In the new bill, they want to exclude insurance companies from the compulsory medical insurance treatment system. How might this impact patients and quality of care?

Amendments to the law “On Compulsory Health Insurance” have been submitted to the State Duma for consideration. The Ministry of Health bill gives regional governors the right to exclude medical insurance organizations from the compulsory medical insurance system. And their functions - monitoring the quality of care provided and protecting the interests of patients - will be transferred to territorial compulsory medical insurance funds. Patient organizations are confident that the new rules will create conditions for conflicts of interest and corruption: insurance companies remain the only independent link in the chain of medical care - unlike territorial funds and hospitals, they are not subordinate to the Ministry of Health. It is unclear who will now protect the interests of patients.

How does the compulsory medical insurance system work?

Any “free” medical service, as we usually talk about medical care under compulsory medical insurance, actually costs money. An appointment with a therapist or neurologist, ultrasound, x-rays, blood tests - all this is paid for from our insurance premiums: for working residents of Russia the employer pays them, for non-working residents - the state. All these contributions flow into the compulsory medical insurance fund, from where they are distributed among the territorial funds that exist in each region. From there they are sent to medical insurance organizations (HIOs).

It is HMOs that allocate these funds to medical institutions to pay for services provided, thus economically stimulating their work. And it is to the CMO that the patient turns to if he cannot receive medical care.

According to the All-Russian Union of Insurers, monthly insurance medical organizations receive approximately 1.5 thousand requests for assistance in state clinics and hospitals.

— Patients may complain, for example, that they did not receive the medicine they were entitled to at the pharmacy.

I know that once they even made an additional purchase to provide a drug at a discount,” says a therapist at a Moscow city clinic on condition of anonymity. - Or if they stand in line for a long time for a test, for example, a CT or MRI. Previously, when there were paper medical records, they could complain that they were not given it in their hands...

In general, the CMO vigilantly ensures that the patient receives everything that is due to him by law, helps resolve problems that arise, and in some cases can even fine the medical institution for violations.

What will change?

The proposed bill excludes medical insurance organizations from the chain. And their functions are transferred to territorial compulsory medical insurance funds, whose tasks are now of a purely theoretical nature: developing territorial programs of state guarantees of medical care under compulsory medical insurance and determining tariffs for its payment, accumulating compulsory medical insurance funds and managing them, as well as monitoring the use of these funds.

According to the new bill, territorial compulsory medical insurance funds will directly interact with medical institutions, allocate money to them and evaluate their work.

What's wrong with this?

It would seem that minus one intermediary in the chain should provide significant savings in budget money. But many experts suggest that it will not be possible to save money, but the risk of corruption increases significantly.

The problem is that territorial compulsory medical insurance funds, like medical institutions, are part of one system - the state healthcare system. It turns out that medical services will be provided and their quality checked by organizations subordinate to one department. Both hospitals and foundations play on the same field as opposed to CMOs, who always take the patient’s side.

“Insurers are an independent link in the chain of government - medical organizations - citizens, their work is based on the principles of patient-centeredness,” says a representative of a patient organization on condition of anonymity. — Insurance representatives accompany patients, help in resolving conflict situations, and monitor the quality of care provided. This mechanism has long proven its effectiveness, and it primarily benefits patients, especially those who need complex and high-tech medical care.

Every year, CMOs conduct 30 million examinations and identify more than 5 million defects in the availability and quality of medical care.

If there is no independent control on the part of insurers, medical institutions may begin to save money - refuse examinations, reduce appointment times, and postpone hospitalization.

“Territorial funds are given the function of executor and controller of their own activities. No fair and independent examination and protection of citizens’ rights is simply possible in this model,” says Alexey Starchenko, a member of the public council for patients’ rights at Roszdravnadzor.

“The transfer of powers to funds will lead to monopolization of the system, loss of independent control and will deprive citizens of the real right to choose an insurance medical organization,” a representative of a patient organization expresses concern. — Preservation of independent insurance organizations and the institution of insurance representatives is not only a matter of structure, it is a matter of people’s trust in state guarantees of medical care. Elimination of this link will inevitably cause dissatisfaction among the population with the healthcare system.

Moreover, the new bill puts patients in unequal conditions. If in some regions the functions of CMOs are transferred to funds, while in others they remain with insurers, the former will be in a more vulnerable position.

Who should I complain to?

Now, if a patient is denied an examination, is not given a referral, or is given incorrect treatment, he contacts the insurance company. She understands the situation, conducts an examination, can impose sanctions on the clinic and even protect the patient’s rights in court.

If the amendments to the law are adopted, then formally, according to a representative of the patient organization, patients will be able to file complaints with territorial funds, but in practice it is still unclear how willing the latter are to perform these functions. If only because for this, funds will need to build from scratch the entire service infrastructure that insurance companies have been creating for years: call centers, an expert control system, digital platforms for feedback, training of specialists. This is both colossal work and significant expenses.

So, in the new system, existing protection mechanisms risk turning into a formality, and people are left alone with the problem. And if his rights are violated, the patient will most likely have to turn not to the “intermediary insurer”, but directly to the court, prosecutor’s office or supervisory authorities.

“This is a step back in terms of accessibility and efficiency in protecting the interests of patients,” a representative of the patient organization is confident.