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 types (according to the corresponding list of the Ministry of Health of the Russian Federation dated 03/04/95

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.

I. Health financing in conditions

compulsory health insurance

In the former USSR, healthcare guaranteed citizens free and accessible medical care. In practice, financing the industry from the state budget led to a constant decrease in the share of medical expenses in the total budget allocations; as a result, insufficient funding and irrational use of funds led the industry to a critical state. The sharp drop in most indicators characterizing the level of medical care has made obvious the need for a fundamental restructuring of domestic healthcare. One of the ways the industry emerged from the crisis was the introduction of new forms of management, planning and financing into the health care system, starting in the early 1990s.

Based on an analysis of the practice of financing and organizing healthcare in foreign countries, we can distinguish three basic models of the economic mechanism of healthcare:

1. Predominantly public free medical care, as, for example, in England, Denmark, Greece, and Ireland.

2. Financing of the bulk of medical care by private insurance companies, for example, in the USA.

3. Mixed budgetary and insurance nature of healthcare financing, when target programs, capital investments and some other expenses are paid for by the state, and basic medical care is financed through the health insurance system: France, Germany, Italy, etc.

In the modern period, insurance systems for medical and social care continue to develop. Health insurance systems are generally government-administered, but are financed from three sources: targeted contributions from employers, government subsidies, and employee contributions. In some countries, there are no state subsidies for medical care, and health insurance contributions are provided by entrepreneurs and employees.

The health insurance system is financed, like the budgetary one, from public consumption funds and is formed on a targeted basis; it is more protected from the residual principle of financing, characteristic of many budgetary health care systems. That is why in our country, in order to combine the positive aspects of public and private medicine, a budgetary insurance model was chosen. On June 28, 1991, the Russian Federation Law “On Medical Insurance of Citizens in the Russian Federation” was adopted, defining a fundamentally new model for financing and organizing healthcare in new economic conditions.

The law establishes two types of health insurance: compulsory and voluntary. The purpose of introducing compulsory health insurance was to provide all citizens of the Russian Federation with equal opportunities to receive medical and pharmaceutical care provided through compulsory health insurance funds in the scope of relevant programs. Voluntary health insurance allows citizens to receive additional medical services.

The economic basis of health insurance is made up of state health funds and compulsory health insurance funds. With the introduction of compulsory health insurance, the entire health care system in the Russian Federation began to represent a combination of two systems: the state (municipal) health care system and the state compulsory health insurance system.

The sources of financial resources for the healthcare system in the Russian Federation are:

Funds from the federal budget, territorial budgets of the constituent entities of the Federation, local budgets;

Funds of organizations, enterprises and other economic entities, regardless of the form of ownership;

Personal funds of citizens;

Income from securities;

Free and charitable contributions and donations;

Other sources not prohibited by the legislation of the Russian Federation.

The financial basis of the state system of compulsory health insurance, deductions from insurers for compulsory health insurance and budget payments for compulsory medical insurance of the non-working population. Financial resources are accumulated in compulsory health insurance funds - federal and territorial, which are independent non-profit financial and credit institutions and created to ensure the stability of the state compulsory health insurance system. The funds' financial assets are not included in budgets or other funds and are not subject to withdrawal.

Non-departmental control of the activities of healthcare institutions is carried out by licensing and accreditation commissions, medical insurance organizations, territorial compulsory medical insurance funds, executive bodies of the Social Insurance Fund of the Russian Federation, etc. The main task of non-departmental control is the organization of medical and economic examination to ensure the rights of citizens to receive medical care of adequate quality and checking the effectiveness of the use of health care resources and financial resources of compulsory health and social insurance. It is carried out in the following areas:

Analysis of the results of providing medical care to the population,

Verification of the implementation of contracts between healthcare institutions and medical insurance organizations, between the policyholder and the insurer and other types of control.

The experience of implementing the Law of the Russian Federation “On Medical Insurance of Citizens in the Russian Federation” has shown the promise of the compulsory health insurance system and raised a number of problems, without solving which further development is impossible. First of all, this is insufficient legal support for the compulsory health insurance system, the need to improve the system for monitoring the quality of medical care in medical institutions and the creation of a system for ensuring the rights of the insured.

II. Planning and financing of activities

medical institutions

In accordance with the approved nomenclature, healthcare institutions are divided into groups:

1. Treatment and prevention institutions.

A) Outpatient clinics - when they receive help both at home and in a clinic (polyclinics, medical centers, dispensaries, paramedic stations, antenatal clinics, children's clinics, pharmacies, pharmaceutical factories).

B) Hospitals - when the patient receives treatment in a bed (hospitals, clinics at scientific medical institutes, military hospitals, sanatoriums, dispensaries (beds).

1.1. Hospital institutions, including: city hospital, city emergency hospital, hospital for war veterans, medical unit, specialized hospitals, hospice, territorial medical association.

1.2. Special types of health care institutions: leper colony, center for the prevention and control of AIDS, bureau of forensic medical examination, bureau of medical statistics.

1.3. Dispensaries: medical physical education, cardiology, narcological, dermatovenerological, oncological, anti-tuberculosis, psychoneurological.

1.4. Outpatient clinics: outpatient clinic, city clinic, children's city clinic, dental clinic, medical unit, consultative and diagnostic center for children, etc.

1.5. Emergency medical care institutions and blood transfusion institutions: emergency medical service station, blood transfusion station.

1.6. Maternity and childhood institutions: children's home, maternity hospital, etc.

1.7. Sanatorium and resort institutions: sanatorium, children's sanatorium, sanatorium, etc.

2. Preventive medicine institutions.

3. Pharmacies.

The costs of maintaining medical institutions occupy the largest share of healthcare costs. The work of each healthcare institution is characterized by operational network indicators, such as: the average annual number of beds (total and by bed profiles), the number of days a bed is operational per year, the number of bed days, the average annual number of staff units for all categories of personnel, the number of medical visits.

A medical and preventive institution can provide medical care to the population in two forms: inpatient and outpatient. One of the main indicators of the work of a hospital is the number of beds, and of an outpatient clinic, the number of medical positions and visits. Depending on this, the methodology for calculating costs is selected. In the modern period, only in-kind rates for food and medicine expenses have been centrally established (depending on the type of institution). Calculations of the value expression of in-kind indicators are carried out by local departments independently. In an outpatient clinic, the main indicators for planning expenses are: the average annual number of medical positions and the number of medical visits.

The main document that determines the total volume, target direction and quarterly distribution of the institution’s funds is the cost estimate compiled for the calendar year in the prescribed form for economic items of the budget classification. The estimate may only include expenses that are necessary due to the nature of the institution’s activities. The allocations provided for in the estimate must be justified by calculations for each cost item. The main economic items for which an institution's expenses are planned include expenses for paying wages, purchasing goods, paying for services, purchasing durable equipment, and carrying out major repairs.

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Formation of funds. The most important characteristic of the compulsory medical insurance system is the targeted formation of funds for healthcare. Contributions from employers and payments from municipal authorities for the non-working part of the population do not go to the general budget, but directly to healthcare needs. Healthcare is less dependent on established budget priorities.

For countries where these priorities are traditionally not in favor of healthcare, switching to an insurance form of fund raising could provide the industry with additional funds.

In Russia the opposite picture is observed. Government spending on healthcare needs (budgets at all levels and compulsory medical insurance funds) decreased both absolutely and relatively. The transition to compulsory health insurance in itself does not automatically attract additional funds. A new source of financing does not necessarily mean new financial revenues. A situation is possible when a new source does not complement, but replaces the old one. This is exactly what happened in Russia. The introduction of employers' contribution to compulsory medical insurance (3.6% of the wage fund) became the basis for reducing budget allocations for healthcare.

The general condition for the positive impact of compulsory medical insurance is the integrity of this system, which presupposes the dominance of one channel for the receipt of funds. In the classic compulsory health insurance model, the main source of revenue is the payroll tax (compulsory health insurance contributions), and the role of budgets at all levels is reduced to the allocation of relatively small subsidies. Under these conditions, the volume of financial resources depends relatively little on general budget revenues.

The predominance of the insurance source is achieved in several ways:

• 1. The amount of the compulsory medical insurance contribution must cover the bulk of the costs of providing medical care under the state-guaranteed “package” of medical services. It is set at such a level as to provide the necessary financial resources not only for the working part of the population, but also for the bulk of the non-working population. The higher the contribution to compulsory medical insurance, the less dependence on the budget source.
• 2. The classic compulsory health insurance system is based on the joint participation of workers and employers in the formation of healthcare facilities. The amount of contributions is set in such a way as to cover the costs of medical care not only for workers, but also for their family members. As a result, a small part of the population remains outside the scope of compulsory medical insurance, for example, single pensioners or the unemployed. State subsidies go to them, and the majority of the population is insured through targeted contributions.
• 3. Even a relatively small budget source of financing must be strictly secured by law: i.e. a fixed amount of government payments for certain contingents of the non-working population should be established. If this is not done, then the financing system will actually be regulated by local authorities.
• 4. It is necessary to establish a firm rule for directing the budget portion to general compulsory medical insurance funds. Only on this basis can the targeted distribution of these funds be ensured across individual territories and medical organizations based on an established scheme. In Russian conditions, local authorities are not only reluctant to allocate funds to healthcare, but also strive to directly finance medical institutions, bypassing compulsory medical insurance channels.

So, the financing system should be either predominantly budgetary or predominantly insurance. The so-called budget-insurance financing system is losing the features of the previous system, removing responsibility for healthcare from the budget, but at the same time does not provide a significant influx of funds from employers - due to the obviously low share of targeted taxes in the total volume of healthcare financing.

Distribution of financial resources in the compulsory medical insurance system. Distribution of funds between insurers can be carried out in three main ways.

• 1. Provides that the collection of contributions is carried out by each insurance organization. At the same time, a legally established rule for the redistribution of insurance premiums is being introduced based on the formula for the per capita funding standard established by the state.
• 2. It comes down to the fact that one of the insurance organizations is singled out as socially responsible. It insures the bulk of the population (including high-risk groups), but is also responsible for the redistribution of funds. All other insurers send the legally established share of collected premiums to the main insurance organization. This amount is used to finance insurers (Czech Republic).
• 3. The method is based on the creation of special state organizations - compulsory medical insurance funds, which collect contributions from various sources and then finance insurers according to a differentiated capitation standard. Such a system operates in Russia (the Netherlands). This method requires additional costs for the maintenance of a special structure, but at the same time ensures regulation and control of the activities of insurance organizations in the compulsory medical insurance system and equality in their role in the compulsory medical insurance system.

Compulsory health insurance financial distribution system: possible based on two options.

Option 1 - a two-channel system for receiving funds to health care facilities. In this case, two sources of financing are separated according to their purpose. Some items of the institution's budget estimate (for example, business expenses) are financed from budget funds, while others are financed from compulsory health insurance funds. The budget is the source of payment for some types of assistance, compulsory medical insurance funds for others. It is possible to separate by sources of financing and treatment of working and non-working citizens.

This option, in various variations, dominates the Russian compulsory medical insurance system. Its advantage is that it, to some extent, reconciles the interests of different parties seeking control over health care finances.

Flaws:

• 1. The presence of several sources and entities for financing medical care (territorial compulsory medical insurance funds, regional health authorities, municipal authorities) significantly complicates financial flows and therefore complicates the financial planning process.
• 2. The unified health care system is divided into separate parts, each of which operates according to its own rules. It is difficult to integrate different types of medical care, ensure their coordination and continuity.
• 3. In those regions where compulsory medical insurance funds cover only the costs of medical care for working people, and treatment of non-working people is directly financed from the budget, different standards of accessibility and service are formed for these population groups.
• 4. Excessive capacity of institutions is conserved, since business expenses are financed from the budget regardless of the actual work of health care facilities.
• 5. The effect of new payment methods operating in the compulsory medical insurance system is reduced, since the budgetary part of the funding goes to health care facilities regardless of the volume of assistance.
• 6. The economic independence of institutions is limited due to control over the intended use of compulsory medical insurance funds. The intended use refers to the expenditure of funds according to the permitted items of the cost estimate.
• Option 2 - merging funding streams from different sources at a level above health care facilities. Not only compulsory medical insurance funds, but also the bulk of budget funds are concentrated in the hands of funds and medical insurance organizations for their subsequent distribution to medical institutions on a single-channel basis.

In a rational health care financing system, the vast majority of public funds intended to pay for medical care should flow to the health care facility from a single source. If the system is built on the principle of health insurance, then the dominant part of the funds should go through compulsory medical insurance channels (at least 70%, but in reality in the Russian Federation - only 30%).

Budgetary funds used to pay for medical care provided for by the basic compulsory medical insurance program should be directed exclusively to compulsory medical insurance funds as payments for insurance of the non-working population. The basic compulsory medical insurance program should cover the bulk of the types and volumes of medical care. The budget covers expenses for a narrow range of socially significant diseases, the purchase of expensive equipment, and new construction.

With such a financing system, the contractual form of relationships with medical organizations becomes dominant: the insurer forms an order for the total volume of medical care for the insured and pays for the medical services provided at full rates, including all items of the budget classification. Medical organizations, in turn, earn funds to cover all types of their operating expenses and the bulk of capital expenses by providing an agreed volume of medical care at full rates.

In the Russian compulsory medical insurance system, insurers enter into contracts primarily with state or municipal health care facilities. The latter, although they have property separate from the owner (the status of a legal entity), nevertheless belong to the state. Their decisions on business issues are strongly influenced by health authorities as representatives of the property owner.

Many citizens of the Russian Federation know that they have every right to receive treatment completely free of charge in state and municipal hospitals and clinics, provided they present a compulsory medical insurance policy. However, not everyone understands where the money to finance health insurance comes from. And if everything is clear with the working population - the main source of providing them with free medical services is the insurance premiums paid by their employers, then what is the situation with non-working citizens? Answers to all questions are further in our material.

Legislative support

The main regulatory legal act that regulates the financing of compulsory medical insurance is 326-FZ of November 29, 2010 “On Mandatory...” (hereinafter referred to as Federal Law No. 326), namely Chapter 5.

Particular provisions are contained in the following regulations:

• Chapter 34 of the Tax Code of the Russian Federation (on the procedure, terms of payment, amounts of transfers to compulsory medical insurance for working citizens, including at reduced rates for certain categories of payers);
• Federal Law No. 354 of November 30, 2011 “On the amount...” (on how the insurance premium rate for medical insurance for unemployed citizens is calculated);
• Order of the Ministry of Health No. 182n dated April 30, 2013 “On approval...” (on the form of a certificate that insurers provide quarterly about accrued and paid insurance premiums for unemployed citizens);
• Order of the FFOMS No. 229 dated December 1, 2010 “On approval...” (on the unified form of the act, which is drawn up by officials of the FFOMS or territorial funds in violation of the legislation of the Russian Federation regarding the financial support of compulsory health insurance);
• Appendix to the Order of the Ministry of Health and Social Development No. 1229n dated December 30, 2010 “On approval...” (on the procedure for spending funds from the normalized safety stock provided for as part of the FFOMS budget expenses);
• other federal and regional regulations on financial support for compulsory medical insurance.

Sources of financing