CC BY
10инновационные технологии управления
(INNoVATING MANAGEMENT TEcHNIQuEs)
DOI: 10.12731/2070-7568-2015-1-104-122 UDC 614.2
INNOVATIVE APPROACH IN THE COMPULSORY HEALTH INSURANCE TARIFF SETTING
Zasypkin M.Yu., Chebykin A.V., Supil'nikov A.A.
Development of a single channelfinancing in the health system of the Russian Federation based on the standards of the compulsory health insurance (CHI) requires a single channelfinancing of the health system through the CHI as one of the main direction using payment of the medical services in the form of so-called «full» tariff [1-12].
It is not a secret that for many years the medical services tariff in the CHI system contained from only five items of expenditures (salary, charges on payroll, soft goods and clothing, medicines, bandages, other medical expenses, and food). On one hand, such defective tariff was based on the parallel government financing of the medical institutions (MIs), on the
other hand, because of this tariff, the manager was hoppled in the control of the financial flows.
Keywords: Obligatory medical insurance; Comprehensive rate; Single source financing; Medical insurance organization.
ИННОВАЦИОННЫЕ ПОДХОДЫ ТАРИФООБРАЗОВАНИЯ В СИСТЕМЕ ОМС
Засыпкин М.Ю., Чебыкин А.В., Супильников А.А.
Взятый курс на выстраивание одноканального финансирования на основе стандартов оказания медицинской помощи через систему обязательного медицинского страхования (ОМС) в системе здравоохранения РФ подразумевает в качестве одного из основных направлений одноканаль-ное финансирование здравоохранения через систему ОМС путем оплаты медицинских услуг в виде так называемого «полного» тарифа [1-12].
Не является секретом, что долгие годы в системе ОМС в тариф на медицинские услуги включались только пять статей расходов (оплата труда, начисления на оплату труда, мягкий инвентарь и обмундирование, медикаменты, перевязочные средства, прочие лечебные расходы, продукты питания). Такой ущербный тариф, с одной стороны, объяснялся параллельным бюджетным финансированием медицинских организаций (МО), в другой стороны,
объективно сдерживал руководителя МО в управлении поступающими к нему финансовыми потоками.
Ключевые слова: обязательное медицинское страхование; «полный» тариф; одноканальное финансирование; страховая медицинская организация.
Now the situation has changed: the MIs turned from the local form of property to the state one, the maintenance charges began to flow not from the CHI system, but from the Compulsory Health Insurance Territorial Funds (CHITF) and from the medical insurance companies (MIC).
It broached a question on the development and implementation of the full tariff which includes all expenditures, except for the expensive equipment purchase and major repairs.
This process is underway now, but still two questions are not completely solved: the first one is how to include all items of the expenditures in the medical services tariff (and whether it is necessary or not), and the second one is how to calculate the share of these items in the tariff?
Supposedly, the first problem has been solved: specific expenditures of the medical institutions are listed in the federal documents and in the regional tariff agreements. The structure of the medical care tariff for the basic CHI program is described in section 7, article 35 of the CHI Law. It includes basic expenditures and others. The basic expenditures include salary, charges on payroll, medicines, supplies, food, soft goods, and medical instruments. In addition, the tariff structure includes other charges, reagents and chemicals costs, other inven-
tories, expenses for laboratory and instrumental studies conducted in the other companies (if the medical institution does not have its own laboratory and diagnostic equipment), food (if the medical institution does not provide it), communication, transport, and public services, upkeep works and services for the equipment, rental payments, software and other services, social services for workers of the medical institutions, other expenses, expenses for equipment purchase up to 100 thousand rubles per unit.
However, there is no normative information on how these funds have to rich the MIs.
Until 2013, transition to a single-channel system was monitored by the Russian Federation Ministry of Health (the Order of the Russian Federation Ministry of Health dated 30.12.2010 N 1240n) and the CHI Federal Fund (the Order of the CHIFF dated 28.06.2010 N 123).
Analysis of the monitoring results and regional regulatory base regulating the transition to the single-channel financing revealed that expenditures can be extended in two directions:
1. Creation of a single-channel financing through the CHI system which allows the medical institution to continue receiving the maintenance charges not through an appropriate budget, but through the CHI system in a form of extra charges.
2. Creation of a full tariff that includes the additional expenditures to pay the provided medical care.
Of course, the first direction is the easiest one - no need to change something: the MI have to pay the charges for a medical service which
include 5 already mentioned traditional CHI expenditures, while the maintenance charges are directed into the MIs as a separate flow.
Analysis of the constituent units of the Russian Federation regarding the transition on the full tariff showed very mixed picture (tab. 1).
Table 1
Description of the methods to include the additional medical institution maintenance charges into the tariffs
Methods Advantages Disadvantages
Transfer of the medical institution maintenance charges through the MIC as separate payments Payments correspond to the real needs of the medical institution. Payments are performed regardless of the actual volume of provided medical services. The system fully contradicts the ideology of the CHI; it is a surrogate of budgetary financing.
The maintenance charges of the medical institution are included into the additional component of the tariff It is easier to track the reason for differentiation and to take actions on the gradual unification of the expenses. This approach complicates the settlement system; the system does not fully correspond to the ideology of pricing (in fact, we are talking about the multiple tariffs).
Continuation of table 1
Medical care charges are used as a base for rates application It allows the MI to retain the existing approach for calculating of the medical care charges In the differential medical care tariff system, the MI maintenance charges depend on the medical care charges; it complicates the process of payment and control of the maintenance charges
An overhead charges rate (for example, the main staff salary) is used as a base for rates application Simple and widespread method The method is not quite accurate: the maintenance charges (first of all, the utility bills) poor correspond to the main staff salary
Establishment of the individual tariffs It allows the MIs to take into account the objective difference between the maintenance charges more precisely This approach complicates the system of tariffs and payments for the insurance companies
Grouping of the payments It allows the MIs to unify the tariffs and to stimulate reduction of the maintenance charges There is a possibility that tariffs become different in the profit status for the MIs taking into account their real maintenance charges
The most common approach is quite simple: the MIs maintenance charges for the last year are divided between the MICs on 1/12 of the annual volume and transferred to the MIs as a separate payment according to the orders of the CHITF.
If the maintenance charges are included into the tariff (the full tariff), the following problems are solved depending on the regional features:
- whether the maintenance charges should be included into the main tariff or into the additional component of the tariff?
- if it is included into the additional component of the tariff, should it be calculated as a fixed part or as the rates?
- what bases should be used for rates application, if it is decided to apply the rates?
- whether the tariffs should be individual or groped?
- how to calculate the maintenance charges (based on the calculated demand or based on the funds obtained earlier for these purposes from the correspondent budgets)?
Based on the selected direction, the territories realize different approaches for composing the tariffs of the maintenance charges:
- on the basis of additional payment for «over-tariff part» -transfer of the twelfth share of the annual amount due to be paid for the operational charges, taking into account the funds transferred from the budget and the adjustment rates:
- on the basis of an additional tariff;
- on the basis of the adjustment rates for different types of the MIs;
- on the basis of the individual rates for each MI (upon fulfillment);
- on the basis of the additional rates, etc.
All these methods have one common characteristic: the funds are distributed on a monthly basis, adjusting their volumes with the amount due to be paid for the MIs operational charges.
It would seem that the approaches of the single-channel financing and tariff composing are fulfilled: money reached the final destination (the MI) in the CHI system, but it should be admitted that it is not the full tariff and it does not correspond to the basic principles of the CHI system: «money follows the patient» and «in the CHI system payment is made for the already provided medical care». In this system the budget financing scheme is realized through an extra-budgetary fund and the commercial MICs. Therefore, it is difficult to accept this scheme as progressive and cost-effective one. Moreover, such schemes of maintenance charges allocation are focused neither on the quantity, nor on the quality of medical care.
In addition, if allocated funds enter the MI from the different flows, it is still difficult for the Head of the MI to distribute it on the particular purposes.
Of course, in practice, the Head of the MI has the right to use all funds regardless of the source (the basic tariff or the maintenance charges) for all purposes associated with providing the medical care in the CHI. It was confirmed by Samara arbitral practice (bringing the necessity of CHITF supervision and auditing service work in this direction into challenge).
Therefore, from our point of view, the full tariff and single-channel financing can be used only after all the funds are included into the medical services tariff and all the services are paid according to the tariffs.
How to calculate these expenditures? The first approach is normative; it is based on the cost provided by the Territorial program of state guarantees for free medical care under the CHI.
The second one is based on calculation of a medical care standard. Both approaches are recommended at the federal level (2, 3). Herewith, it is noted that «calculation of the relative cost rates for DRG and Clinical Profile Groups (GPG) should be performed based on the cost of the medical standards». In other words, it is stated that there are calculations of the federal standards cost and their combination corresponds to the financial ratios of the federal government guarantee program.
It's hard to believe, first of all, because the standards available not for all nosology, secondly, the results of the modernization program in a health care sector and its part concerning standards implementation in the regions revealed a significant increase of the tariffs after standards implementation exciding the real capabilities of the CHI system, and thirdly, if such calculations exist, why it have not been introduced as a single tariff system on the entire territory of the Russian Federation?
Therefore, in our opinion, the only real option is a regulatory method described in the «Guidelines ...» approved by the Order of FCHI dated 14.11.2013 N 229.
In terms of maintenance charges calculation in the tariff, we propose to use experience of the full tariff development and application in the Samara region at the end of 80's-90's of the last century, where it was used firstly under the framework of the so-called «new economic mechanism (NEM) in the health care» and then under the single-channel financing of the CHI system.
It should be noted that those years, though the different game rules at the level of the Russian Federation, in the Samara region almost all types of medical care were included in the CHI system (particularly emergency medical care, socially significant diseases (tuberculosis, psychiatry, venereology, narcology), health resort institutions, etc.). Nowadays, it is perceived as a strategic objective of the health care system development, while those days it was a revolution.
Concurrently, there also was a full tariff for the medical services, which contained all items of expenditure, including the maintenance charges, except for the expensive equipment purchase and major repairs.
How it was calculated?
In 1991, based on 100,000 medical records of inpatients received medical care in 1990, it was decided to develop the Diagnosis Related Groups (DRG), combined on the basis of similarity of diagnostic and therapeutic methods, as well as the cost per bed / 1 day of hospitaliza-tion.
This approach required a new pricing method based on calculation of all (!) actual costs per medical case of average duration, determination of the cost per patient-day according to the department profile
for a typical 500-beds clinic. Accordingly, payment for the medical services begun to perform based on a sticker group of DRG.
Taking into account the categorization of the MIs at that time, the tariffs also contained graduation (additional fee rate for a category of the medical institution).
The advantages of this method included more detailed approach to nosology classitiocation in terms of severity level and much more predictable level of expenses per specific case in the MI.
The disadvantages included:
- the necessity to continuously control the consumer price index (inflation rate);
- no flexibility in the pricing policy for introduction of the new medical technologies;
- the cost of the treatment still depended on the sticker category of the MI;
- there were unreasonable attempts to reduce the volume of services provided to patients;
- for the clinics, it is more advantageous to treat the «simple» patients billing them as more «expensive» DRG category.
This tariff made it possible to introduce the single-channel principle in the Samara region, and in a short time, in 1996, led to abandonment of the MI categorization and grading payment for the medical services depending on the status of the MI. In other words, the principle of payment depending on the complexity of the nosology has been implemented. As a result, for highly-specialized hospitals it was
disadvantageous to provide «simple» medical care, while low-specialized hospitals were unable to provide «expensive» medical care as the MICs through medical evaluation carefully monitored the provided medical care depending on the level of services.
Of course, as of today, it is not appropriate to calculate the tariff using only one typical MI as an example, but «adjustment» of the tariff for each institution (calling it «a categorization» or «levels» of the MIs) would be a step backwards.
Therefore, in our opinion, it is appropriate to calculate the part of maintenance charges based on three levels of the typical MIs (for example, clinics with 1000/500/300 beds) and to bind this part not with a specific level of the MI, but with a level of a medical service, which also has three grads. Thus, the cost for treatment of a simple uncomplicated appendicitis will contain the maintenance charges for low-level MI (300-beds capacity), and the cost for treatment of acute coronary syndrome (ACS) will be taken from the highly-specialized MI (1000-beds clinic).
In conclusion, it should be noted that this approach, of course, can be associated with some difficulties in terms of the maintenance charges for non-standard MI, however, only in this case we can talk about the full tariff and observance of the basic CHI principles «mo-ney follows the patient» and «treatment of an appendicitis in any hospital should be performed in accordance with the standard and cost should be the same».
References
1. Bulaev S. Question-answer // Budgetary medical institution: accountancy and taxing. 2010. N 11. Pp. 44-47. http://www.lawmix. ru/medlaw/612 (accessed date: 21.01.2013).
2. Letter from the Russian Federation Ministry of Health dated 20.12.2012 . N 14-6/10/2-5305 « Recommendations on the methods of payment for the health care sector under the state guarantees program on the basis of the diseases groups, including the Diagnosis Related Group (DRG)».
3. The Order of the FCHI dated 14.11.2013 N 229 On approval of «The Guidelines for the methods of payment for specialized medical care in the hospitals and in the day hospitals on the basis of the diseases groups, including the Diagnosis Related Groups (DRG) at the expense of the compulsory health insurance».
4. The Order of the Russian Federation Ministry of Health dated 28.02.2011 N 158n «On approval of the compulsory health insurance rules» (date of registration in the Russian Federation Ministry of Justice: 03.03.2011 N 1998) http://base.consultant.ru/cons/ cgi/online.cgi?req=doc;base=LAW;n=120516 (accessed date: 21.01.2013).
5. The Order of the Russian Federation Ministry of Health dated 30.12.2010 N 1240n «On approval of the procedure and form for reporting the implementation of the regional healthcare modernization programs in the constituents of the Russian Federation and the modernization programs for the Federal State Institutions providing health care» http://base.consultant.ru/cons/cgi/online. cgi?req=doc;base=LAW;n=130871 (accessed date: 21.01.2013).
6. The Order ofthe CHIFF dated 28.06.2010 N 123 «About the control of the transition on the predominantly single-channel financing through a compulsory health insurance system in the constituents of the Russian Federation» http://base.consultant.ru/cons/ cgi/online.cgi?req=doc;base=LAW;n=103240 (accessed date: 21.01.2013).
7. Website of the Russian Federation Ministry of Health http://www. rosminzdrav.ru
8. The Compulsory Health Insurance Federal Fund of the Russian Federation, http://www.ffoms.ru
9. Website of the Samara Region Ministry of Health, http://www. samregion.ru/authorities/ministry/health_min
10. The Compulsory Health Insurance Territorial Funds (CHITF). http://www.samtfoms.ru
11. Tariff agreement for medical care under CHI in the Samara region for 2014 dated 31.01.14.
12. Decree dated 28.06.2007 N 825 «On assessment of the executive authority efficacy for the constituents of the Russian Federation» http://base.garant.ru/191419/ (accessed date: 21.01.2013).
13. Benjamin B., Pollard J.H. The Analyse of Mortality and Other Actuarial
14. Blendon R. The public's view on the future of health care. JAMA, 1998. Vol. 259. Pp. 3588-3601.
15. Statistics. - Oxford, Butterworth- Heineman Ltd, 1980.
16. Bowers N.L., Gerber H.U., Hickman J.C., Jones D.A., Nesbitt C.J. Actuarial.
17. Mathematics. The Society of Actuaries, Itasea, Illinois, 1986.
18. Lane M. The perfume of the premium.or pricing insurance derivatives.
19. Lukarsch G. Health Insurance. CEA, TTF, 1999.
20. Proceeding of the Bowles Symposium on Securitization of Risk. Georgia State University, Atlanta. 1995. Itasca, IL: The Society of Actuaries. 1996.
21. Mangan J., Harrison С. Underwriting Principals. Institute of America. 1995.
Список литературы
1. Булаев С. Вопрос-ответ // Бюджетные учреждения здравоохранения: бухгалтерский учет и налогообложение. 2010, № 11. С. 44-47. http://www.lawmix.ru/medlaw/612 (дата обращения: 21.01.2013).
2. Письмо МЗ РФ от 20.12.2012г. № 14-6/10/2-5305 «Рекомендации по способам оплаты медицинской помощи в рамках программы государственных гарантий на основе групп заболеваний, в том числе клинико-статистических групп болезней (КСГ).
3. Приказ ФОМС от 14.11.2013 г. №229 «Об утверждении «Методических рекомендаций по способам оплаты специализированной медицинской помощи в стационарных условиях и в дневных стационара на основе групп заболеваний, в том числе клинико-статистических групп болезней (КСГ) за счет средств системы обязательного медицинского страхования.
4. Приказ Минздрава РФ от 28.02.2011 N 158н «Об утверждении Правил обязательного медицинского страхования» (Зарегистрировано в Минюсте РФ 03.03.2011 N 1998) М1р:/^е. consultant.ru/cons/cgi/online.cgi?req=doc;base=LAW;n=120516 (дата обращения: 21.01.2013).
5. Приказ Минздравсоцразвития РФ от 30.12.2010 N 1240н «Об утверждении порядка и формы предоставления отчетности о реализации мероприятий региональных программ модернизации здравоохранения субъектов Российской Федерации и программ модернизации федеральных государственных учреждений, оказывающих медицинскую помощь» http://base. consultant.ru/cons/cgi/online .cgi?req=doc ;base=LAW;n=130871 (дата обращения: 21.01.2013).
6. Приказ ФФОМС от 28 июня 2010 г. N 123 «О мониторинге перехода субъектов Российской Федерации на преимущественно одноканальное финансирование через систему обязательного медицинского страхования» http://base.consultant.ru/cons/ cgi/onHne.cgi?req=doc;base=LAW;n=103240 (дата обращения: 21.01.2013).
7. Сайт министерства здравоохранения Российской Федерации http://www.rosminzdrav.ru
8. Сайт Федерального Фонда ОМС Российской Федерации, http://www.ffoms.ru
9. Сайт Министерства здравоохранения Самарской области, http://www.samregion.ru/authorities/ministry/health_min
10. Сайт территориального фонда ОМС Самарской области. http://www.samtfoms.ru
11. Тарифное соглашение на оплату медицинской помощи по обязательному медицинскому страхованию в Самарской области на 2014 год от 31.01.14.
12. Указ Президента Российской Федерации от 28 июня 2007 г. N 825 «Об оценке эффективности деятельности органов исполнительной власти субъектов Российской Федерации» http://base.garant.ru/191419/ (дата обращения: 21.01.2013).
13. Benjamin В., Pollard J.H. The Analyse of Mortality and Other Actuarial.
14. Blendon R. The public's view on the future of health care. JAMA, 1998. Vol. 259. Рр. 3588-3601.
15. Statistics. Oxford, Butterworth-Heineman Ltd, 1980.
16. Bowers N.L., Gerber H.U., Hickman J.C., Jones D.A., Nesbitt C.J. Actuarial.
17. Mathematics. The Society of Actuaries, Itasea, Illinois, 1986.
18. Lane M. The perfume of the premium.or pricing insurance derivatives.
19. Lukarsch G. Health Insurance. CEA, TTF, 1999.
20. Proceeding of the Bowles Symposium on Securitization of Risk. Georgia State University, Atlanta. 1995. Itasca, IL: The Society of Actuaries. 1996.
21. Mangan J., Harrison С/ Underwriting Principals. Institute of America. 1995.
DATA ABOUT THE AUTHORS
Zasypkin Mihail Yurevich, Holder of Chair of Public Health and
Health Protection at Non-state Educational Establishment of HPE Samara MI «REAVIZ», Doctor of Medical Science, professor Samara Medikal Institute «REAVIZ»
st. Chapaevskaya, 227, Samara, 443001, Russian Federation Chebykin Andrey Vyacheslavovich, assistant professor of Chair of Public Health and Health Protection at Non-state Educational Establishment of HPE Samara MI «REAVIZ», Candidate of Medical Science
Samara Medikal Institute «REAVIZ»
st. Chapaevskaya, 227, Samara, 443001, Russian Federation е-mail: Chebykin79@gmail.com
Supil'nikov Aleksey Aleksandrovich, first prorector for research at Non-state Educational Establishment of HPE Samara MI «REAVIZ», Candidate of Medical Science, assistant professor
Samara Medikal Institute «REAVIZ»
st. Chapaevskaya, 227, Samara, 443001, Russian Federation ДАННЫЕ ОБ АВТОРАХ
Засыпкин Михаил Юрьевич, заведующий кафедрой общественного здоровья и здравоохранения, доктор медицинских наук, профессор
Самарский медицинский институт «РЕАВИЗ» Чапаевская 227, г. Самара, 443001, Российская Федерация Чебыкин Андрей Вячеславович, доцент кафедры общественного здоровья и здравоохранения, кандидат медицинских наук
Самарский медицинский институт «РЕАВИЗ» Чапаевская 227, г. Самара, 443001, Российская Федерация e-mail: Chebykin79@gmail.com
Супильников Алексей Александрович, первый проректор по научной деятельности, кандидат медицинских наук, доцент Самарский медицинский институт «РЕАВИЗ» Чапаевская 227, г. Самара, 443001, Российская Федерация
Рецензент:
Блашенцева Светлана Александровна, Проректор по учебной и воспитательной работе НОУ ВПО МИ «РЕАВИЗ», доктор медицинских наук, профессор
