The situation around the Ministry of Health’s idea to single out a federal segment in the CHI system, in which the Federal Compulsory Medical Insurance Fund (FFOMS) should play the role of an insurance company, is getting more complicated. Large insurers sent a letter to head of government Mikhail Mishustin with a proposal to stop this and other changes in the compulsory medical insurance. Representatives of the Central Bank and the Ministry of Finance, who had previously agreed on the budget package, supported them in the State Duma. The insurance lobby’s reaction to moderate changes in the system is hardly justified by the cost of the issue, amounting to billions of rubles a year in a market with a turnover of 2 trillion. The statements about the “departure from the CHI’s insurance principles” rather demonstrate the industry’s suspicion about the Ministry of Health’s possible plans.
The draft amendments to the law on MHI, submitted by the government to the State Duma on September 30, together with the draft MHI budget as part of the full budget package, did not retain its “technical” status. Yesterday, the budget committee of the State Duma, as a co-executor of the project, supported him. Nevertheless, the document was discussed yesterday at a meeting of the expert council of the State Duma on insurance, where representatives of the Central Bank and the Ministry of Finance (recall, the budget package is endorsed by departments) supported the insurance community’s sharp criticism of its provisions ( see Kommersant on October 8). Meanwhile, as it became known to Kommersant, the heads of the five largest insurers of compulsory medical insurance (SOGAZ, AlfaStrakhovanie, RESO-Garantia, Ingosstrakh, MAKS) declared their disagreement with such a reform – they sent a letter to the head the government of Mikhail Mishustin (Kommersant has the text of the letter) expressing “extreme concern about the situation”, calling it a real “reform” of the CHI system.
Let us recall, as Kommersant has already written, that the government’s proposals (the bill was approved by it before being submitted to the State Duma) consist of two fundamental changes. The first is the allocation of a separate, federal link in the CHI system, from which insurance medical organizations (CMO, that is, medical insurers) are excluded – federal clinics will make up their own “floor”, the role of the insurer in which, as expected, FFOMS will independently perform. The second systemic amendment is to reduce the limits of the normative amount of funds provided by the territorial CHI fund from the current 1-2% by half, to 0.5-1%.
As a result of the implementation of the first block, insurers will lose, based on the explanatory note to the project, access to about 5% of the funds of the CHI fund per year (over 100 billion rubles of turnover per year).
It is more difficult to objectively assess the second block, since specific limits are set by the regions (and now it is usually about 1%), according to insurers, we are talking about a loss of about 6.8 billion rubles. per year or reducing their costs of doing business in the CHI system by half.
The positions of representatives of the Central Bank and the Ministry of Finance on the profile council in the State Duma were similar to those of insurers. According to Ekaterina Abasheeva, deputy director of the Central Bank’s insurance market department, “all the provisions of the draft law are largely aimed at departing from insurance principles that have been consistently implemented in the compulsory medical insurance market for several years”. The project does not contain a financial and economic justification for reducing the standards for the cost of doing business (RBO). The Bank of Russia is also concerned about the problem of “continuity” of patient support at every stage of receiving medical care. “The existing two-tier system is leaving, there is only one link in the form of FFOMS,” said Ms. Abasheeva. In addition, the Central Bank believes that it has not received the necessary time to analyze the document. According to Alexander Itselev, deputy head of the insurance regulation department of the Ministry of Finance, the bill was not analyzed for possible consequences. The opinion of the market curators at the Central Bank and the Ministry of Finance on the amendments is similar to the position of insurers.
What changes in the principles of the CHI system does the Ministry of Health suggest
In turn, a letter from five insurers to the White House under the auspices of the All-Russian Union of Insurers (ARIA) generalizes all claims against the Ministry of Health and the government. In their opinion, the reduction of the tariff limits for RVD and the allocation of the federal “floor” in the CHI without their participation “radically change the principles of the CHI operation.” The arguments of the insurers and ARIA are already close to political ones. Thus, the President of the ARIA, Igor Yurgens, recalled that medical facilities are an essential part of the implementation of the national project “Health”, the proposals of the Ministry of Health are a threat to him. “In the national project … insurers are legitimate and an essential part of its implementation. For this national project, we have created 14 thousand insurance representatives who are entrusted with medical examination, escorting cancer patients and all measures to promote a healthy lifestyle. The bill calls into question not only the presence of insurers in the national project, but also its implementation itself, ”Mr. Yurgens said. One of the insurers’ arguments in the letter is that insurance companies return about 12 billion rubles to the CHI system annually. according to the results of medical expertise, a decrease in the profitability of medical insurance companies “in some cases” will lead to their withdrawal from the market.
Insurers promise the White House “acute social tension in a pandemic.” The Ministry of Health declined to comment on the discussion in the State Duma, indicating that it had already stated its position last week. Let us recall the position of the department. Changes in the CHI are not considered a “reform” there, the assessments of insurers on the loss of income from RVD are considered overestimated, especially taking into account the future growth in the turnover of the CHI market, besides, the digitalization of healthcare has significantly reduced their costs. The purpose of the allocation of the federal level of compulsory medical insurance, the Ministry of Health considers increasing its accessibility for the population – the system will have quotas for federal centers.
Note that in a sense, they are now an analogue of high-tech medical care that exists outside the general compulsory medical insurance system, the idea of the Ministry of Health is that on this “floor” paid opportunities for insurers that are important for compulsory medical insurance in regions are not needed.
According to Kommersant sources in the industry, the package of changes to the CHI system proposed by the Ministry of Health is not final – in the future, the department also plans to toughen the conditions for entering the system for private organizations, changing the notification procedure for them to declarative and introducing additional requirements for capacities. As Ilya Shilkrot, the head of the Independent Association of Non-State Medical Organizations, explained to Kommersant, the business community is concerned about the prospect of such a bill and sent to Deputy Prime Minister Tatyana Golikova their proposals on reforming the procedure for choosing a medical organization for treatment by a patient (Kommersant has it). However, the association is not proposing a rejection of the changes, but larger changes.
It is necessary to modernize this procedure as a whole, and not to reshape its individual parts, as is now happening with the allocation of quotas to federal medical centers. “
Although it is obvious that the changes in the role of insurers planned by the Ministry of Health are somehow due to the desire to centralize the CHI system in anticipation of the modernization of primary care, it is likely that the practice of combating the coronavirus epidemic also played a role in the emergence of this initiative. With its beginning, the Ministry of Health significantly reduced the functions of insurers. In particular, by canceling inspections of hospitals and clinics, seeking to reduce medical organizations’ burden during the force majeure. Perhaps this experience prompted the department to take concrete ways to reduce control on their part even in “peacetime.” In any case, the overreaction of insurers to the CHI initiatives, probably, to a greater extent reflects not the scale of losses, but fears of further steps by the Ministry of Health and the relevant Deputy Prime Minister Tatyana Golikova – a larger withdrawal in favor of the FFOMS of a part of the CMO’s powers. Changes in the CHI system (insurance in many respects nominally) will have winners and losers. The current players are proactive, especially since the government, in their opinion, is setting an example by refusing to discuss the current “reform” in advance.