Profit at all costs!
Vladimir Putin recently, a little over a week ago, spoke about the state of affairs in our healthcare. And if you remember, he did not say anything good about this. The primary link was especially given, the position in which was recognized, to put it mildly, unsatisfactory. In my article on VO, I already tried to quickly analyze the situation, and you can familiarize yourself with some conclusions. But, as it turned out, a deeper study of the issue reveals to us the real abysses of "common sense" and managerial "genius". What are we going to talk about today …
As usual, a look at the problem from the inside, although not without some subjectivity, nevertheless reflects its distinctive features much more accurately and more fully. And often it allows you to see at all that which, unfortunately, is almost indistinguishable from the outside. And it is precisely the opinion of some doctors that allows me to say today that one of the biggest problems in our health care (and not just primary care) is the system of compulsory health insurance.
First, let's emphasize a rather obvious thing: insurance companies, which are now appointed as an intermediary between the state and the healthcare system, are commercial organizations. Their goal, alas, is not our health, but the personal benefit of their owner. Moreover, this goal is not hidden by anyone, it is spelled out in the constituent documents of companies, and for its successful achievement, company management receives bonuses, bonuses and other “goodies”. It would seem that there is nothing wrong with this, because the whole (almost) West works on this principle, and in principle, private initiative over long periods of history is more successful than state regulation.
Everything is so, and yet not quite … To begin with, let's understand that the example of Western countries is not entirely correct: there, insurance companies evolutionarily, in the conditions of fierce competition with each other, achieved their current situation. They simply turned out to be the best of the possible alternatives in the conditions of an almost complete absence of state health care (now it’s not quite so, in many countries there are some forms of state participation, but it was almost exclusively private during the period of formation of Western health). Yes, the system was formed, survived and even proved to be somewhat effective, but there are still many problems there, and it cannot be said that this was obviously the best option for copying.
In our country, the system was artificially formed when insurance companies appeared literally from nowhere, their level of competence was appropriate (“no-where-no” correspondence), everything was done on the fly, but with the expectation of making a profit – this, as they say, is sacred. In addition, the corruption component that has been unchanged in our country in recent decades has left its mark on the process: wherever insurance companies have been appointed responsible for the distribution of state money (which is all social insurance, from the poor and disabled to emergency assistance, etc.), they needed to share part of it to get a sweet cake.
That is, you want to insure those who cannot provide for themselves, and for whom the state spends a lot of money annually? Pay! Moreover, also annually. And now, for many insurers, the budget for the years ahead is laid out exactly like this: to bring to the person responsible for the appointment, to thank the inspector, to please the approving decision, etc. But you also need to pay dividends to the owner!
Of course, it is possible without this, but then you are guaranteed to lose access to the flows of state money. And finally, it’s necessary not to “distribute and regulate”, but to really work: to form a client base, offer discounts to enterprises and firms, pay insurance agents, and so on. And here, as you know, we don’t really like to work when there is an opportunity to “scoop a sip from the stream” …
Bureaucracy and arbitrariness – synonyms for insurance medicine?
No, this is not written to pity the poor insurers – not at all! And they are not poor at all … But you should at least roughly understand the list of priorities of the current insurance business and the fact that for its successful work you need not just profit, but solid profit.
This profit is formed not simply from the difference between the money allocated to the patient and the actual spent on it. More precisely, excuse me, precisely from this, but you can really spend a thousand and one hundred rubles on a patient. Feel the difference?
I must admit that I myself was quite naive in this matter and believed that the insurance company meekly pays all the hospital bills. After all, they are signed by doctors, this is the result of serious medical research and appointments. Admit it, did you think so too?
In fact, everything, to put it mildly, is not quite so. Alas, the bureaucracy reigns in this business, much more terrible than the state, and arbitrariness, what else to look for …
Imagine that a doctor prescribes a blood transfusion to a patient. It would seem that the process in many clinics is routine, sometimes urgent. But it is not enough to appoint – he needs to fill out five pages of documents. And what’s most interesting – for every portion of donated blood!
Of course, part of this work can be transferred to the nurse, and many do. But even if we leave aside the fact that the nurses in the hospital usually do not sit idle and this is a big additional load, all the same, the bottom line is: the doctor still has to personally check the completed forms. Why? And here's why – if at least one of them has some kind of mistake, then employees of the insurance company have the right not to pay for treatment. Moreover, attention – completely! That is, the doctor or nurse made a typo, inaccuracy, even some kind of annoying blot, and the insurance company on this basis may refuse to pay for the entire treatment of the patient! Days, weeks, or even months spent in the hospital become conditionally free – that is, it turns out that the doctors will not receive money for his treatment, and the hospital will pay for medicines, necessary tests, studies, depreciation of equipment, and so on. Money for this, of course, will not be taken from the air – they will be deducted from the hospital's salary fund.
It is clear that in such a situation the head physician requires employees to strictly follow all the formalities. And since such situations occur in medical practice every day and more than once, just imagine how much additional bureaucratic burden falls on physicians.
Of course, it can be assumed that the head doctor of the hospital will hire lawyers, sue the insurance company and force her to pay for the medical care rendered. But here it’s how: the insurance company has money, it gives or does not give it by the decision of its experts (it doesn’t need a court decision for this), and the whole burden of proof in court lies with the hospital, whose budget is already without Trishkin’s caftan, constantly requires more and more patches. Therefore, I’m talking about the arbitrariness with which doctors, unfortunately, are forced to put up.
By the way, in order to make it easier for insurance companies to earn their profits, in Russia there is such a thing as a “medical and economic standard”. Our, one might say, revolutionary know-how, because even in the West they haven’t come up with this, using the much more flexible concept of “clinical-statistical group”.
In short, the medical and economic standard is an attempt to standardize the treatment of each disease at a cost. That is, if you have a sore throat, you should be cured without going beyond the limits of a certain amount prescribed in this standard. If your doctor, such a fine fellow, has met a smaller amount, a part of the money saved will go to the hospital and affect the already mentioned salary fund. Well, if he went beyond this standard, then the insurance company either will not pay at all, or will pay the amount prescribed in the MES.
This is done, not least, in order to prevent abuse among doctors. And it seems, at first glance, it looks reasonable. But only until we remember that it is impossible to standardize a person. And the only attempt at such “standardization” was the activity of the ancient Greek robber Prokrust, who lured travelers to his house, after which he either chopped off his legs if his bed was too small for them, or pulled them out, hanging huge loads at his feet if the bed was large .
Actually, MES in its modern meaning is such a "Procrustean bed" – if your illness is not complicated by anything, you will be cured. But if, for example, you have antibiotic intolerance, hormonal problems, kidney failure, or another million individual characteristics of the body that interfere with standard treatment within the framework of MES, then “options are possible” …
Service sector or primary obligation of the state?
Strictly speaking, the attempt to make health care a part of the service sector is, in principle, quite controversial. Why? Well, if only because the patient does not need an ultrasound scan, an X-ray is not needed, other tests and consultations are not needed as separate services. He needs, if you like, only one service – recovery. And analyzes, consultations of narrow specialists, ultrasound, MRI and many other things are needed, as a service, to the attending physician, who cannot make an accurate diagnosis and treatment for the patient without them.
The system of compulsory health insurance also raises big complaints. We, each of the working Russians, are obliged to give about 5% of our salary to the MHIF. As a result, this fund, acting solely as an intermediary structure, transfers money to its private contractors. Significant funds are also required for its maintenance, especially since the MHIF office is in almost every major city. How the "contractors" work is a little described above. And there are also huge, nationwide, states, thousands and thousands of “effective managers”, experts, lawyers, and so on. All this requires a lot of money, which are regularly taken from our pocket.
It is also noteworthy that pricing in the health care system is very arbitrary. For example, the price increase for a number of services provided under the compulsory medical insurance in 2017 amounted to 26-30%. Good outstripping growth, agree? With such growth, no inflation is scary and there is always enough money for caviar.
Interestingly, under the law, insurance companies can keep no more than 2.3% of the funds that go through them. But in fact, this figure sometimes reaches 14%! True, this question is more likely to the prosecutor and the TFR, why this happens, but I would like to understand.
It is not surprising that even the main Russian senator Valentina Matvienko last year proposed to abandon compulsory medical insurance and switch to direct budget financing of the healthcare system. And in general, the idea of abandoning the rather useless, as practice has shown, “laying” between state money and health care is gaining more and more supporters.
However, it is obvious that the struggle is still ahead, and the struggle is serious. After all, the money at stake is such that they will definitely fight.
Fight hard. Maybe – to the blood …
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