The CHI System Started Working Under The New Rules

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The CHI System Started Working Under The New Rules
The CHI System Started Working Under The New Rules

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The CHI system started working under the new rules

At the end of May, new rules for compulsory health insurance came into force. The document prescribes step-by-step regulations for accompanying patients at all stages of treatment. Insurance companies will control the provision of medical care and dispensary observation, inform patients about the treatment they are entitled to, and fine hospitals in case of prescribing irrational pharmacotherapy.

The CHI system started working under the new rules
The CHI system started working under the new rules

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At the end of May, new rules for compulsory health insurance (MHI) came into effect. The document prescribes step-by-step regulations for accompanying patients at all stages of treatment. Insurance companies will control the provision of medical care and dispensary observation in the presence of oncological, cardiovascular and other chronic diseases, inform patients about the treatment they are entitled to, and fine hospitals in case of prescribing irrational pharmacotherapy.

The role of compulsory medical insurance in the "patient-centered model of healthcare" and what the industry expects from the new rules were discussed at the Round Table held as part of the XIII All-Russian Forum "Health of the Nation is the Basis of Russia's Prosperity".

Information resource

According to the head of the Federal CHI Fund Natalya Stadchenko, life has shown the need to further strengthen the interaction of all participants in the CHI system: medical organizations, territorial CHI funds, insurance companies and patients. And the new rules "create an information resource that will become a single platform" for such interaction. “Territorial funds are the operators of this resource. Medical organizations are obliged to enter here information on all changes related to the insured on a daily basis. On the same resource, an individual history of each oncological patient is kept at all stages of the provision of medical care from the moment of suspicion of the disease,”said the head of the MHIF.

Insurance representatives

The order of the Ministry of Health defines the responsibilities of insurance representatives. It is they who will be engaged in "support", work with complaints. The new rules oblige insurers to carry out full "information support" of patients at all stages of medical care. We are talking about informing citizens about medical institutions working in the compulsory health insurance system, the right to choose a clinic and a doctor, the type, quality and conditions for the provision of medical care within the framework of the state guarantees program. And also about the need to undergo preventive measures.

In addition, insurers will have to inform citizens about the identified violations in the medical care provided to them. And the patients themselves had the right to demand an examination on his specific case.

The workplaces of insurance representatives will be located directly in hospitals and clinics: “This means that patients will be able to receive advice about their rights right where they may be violated. And the insurance representative will be able to quickly resolve a possible conflict, "- said the expert of the working group on the development of compulsory health insurance of the All-Russian Union of Insurers, Ph.D. Alexey Starchenko.

Insurers are getting closer to the people

Until a few years ago, insurance companies were the last resort, recalled by patients faced with a violation of their rights. But the situation is gradually changing. According to Nikolay Sviridov, an expert from the All-Russian Union of Insurers, in 2018 insurance representatives received 6.5 million consultative and explanatory appeals and 32 thousand complaints. Among the complaints, more than 8.2 thousand related to the quality of medical care, 2.6 thousand - complaints about the organization of work of medical organizations, more than 2 thousand - about collecting money, 450 - about refusal to provide assistance.

But still, most of the citizens continue to seek justice not from insurers, but from the authorities. Natalya Stadchenko urged her colleagues to go to the people - to participate in village gatherings, meetings at work: “let people turn to you and not the president for solving their problems”.

Professional examinations and dispensary registration

New rules oblige medical institutions to provide insurance companies with all information about patients. First of all, this concerns clinical examination and preventive examinations, accompanying patients with chronic and oncological diseases. For example, if a patient does not appear for a routine examination or an appointment with a doctor with whom he is registered, an insurance representative may contact him to find out the reasons.

The new rules also set out in detail the control over dispensary observation of patients, a database is created on the dispensary registration of each patient under observation. For this, medical institutions provide insurers with access to their internal information systems. “If earlier the insurance companies controlled the quality of the medical care provided on the basis of its provision on the basis of documentation or upon the application of citizens, now the new rules define step-by-step regulations for accompanying insured persons at all stages of treatment,” said Natalya Stadchenko.

In addition, the insurers will monitor planned hospitalizations. On a daily basis, polyclinics will send information about patients sent to hospitals to the Unified Register of Planned Hospitalizations. And hospitals, in turn, will submit lists of patients who have come for hospitalization to insurance companies.

The new rules also regulate the procedure for monitoring telemedicine consultations. Insurers will ensure that the recommendations made by federal medical centers during such consultations are followed in the field. Information about a remote consultation or consultation should be posted on a single information resource within one working day.

Oncological support

The escort of patients with cancer is prescribed separately. In the new rules, a rule has appeared on the formation by insurance companies on the websites of territorial CHI funds of the history of insured events of patients with confirmed malignant neoplasms or with suspicion of them. Thus, an integrated database will be created for quick assessment of the place and time of the patient's stay at the stages of diagnosis and treatment. According to the authors of the idea, this will enable insurers to quickly restore violated rights of patients, as well as control the timing of diagnosis and the course of treatment.

Insurance representatives will monitor the timeliness of patients receiving referrals to the subsequent stages of treatment, inform patients about the calendar (roadmap) of chemotherapy or radiotherapy cycles, and explain to patients their rights to comply with dose-interval requirements. And if necessary, provide psychological assistance and support. As Alexei Starchenko noted, “the patient-oriented model is not only patient orientation, but also patient orientation in the compulsory medical insurance rules”.

Penalties

The new rules have adjusted the size of fines for not providing medical records and for distorting information in account registers. According to Andrey Ryzhakov, Chairman of the Council for Medical Insurance of the All-Russian Union of Insurers, this will ensure a fairer application of sanctions, while reducing the volume of registrations and saving money in the CHI system.

In addition, the responsibility of medical organizations for the appointment of irrational pharmacotherapy is increasing. For example, if a cancer patient was prescribed an old chemotherapy regimen, instead of carrying out genetic studies and prescribing a modern targeted drug, the sanction will be 90% of the cost of medical care.

The reform continues

Meanwhile, the reform of the CHI system will not be limited to new rules. According to Tatiana Golikova, Deputy Chairman of the Government of the Russian Federation for Social Issues, "a number of legislative changes are ripe for the OMS." “It is necessary to more clearly spell out the powers that are now assigned to territorial funds, insurance companies, and, for example, Roszdravnadzor. Because today an insurance company can also come to a medical organization - fine for what it has in its competence, and Roszdravnadzor can come and say that the organization does not meet the licensing requirements. He can fine, he can take away the license. Here we need to clearly distinguish all this,”Golikova said at the panel discussion“The Modern Role of Medical Insurance Organizations in the Compulsory Health Insurance System,”held as part of SPIEF-2019.

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