Organization of compulsory health insurance at the present stage of health care development. Insurance consultant Financial support of an insurance company in the OMS system

Formation of funds. The most important characteristic of the CHI system is the targeted formation of funds for health care. Employers' contributions and municipal payments for the non-working part of the population go not to the general budget, but directly to health care needs. Health care is less dependent on established budgetary priorities.

For countries where these priorities are traditionally not in favor of health, the transition to insurance form fundraising can give the industry additional funds.

The opposite picture is observed in Russia. Government spending on health care needs (budgets of all levels and compulsory medical insurance funds) has been reduced both absolutely and relatively. By itself, the transition to compulsory medical insurance does not automatically provide additional funds. A new source of funding does not necessarily mean new funding. A situation is possible when the new source does not supplement, 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 bill) became the basis for reducing budgetary allocations for health care.

The general condition for the positive influence of CHI is the integrity of this system, which assumes the dominance of one channel for the receipt of funds. In the classical MHI model, the main source of revenue is the payroll tax (contributions to MHI), and the role of budgets at all levels is reduced to the allocation of relatively small subsidies. Under these conditions, the volume financial resources relatively weakly dependent on total budget revenues.

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

• 1. The amount of the compulsory medical insurance contribution should cover the bulk of the cost of providing medical care for 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 population, but also for the bulk of the non-working population. The higher the amount of the compulsory medical insurance contribution, the less dependence on the budget source.
• 2. The classical CHI system is based on the joint participation of workers and employers in the formation of health care funds. 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 families. As a result, no most of population, such as lonely pensioners or unemployed. State subsidies go to them, and most of the population is insured through targeted contributions.
• 3. Even a relatively small budgetary source of funding should be strictly fixed by law: i.e. should be installed solid size government payments for certain contingents of the non-working population. If this is not done, then the funding system will actually be regulated by local authorities.
• 4. It is necessary to establish a firm rule of allocating the budgetary part to the general funds of the CHI. Only on this basis it is possible to ensure the targeted distribution of these funds to individual territories and medical organizations on the basis of the established scheme. In the Russian context, local authorities are not only reluctant to channel funds for health care, but also seek direct financing. medical institutionsbypassing OMC channels.

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

Distribution of funds in the CHI system. The 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 legislatively enshrined rule for the redistribution of insurance premiums is introduced on the basis of the state-established formula for the per capita financing ratio.
• 2. It boils down to the fact that one of the insurance organizations stands out as socially responsible. It insures the bulk of the population (including high-risk groups), but is also responsible for reallocating funds. All other insurers send to the main insurance organization the statutory share of collected contributions. This amount is used to finance insurers (Czech Republic).
• 3. The method is based on the creation of special state organizations - MHI funds, which collect contributions from various sources and then finance insurers at a differentiated per capita rate. This system operates in Russia (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 CHI system and equality in their role in the CHI system.

The system of distribution of CHI financial resources: possibly based on two options.

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

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

Disadvantages:

• 1. The presence of several sources and subjects of financing medical care (territorial cHI funds, regional health authorities, municipal authorities) significantly complicates financial flows and therefore complicates the process of financial planning.
• 2. The unified health care system is divided into separate parts, each of which operates according to its own rules. Difficult to integrate different types medical care, ensure their coordination and continuity.
• 3. In those regions where the compulsory medical insurance funds cover only the costs of medical care to workers, and the treatment of non-workers is directly financed from the budget, different standards of accessibility and service are formed for these groups of the population.
• 4. Surplus capacities of institutions are conserved, since economic expenses are financed from the budget, regardless of the actual work of the health facility.
• 5. The effect of new payment methods operating in the compulsory medical insurance system is decreasing, since the budgetary part of financing goes to health facilities without regard to the amount of aid.
• 6. The economic independence of institutions is limited due to control over the targeted use of compulsory medical insurance funds. Targeted use is understood as the expenditure of funds under the permitted items of the cost estimate.
• Option 2 - the merger of funding flows from different sources at the level above the healthcare facility. Not only compulsory medical insurance funds, but also the bulk budget funds is concentrated in the hands of funds and medical insurance organizations for their subsequent referral to medical institutions on a single-channel basis.

In a rational health care financing system, the overwhelming majority public fundsintended to pay for medical care must come to a medical institution from a single source. If the system is built on the principle health insurance, then the dominant part of the funds must follow the CHI 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 CHI program should be directed exclusively to CHI funds as payments for insurance of the non-working population. The basic CHI 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, new construction.

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

In system OMS of Russia insurers conclude contracts mainly with state or municipal health care facilities. The latter, although they have separate property from the owner (the status of a legal entity), nevertheless belong to the state. Their decisions on business issues are shaped under the strong influence of health authorities as representatives of the property owner.

We understand the issues of financing the clinic from the MHI budget, restrictions on spending the corresponding amounts and tariffication.

CHI budget - basic factors

In accordance with paragraph 5 of Part 2. of Art. 20 of the Federal Law of November 29, 2010 No. 326-FZ "On compulsory health insurance in Russian Federation»Medical organizations are obliged to use the compulsory medical insurance funds received for the provided medical care in accordance with the compulsory medical insurance programs. Such programs are reviewed annually. On the basis of the Program of State Guarantees for the Free Provision of Medical Care to Citizens, adopted by the Government of the Russian Federation (Article 35 of the Law on CHI), the constituent entities of the Russian Federation adopt Territorial Programs (Article 36 of the Law on CHI).

Immediately I will make a reservation that by the words "medical organization" I mean a legal entity, regardless of its organizational and legal form, carrying out medical activities as the main (statutory) type of activity on the basis of a license (clause 11, article 2 of the Federal Law No. No. 323-FZ "On the basics of health protection of citizens in the Russian Federation"). Thus, if we are talking about budget financing of an organization, then it should be understood that we are talking about a government institution. In the case of a private clinic, instead of the budget, one should bear in mind the funds of the organization received by it in addition to program transfers from the MHI budget.

The territorial program, among other things, includes the structure of tariffs (in accordance with article 30 of the Law on CHI) for the payment of medical care provided within the framework of the Territorial CHI program. For Moscow, for example, the structure of tariffs is deciphered in clause 4.9 of the Program, which contains a list of expenses included in the MHI Tariff. According to clause 4.11, Tariffs in terms of wages and salaries include financial security of cash incentive payments.

What you shouldn't spend your CHI budget on

Regarding the purchase of equipment, I want to say that financing of a medical organization from the budget of the CHI fund in accordance with clause 4.9 of the Program for the purchase of fixed assets (equipment, production and household inventory) has a limit of 100,000 rubles. That is, the purchase of expensive equipment should be made not at the expense of funds transferred to a medical organization as part of the implementation of the MHI Program, but at the expense of funds provided to the institution from the relevant budget.

Remuneration of employees (base rate) is provided to institutions at the expense of the corresponding budget, depending on the subordination of the institution (Article 133 of the Labor Code of the Russian Federation). Clause 4.9 of the Program states that the MHI budget can be spent on wages and salaries. Stimulating part wages, stipulated separately by clause 4.11 of the Program, is paid to employees in accordance with an employment contract based on local regulations and laws of the constituent entity of the Russian Federation.

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Consequently, within the meaning of the provisions of the Program, other payments that are included in the wage system in accordance with Art. 135 of the Labor Code of the Russian Federation. These include, for example, additional payments and bonuses of a compensatory nature, including for work in conditions deviating from normal, a system of additional payments and bonuses of a stimulating nature and a bonus system. These additional payments are established by the collective labor agreement and local regulations in accordance with applicable law. Payments for overtime and incentives are definitely not specified in the Tariff structure.

Also, the structure of the Tariffs does not imply payment for rented premises, except for cases when this premises is used by the institution itself for the provision of medical care under the CHI program. That is, the words of clause 4.9 of the Program “expenses for payment of communication services, transport services, utilities, works and services for the maintenance of property, the cost of rent for the use of property "should be attributed only to those funds that are used directly in the provision of medical services under the CHI.

The Tariff structure also does not provide for the payment of penalties against a medical organization. Unfortunately, the legislator does not give an unambiguous answer to the question “is it possible to pay fines to the account of the CHI budget”. Thus, the resolution of this issue remains at the discretion of the subjects of the Russian Federation.

Personal opinion. Based on the above, we can conclude that the simplest way to avoid penalties for misuse of CHI funds is to follow the definition of the Program, or to justify spending taking into account the structure of the Tariffs.

The procedure for financing the costs of medical institutions for the provision of inpatient and polyclinic care to the population in the amount of the territorial compulsory medical insurance program for the year is approved by the territorial compulsory medical insurance fund. (Appendix 4).

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

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

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

3. at the cost of one bed-day for the purchase of medicines and consumables for the departments of medical institutions before calculating the tariffs of the MES.

Financing of polyclinic and inpatient care depends on the volume and level of quality of care provided. The items of expenditure included in the tariff for medical services are determined by the tariff agreement for payment for medical services in the compulsory medical insurance system. The tariff agreement is an interdepartmental document, in the development and approval of which the Government of the UR, the Ministry of Health of the UR, the Ministry of Finance of the UR, the Ministry of Economy of the UR, the Price Committee under the CM UR, the territorial fund of compulsory medical insurance of the UR, as well as representatives of insurance companies and the association of doctors of the UR take part. In accordance with this document, the funds of the territorial insurance fund of the medical institution can only be spent on food for patients, medicines and soft equipment, as well as on salaries and charges.

When using the financial resources of the compulsory medical insurance, health care institutions are obliged to reimburse the expenses under the item “Medicines and dressings”. The remaining funds are used for other items of expenditure 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, the standards for the cost of food, the purchase of medicines and consumables for the departments of medical institutions are approved and indexed per bed-day. So, for example, by order of UTFOMS No. 46 of 03/19/96, the standards for food expenses per 1 bed-day in various health care facilities and departments were approved from 1407 rubles. (in departments for newborns) up to 39,061 rubles. (in the departments - burns, neurosurgical, hematological). For the purchase of medicines and consumables, standards ranged from 6646 rubles. in therapeutic, up to 33205 rubles. in surgical purulent departments.

Financing of the CHI funds is not provided for:

1. payment for treatment of socially significant diseases;

2. payment for diseases caused by HIV infection;

3. payment for medical treatment of military personnel;

4.medical, assistance classified as expensive (according to the corresponding list of the Ministry of Health of the Russian Federation dated 03/04/95, No.

Routine 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 CHI fund for payment of medical services.

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The CHI is designed to provide all citizens of Russia with equal opportunities to receive medical and drug assistance provided at the expense of CHI funds in the amount and on conditions corresponding to CHI programs, as an integral part of the Program of state guarantees for the provision of free medical care to citizens of the Russian Federation.

In system OMS object insurance - insurance risk associated with the cost of providing medical care in the event of insured event... In this case, the insured risk is an alleged, possible event, and the insured event is an event that has already occurred, provided for by the insurance contract (illness, injury, pregnancy, childbirth).

Participants (subjects) of the CHI are a citizen, an insured, an insurance medical organization (CMO), a medical institution, compulsory health insurance funds (MHIF) (Fig. 8.1). Compulsory health insurance is carried out on the basis of contracts concluded between the subjects of health insurance.

Figure: 8.1. Subjects of compulsory health insurance

Every citizen in respect of whom a compulsory health insurance contract has been concluded or who has independently entered into such an agreement receives insurance medical policy, which is equally valid throughout the territory of the Russian Federation.

Citizens of the Russian Federation in the CHI system have the right to:
... choice of an insurance medical organization, medical institution and doctor;
... receiving guaranteed (free) medical care throughout the territory of the Russian Federation, including outside the permanent place of residence;
... receiving medical services that correspond in volume and quality to the terms of the contract, regardless of the amount of the actually paid insurance premium;
... filing a claim against the insured, an insurance medical organization, a medical institution, including for material compensation for damage caused through their fault.

Along with the citizens of the Russian Federation, the same rights in the compulsory medical insurance system are enjoyed by stateless persons in Russia and foreign citizens permanently residing in Russia.

The functions of insurers in compulsory health insurance are performed by medical insurance organizations and territorial compulsory health insurance funds.

Compulsory health insurance of citizens can be attended by medical insurance organizations with any form of ownership, having a state permit (license) for the right to engage in health insurance. The main task of an insurance medical organization is the implementation of compulsory medical insurance by paying for medical care provided to citizens in accordance with the territorial program of compulsory medical insurance. CMOs monitor the volume and quality of medical services, and also ensure the protection of the rights of the insured, up to the presentation of claims to a medical institution or a medical worker in court for material compensation for material or moral damage caused to the insured through their fault.

The financial resources of the CHI system are formed at the expense of deductions from policyholders for all working and non-working citizens. The size of the insurance premium for the working population is established federal law as interest rate to the accrued wages of each employee as part of the unified social tax. In 2008, the amount of the contribution to the compulsory medical insurance of the working population was 3.1%. The amount of the insurance contribution for non-working citizens is annually established by the state authorities of the constituent entity of the Russian Federation when the territorial program of state guarantees for the provision of free medical care to citizens of the Russian Federation is budget of the constituent entity of the Russian Federation. These contributions are accumulated in the Federal and regional CHI funds.

Financing of medical insurance organizations is carried out by the TFOMI on the basis of differentiated per capita standards and the number of insured citizens. Financial relations between medical insurance organizations and TFOMI are governed by an agreement on financing of CHI and territorial oMS rules, which are approved by the relevant state authorities of the constituent entity of the Russian Federation.

An important role in protecting the interests of citizens when receiving medical care is played by experts from medical insurance organizations, who monitor the volume, timing and quality of medical care (medical services) in the event of an insured event.

Federal and territorial CHI funds are independent state non-profit financial and credit institutions that implement public policy in the field of compulsory medical insurance. The federal CHI fund is created by the supreme legislative body of Russia and the Government of the Russian Federation. Territorial CHI funds are created by the relevant legislative and executive authorities of the constituent entities of the Russian Federation. MHI funds are legal entities, and their funds are separated from the state budget funds. MHI funds are intended to accumulate financial resources, ensure financial stability of the state MHI system and equalize financial resources for its implementation.

Medical care in the CHI system is provided by healthcare organizations of any form of ownership, which have received the appropriate license in the prescribed manner.

In the context of decentralization of the management of state and municipal medical institutions on the part of state healthcare authorities, the licensing mechanism allows solving the issues of optimizing the structure of medical care and increasing the level of technical equipment of medical institutions, bringing the volume and conditions of medical care to the insured population in accordance with the CHI programs.

In recent years, it has become a practice to allow private healthcare organizations to participate in the implementation of territorial cHI programs on a competition basis. This contributes to the creation of a competitive environment and is a factor in improving the quality and reducing the cost of providing medical care to the insured.

Medical institutions are financed by medical insurance organizations on the basis of submitted bills. Bills are paid at rates in accordance with the volume of medical care provided by the institution. For outpatient clinics, such a unit of care is a doctor's visit, for inpatients - a completed hospitalization.

An analysis of the implementation of compulsory medical insurance in individual constituent entities of the Russian Federation shows that today four models can be distinguished cHI organizations in various subjects of the Russian Federation.

The first model basically matches legislative framework and most fully takes into account the basic principles of the implementation of state policy in the field of compulsory medical insurance. Funds from policyholders (enterprises and executive authorities) are transferred to the TFOMI account. The fund accumulates financial resources and, under contracts with health care organizations, transfers them to finance the activities of health care organizations; health care organizations conclude contracts directly with medical organizations and with policyholders.

The second model represents the combined CHI system. This means that insurance of citizens (issuance of policies and financing of medical institutions) is carried out not only by medical institutions, but also by branches of the TFOMS.

The third model is characterized by the absence in the system OMS insurance medical organizations. These functions are performed by TFOMI and their branches.

The fourth model is characterized by the absence of the CHI system as such in the regions. In these constituent entities of the Russian Federation, the Law of the Russian Federation "On Compulsory Medical Insurance of Citizens in the Russian Federation" is implemented only in terms of collecting insurance premiums for the working population. These funds are managed by local health authorities, financing directly medical institutions.

An analysis of the long-term experience of the establishment of the CHI system in the Russian Federation has shown that the first model of the organization of compulsory medical insurance is most suitable for ensuring the effective spending of financial resources and providing the population with high-quality medical care.

Thus, being an integral part of the state social insurance, The compulsory medical insurance has a pronounced social character. Its basic principles are:
... universal and compulsory: all citizens of the Russian Federation, regardless of gender, age, health status, place of residence, level of personal income, have the right to receive free medical services included in the basic and territorial compulsory medical insurance programs;

The state nature of compulsory health insurance: the implementation of the state financial policy in the field of public health protection is provided by the Federal and territorial CHI funds as independent non-profit financial and credit organizations. All compulsory medical insurance funds are in state ownership;

Public solidarity and social justice: insurance premiums and payments are transferred for all citizens, but these funds are spent only when seeking medical help (the principle of "healthy pays for the sick"); citizens with different income levels have the same rights to receive free medical care (the principle “the rich pays for the poor”); despite the fact that the costs of providing medical care to older citizens are higher than those of young people, insurance premiums and payments are transferred in the same amount for all citizens, regardless of age (the principle of “young pays for the old”).

The main direction of further improvement of the CHI system is the creation of conditions for sustainable financing of medical organizations to provide the population with guaranteed (free) medical care within the framework of basic and territorial programs OMS.

This requires a consistent solution of a number of tasks:
... to ensure a balance between the incomes of the CHI system and the state's obligations to provide guaranteed (free) medical care to insured citizens;
... to develop legal mechanisms of responsibility of the executive power of the constituent entities of the Russian Federation for the fulfillment of the obligations of the insured of the non-working population living in this territory;
... to develop new approaches to the formation of basic and territorial compulsory medical insurance programs within the framework of the Program of state guarantees for the provision of free medical care to citizens of the Russian Federation.

The most important task remains to find mechanisms to increase the amount of financing of the CHI system.

An additional source of funding can be funds from the Pension Fund of the Russian Federation to finance the costs associated with the provision of targeted medical care to non-working pensioners.

As the CHI reform develops, tasks related to expanding the participation of the population in the CHI system should be addressed. At the same time, an increase in the share of financial participation of the population should be accompanied by an improvement in the quality and expansion of the list of medical services. A prerequisite the civilized development of the CHI system should be the development of legal and financial mechanisms to exclude informal payments by patients to medical workers.

One of the forms of citizens' participation in health insurance can be the provision of the possibility of voluntary refusal to participate in the CHI system and the solution of the issue of payment for medical care through the voluntary medical insurance system.

And finally, the main direction of the reform of compulsory health insurance is the creation in the future unified system medical and social insurance, which could provide the population with the necessary complex of social guarantees, including the provision of guaranteed (free) medical care.

A prerequisite for this should be the transition to single-channel financing of the health system.

O.P. Shchepin, V.A. Medic

I... Health financing in the context

compulsory health insurance

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

Based on the analysis of the practice of financing and organizing health care in foreign countries, three basic models of the economic mechanism of health care can be distinguished:

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

2. Funding of the bulk of medical care by private insurance companies, for example, in the United States.

3. The mixed budgetary and insurance nature of health care financing, when targeted programs, capital investments and some other expenses are paid by the state, and the financing of basic medical care is carried out through the health insurance system: France, Germany, Italy, etc.

In the modern period, the insurance systems of medical and social assistance continue to develop. Health insurance systems are usually government-run, but funded from three sources: earmarked contributions from employers, government subsidies, and employee contributions. In some countries, there are no government subsidies for health care payments, and health insurance premiums are provided by entrepreneurs and workers.

Insurance system health care is financed, like the budget, from public consumption funds and is formed on a targeted basis, it is more protected from the residual principle of financing, characteristic of many budget systems health care. That is why in our country, in order to combine the positive aspects of public and private medicine, a budget-insurance model was chosen. On June 28, 1991, the RF Law "On Health Insurance of Citizens in the Russian Federation" was adopted, which defines a fundamentally new model of financing and organizing health care in the new economic conditions.

The law establishes two types of health insurance: compulsory and voluntary. The purpose of the introduction of compulsory health insurance was to provide all citizens of the Russian Federation with equal opportunities in obtaining medical and pharmaceutical care provided at the expense of compulsory health insurance funds in the volume 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:

Facilities federal budget, territorial budgets subjects 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 valuable papers;

Gratuitous 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 - contributions of policyholders for compulsory health insurance and budget payments for compulsory health insurance of the non-working population. Financial resources are accumulated in compulsory health insurance funds - federal and territorial, which are independent non-commercial financial institutions and created to ensure the stability of the state system of compulsory health insurance. The financial resources of the foundations are not included in the budgets, other funds and are not subject to withdrawal.

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

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

Verification of the fulfillment of contracts between health care institutions and medical insurance organizations, between the insured and the insurer and other types of control.

The experience of implementing the Law of the Russian Federation "On Health Insurance of Citizens in the Russian Federation" has shown the promise of the compulsory health insurance system and posed a number of problems, without the solution of which further development is impossible. First of all, this is insufficient legal support for the compulsory health insurance system, the need to improve the quality control system of medical care in medical institutions and the creation of a system to ensure 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-prophylactic institutions.

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

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

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

1.2. Health care institutions of a special type: a leper colony, a center for the prevention and control of AIDS, a forensic medical examination office, a medical statistics office.

1.3. Dispensaries: physical education, cardiology, narcological, dermatovenerologic, oncological, anti-tuberculosis, neuropsychiatric.

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

1.5. Ambulance and blood transfusion facilities: ambulance station, blood transfusion station.

1.6. Institutions of motherhood and childhood: children's home, maternity hospital, etc.

1.7. Sanatoriums: sanatorium, children's sanatorium, sanatorium-preventorium, etc.

2. Institutions of preventive medicine.

3. Pharmacy institutions.

The costs of maintaining health care institutions account for the largest share in health care costs. The work of each health care institution is characterized by operational-network indicators, such as: the average annual number of beds (total and by bed profiles), the number of days of bed functioning 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 prophylactic institution can provide medical care to the population in two forms: inpatient and outpatient. One of the main indicators of the work of the hospital is the bed capacity, and of the outpatient clinic, the number of doctor posts and visits. Depending on this, a methodology for calculating costs is selected. In the modern period, only natural norms of expenditures for food and medicines (depending on the type of institution) are centrally established. Calculations of the value of natural indicators are carried out by local departments independently. In an outpatient clinic, the main indicators in planning costs are: the average annual number of doctor's posts and the number of doctor 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 the economic items of the budget classification. The estimate can only include expenses that are necessary due to the nature of the activities of the institution. The appropriations provided in the estimate must be justified by calculations for each cost item. The main economic items for which the costs of the institution are planned include the costs of paying wages, purchasing goods, paying for services, purchasing durable equipment, and overhauling.