations.

Tariffs for medical and other services under voluntary health insurance are established by agreement between medical insurance organizations and the enterprise, organization, institution or person providing these services.

List of used literature

1. Law “On medical insurance of citizens in the Russian Federation”.

2. Borodin A.F. About health insurance//Finance.-1996.- No. 12.

3. Grishin V. Federal Compulsory Medical Insurance Fund//Healthcare of the Russian Federation.-2000.- No. 4.

4. Starodubtsev V.I. Savelyeva E.N. Features of health insurance in modern Russia//Russian Medical Journal.-1996.-No. 1.

5. Federal Compulsory Medical Insurance Fund//Analytical review.-2001.

6. G.V. Suleymanova. Social security and social insurance – M.1998

7. Magazine "Expert". – 2001.- No. 9.

8. Magazine "Insurance Business". -2001.- No. 4.

The main purpose of compulsory medical insurance is the collection and capitalization of insurance premiums and the provision of medical care to all categories of citizens at the expense of the collected funds on legally established conditions and in guaranteed amounts.

The sources of financial resources for the healthcare system are:

1. Budget funds.

2. Insurance contributions of employers (3.6% of the wage fund accrued on all bases: of which 0.2% - to the FFOMS, 3.4% - to the TFOMS).

3. Free and charitable contributions and donations.

4. Income from securities.

5. Other sources not prohibited by law.

Funds are directed to:

Financing of activities for the development and implementation of target programs within the framework of compulsory medical insurance.
Providing professional training.
Research funding.
Development of material and technical base, institutions, healthcare.
Subsidizing specific territories in order to equalize the conditions for providing medical care to the population under compulsory medical insurance.
Payment for particularly expensive types of medical care.
Financing of medical institutions providing assistance for socially significant diseases (tuberculosis, AIDS).
Providing medical care for mass diseases in areas of natural disasters, catastrophes and other purposes in the field of protecting public health.

Health Fund funds not used in the past year are not subject to withdrawal and are not taken into account when appropriating budget allocations for the next year.

Sustainable balances from the Health Fund can be used on a commercial basis to develop the health system.

In accordance with the Federal Law “On Health Insurance”, there are 3 groups of subjects managing the organization and financing of compulsory medical insurance.

The first level of insurance in the compulsory medical insurance system is the FFOMS, which provides general regulatory and organizational management of the compulsory medical insurance system. The Fund itself does not carry out insurance operations and, in general, does not finance the compulsory medical insurance system for citizens. The main financial function of the Fund is the provision of TFOMS subventions to equalize the conditions for providing medical services to the population of regions with different economic development. In addition, at the expense of its funds, various targeted programs are implemented, medical assistance is provided in emergency situations arising in connection with disasters, natural disasters, and military operations.

The Foundation carries out organizational management of the compulsory medical insurance system through the development of regulatory documents on the management of health insurance in the regions, the preparation of standard or approximate rules for insurance of the population, and participation in the creation of the Federal Compulsory Medical Insurance Fund.

The second level of compulsory health insurance organization is represented by TFOMS and their branches. This level is legislatively the main one in the system, since it carries out the accumulation and distribution of financial resources of compulsory medical insurance, which is formed mainly from 2 sources:

Parts of insurance premiums paid by employers for compulsory health insurance of the working population (3.4%) within the framework of the Unified Social Tax.
Funds provided by the budgets of the constituent entities of the Russian Federation for compulsory health insurance of the non-working population (the amount of payments is established by the executive authorities of the constituent entities of the Russian Federation).

The main task of the TFOMS is to ensure the implementation of compulsory health insurance on the territory of a constituent entity of the Russian Federation on the principles of universality and social justice.

The TFOMS is entrusted with the main work of ensuring the financial balance and sustainability of the compulsory health insurance system.

In connection with the enactment of the Unified Social Tax, the TFOMS does not collect insurance contributions, does not exercise control over their payment, these functions are assigned to the tax authorities.

Territorial compulsory medical insurance programs are approved by the executive authorities of the constituent entities of the Russian Federation, and the Federal Compulsory Medical Insurance Fund only participates in their development.

The third level in the implementation of compulsory medical insurance is represented by medical insurance organizations. In the absence of medical insurance organizations in a given territory, TFOMS is allowed to carry out compulsory medical insurance, that is, to accumulate insurance premiums and make payments to medical institutions.

The main function of a medical insurance organization is payment of insurance cases. Medical insurance organizations base their activities on a contractual basis, concluding three groups of contracts:

1. Insurance contracts with employers and local administrations obligated to pay insurance contributions to the TFOMS. According to such contracts, the list and age and gender composition of the population insured by medical insurance organizations is determined.

2. Agreements with the Federal Compulsory Medical Insurance Fund for financing compulsory medical insurance of the population in accordance with the number and categories of insured. TFOMS does not have the right to refuse an insurance company to finance compulsory medical insurance if it has insurance contracts concluded with policyholders who have paid contributions to this TFOMS. Financing is carried out according to a differentiated per capita standard, which reflects the cost of the territorial compulsory medical insurance program per resident and the age and gender structure of the insured population.

3. Agreements with medical institutions for payment of services provided to citizens insured by this insurance medical organization. The procedure for payment for medical services is fixed in the Federal Compulsory Medical Insurance Program.