The Medical Insurance System of the Russian Federation

135 NFT 2/1999 Sources of financing According to the law, the sources of financing of the system of medical insurance are funds from the national and regional Budgets on all levels, earmarked funds, government and municipal companies, organizations, public associations, revenue from the turnover of securities, bank loans, or income from chari- ties and other sources not forbidden by the legislation of the Russian Federation (1). From these sources is formed the financial resourc- es of the government and municipal systems of health care and the government system of obligatory medical insurance. The financial resources of the government system are built up at the expense of the individual insured. The insurance premiums from enterprises, organizations and companies are allocated to obligatory medical insurance over and above appropriations established for the develop- ment and function of health care. Federal and Territorial Funds, independent non-commer- cial financial-credit institutions, are created for the accumulation of insurance premiums for obligatory medical insurance. The finan- cial resources of the funds are part of the government property of the Russian Federa- tion. They are not included in the Budget and are not subject to withdrawals. The insured party transfers the financial resources to the Federal and Territorial Funds and through the latter the money is disbursed to the medical organizations. The Medical Insurance System of the Russian Federation by Diana W. Wormuth, Ph.D., Insurance Training and Consulting BICON AB and Atai S. Gadjiev, M.D., Ph.D. Atai S. GadjievDiana W. Wormuth By the law of the Russian Fede- ration ”On Medical Insurance of Citizens of the Russian Federa- tion” from January 1, 1993 the system of medical insurance was introduced as a form of social security and medical assistance for the population of the Russian Federation. The law defines the kinds of medical insurance, le- gal relations and obligations of the objects of the insurance and the sources of financing. 136 Obligatory and voluntary medical insurance In the Russian Federation there are two kinds of medical insurance for the population – obligatory and voluntary. In order to receive medical assistance according to the system of obligatory insurance it is necessary to con- clude three kinds of contracts – contracts on the organization and financing of medical services, contracts for medical insurance and contracts on the provision of medical assist- ance. The structure of the mutual relationship and the order of payments depend on the social status of the insured (citizen, working at a company, a member of liberal professions or a person conducting his own individual work activity, an unemployed person, child or pensioner). (See Diagrams 1,2,3). After the conclusion of the contract the insured re- ceives a certificate with his or her name where- by he or she can receive medical services at any point in the Russian Federation within the scope of the stipulated obligatory medical insurance. Voluntary medical insurance guar- antees the citizen additional services over and above the established programme of obliga- tory medical insurance, upon payment on his own account. Voluntary medical insurance can be implemented in individual and collec- tive forms (see Diagrams 4,5). In accordance with the contract, the medical insurance com- pany is obliged to conclude a contract with the medical care institution on the organiza- tion of medical assistance, to pay, in the case of a claim (illness, trauma), for the stipulated medical services, while the insured party is obliged to pay the premiums within the time period stipulated. The right to choose The typical contract forms of obligatory and voluntary medical insurance, as well as the order and conditions for concluding such contracts, are established by the government Diagram 1: Obligatory medical insurance for the working population in Russia 1. Contract for obligatory medical insurance between the insured party and the medical insurance company 2. Contract for the organisation and financing of medical services between the medical insurance company and the medical care institution 3. Contract for the provision of medical assistance between the medical care institution and the citizen (patient) Medical care institution Medical insurance company Federal fund for obligatory medical insurance Insured citizen (patient) Insured party = company, institution, at the work place Territorial fund for obligatory medical insurance 3 2 1 137 Diagram 2: Obligatory medical insurance for the non-working population in Russia 1. Contract for obligatory medical insurance between the insured party and the medical insurance company 2. Contract for the organisation and financing of medical services between the medical insurance company and the medical care institution 3. Contract for provision of medical assistance between the medical care institution and the citizen (patient) Medical care institution Medical insurance company Federal fund for obligatory medical insurance Insured citizen (patient) Insured party = government of the republics constituting the Russian Federation, organs of government management of autonomous education, regions, of the cities of Moscow and St Petersburg, local administration Territorial funds for obligatory medical insurance 3 2 1 agram 3: Legal regulation of the health organisation in Russia 1. Contract for obligatory medical insurance between the insured party and the medical insurance company 2. Contract for the organisation and financing of medical services between the medical insurance company and the medical care institution 3. Contract for provision of medical assistance between the medical care institution and the citizen-patient (insured party) Medical care institution Medical insurance company Federal fund for obligatory medical insurance Insured party = citizen (patient) Territorial fund for obligatory medical insurance 3 1 138 of the Russian Federation. An essential part of the contract is the specification of pro- grammes included and the kinds of services, with a list of the medical institutions where they are provided. The insured party has the right to freely choose his medical insurance company. The medical insurance company does not have the right to refuse entering into an obligatory medical insurance contract with the insured party. In order to enter into a voluntary medical insurance contract the in- sured party submits a written notice to the insurance company, which must make a deci- sion within five days from the moment of receiving the notice. The contract for volun- Diagram 4: Indi The citizen inde from his own fun Diagram 5: Col The company tra 1. Contract for insurance c 2. Contract for insurance c 3. Contract on and the citiz Medical care institution ???????? Medical insurance company Medical care institution Medical insurance company tary medical insurance is considered to have been entered into at the moment of the pay- ment of the first insurance premiums and to be valid from the moment of signing. The parties to the contract are the medical insurance company and the insured party. Medical insurance company rules The medical insurance company is a legal entity carrying out medical insurance and in possession of a government license issued by the Insurance Supervisory Service of the Russian Federation for each kind of insurance 139 (obligatory or voluntary) no later than 60 days after presentation of the company’s Ar- ticles of Association (2). Regulatory limits Medical insurance companies do not have a legal right to conduct industrial, business or banking operations. It is forbidden for such companies to buy or sell real estate, although real estate may be acquired as one form for investing funds and insurance reserves. Gov- ernment organs for directing health care and medical institutions do not have the right to be founders of medical insurance companies, but they can own shares, whose sum may not exceed 10 percent of the medical insurance company. The medical insurance company must have a shareholders equity no less than 1200 times the minimum annual wage estab- lished by the government of the Russian Fed- eration (approximately SEK 36 650 or EURO 4072). The reserve funds by kind of insurance are formed at the expense of investments of from 15 to 20 percent of the funds received in connection with insurance contracts. The ra- tio of equity to the proceeds cannot be more than 1:20. The medical insurance company conducting obligatory medical insurance does not have the right to use funds intended for carrying out obligatory insurance programmes for commercial purposes, with the exception of temporary acquisition of very liquid secu- rities and bank deposits using free funds of the reserves. The funds of the obligatory insurance company are formed through de- ductions made from all kinds of companies, institutions, all kinds of property organizsa- tions and through premiums paid by individ- uals conducting their own activities. The scope of the premiums is regulated by the law of the Russian Federation ”On insurance tariff in- come to the Social Insurance Fund of the Russian Federation, the Government Em- ployment Fund of the Russian Federation and Obligatory Medical Insurance Funds”, which stipulates the following deductions for the separate kinds of obligatory insurance: 5.4 percent of the basic salary to the Social Insurance Fund for the payment of benefits during temporary disability, pregnancy, birth; 2 percent to the Government Employment Fund of the Russian Federation; 3.6 percent to the Obligatory Medical Insu- rance Funds; 0.2 percent to the Federal Fund of the Russian Federation for Obligatory Medical Insurance; 3.6 percent to the Territorial Fund for Obli- gatory Medical Insurance; up to 28 percent to the Pension Fund. An additional one percent is paid to the Pen- sion Fund by the workers themselves from their wages. The public organizations of the disabled and various forms of property rela- ting to them (3) are exempted from the pay- ments of premiums to the funds enumerated above. Calculation of results The sum of revenue exceeding expenses is used to fill reserves in the order and to the size established by the territorial fund of obligatory medical insurance, with the exception of funds saved in conducting obligatory medical in- surance, which are regarded as income of the medical insurance company. The final finan- cial total (profit or loss) for obligatory medi- cal insurance is composed of the financial result from medical insurance operations, al- location of insurance reserves (payment of medical services, of additional financial pre- cautionary measures) and income from opera- tions not relating to insurance and the distri- bution of reserves for obligatory medical in- surance, less the sum of the expenses for these operations. The financial result of obligatory medical insurance operations is defined as the 140 difference between the sum of insurance pay- ments received together with the returns on insurance reserves of the previous year and expenses for payment of medical services together with the deductions in insurance reserves, the sum of expenses for conducting operations and the sum of excess of other expenses over income. The financial result of the allocation of insurance reserves (payment of medical services, additional reserve, re- serve for precautionary financial measures) is defined as the difference between the sum of income received from investment of reserves together with the account of the sums of income transferred to corresponding insur- ance reserves in the size of the defined terri- torial fund for obligatory medical insurance and the sum of other expenses, linked to investment of reserves for obligatory medical insurance. Included in the defined financial results on the basis of special calculations are changes in the size of the reserves for pay- ment of medical services and the additional reserve (deducted from the insurance pay- ments to the reserves or reduction of the funds of the reserve from the sums allocated for payment of medical services) transferred from the income from the investment of reserves and the surplus of income over expenses, connected with obligatory medical insurance operations (4). Restrictions on voluntary insurance cover The other party to the contract is the insured party. The insured party for obligatory medi- cal insurance for the non-working part of the population is the government of the Repub- lics of the Russian Federation, government organs of autonomous districts or regions, the cities of Moscow and S:t Petersburg for the working population, institutions, organiza- tions at the working place. The insured parties for voluntary medical insurance are the indi- vidual citizens or companies representing the interests of the citizens. During the period of validity of the contract for voluntary medical insurance, upon recognition by court of in- capability of the insured party, the insured’s rights and obligations are transferred to a guardian or trustee acting in his interests. In accordance with the law on voluntary medi- cal insurance the insured party may not be a citizen receiving care at a dispensary for drug addiction, psycho-nervous problems, tuber- culosis, and skin and venereal diseases. For people serving prison terms, the validity of the contract on voluntary medical insurance extends until the end of the prison sentence or privation of freedom. Contract rules The insured party has the right to annul the contract of the voluntary medical insurance in advance at any time if the insurance company does not fulfil its obligations. In that case the insurance premiums are returned to the in- sured party, proportionately calculated on what the insurance company has so far re- ceived up to the point of the cancellation of the contract minus expenses. To enter into the contract the insured party must undergo a medical examination for certain risks. If the insured has intentionally concealed facts on his health or provided false information, this is grounds for the insurance company to cancel the insurance policy or to impose sanctions. Voluntary medical insurance is implemented at the expense of the individual citizen or taken from the profit of the company acting in his interest. Separate categories of clients (the disabled, for example) can be insured on the basic conditions corresponding to the specific risks of the category limited by the scope of responsibility and the calculation of the in- creased tariff level. The medical insurance company (the insurer) is obliged to provide the insured citizen (the insured party) with a 141 medical policy and an insurance card with his name. Role of medical insurance com- pany The medical insurance company is not in- cluded in the health care system of the Rus- sian Federation and it does not itself provide medical assistance. In the case of obligatory medical insurance the insurer is obliged to organise and finance the provision of medical services of a scope and quality defined by the programme for obligatory medical insurance. In the case of voluntary medical insurance the insurer is obliged to pay and organise medical and social services that are stipulated in the programme for voluntary medical insurance in addition to the established programme of obligatory medical insurance. In this way the Diagram 6: Health care system in the Russian Federation State health system State Committee for Sanitary- epidemiological Supervision Academy of Medical Sciences Ministry of Health and of Medical Industry of the Russian Federation Health care institutions, pharmacies, pharmaceutical companies outside the system of the Ministry of Health of the Russian Federation Ministries of Health of the republics constituting the Russian Federation Health management organs of autonomous regions Health management organs of regions and of the cities of Moscow and St Petersburg Companies for the production of medical products and medical technology, pharmaceutical companies and pharmacies Institutions of forensic medical expertise Material-technical security services Scientific, research and educational institutions Institutions for health care and prophylactics and sanitary- prophylactics 142 insurance company has the role of an inter- mediary between the patient and the medical institution. Health care systems In the Russian Federation there are govern- ment, municipal and private health care sys- tems (see Diagram 6). Hospitals, polyclinics, dispensaries, maternity hospitals, and emer- gency care units provide medical assistance. These medical organizations have the rights and obligations of legal entities. They con- duct their activities solely according to li- censes on defined kinds of activities. The license is granted on the basis of the certificate of corresponding conditions for medical ac- tivities according to the standard established by the Health Care Ministry of the Russian Federation. Licenses and certificates are grant- ed by a commission composed of the govern- ment organs of a subject of the Russian Fed- eration (for example, an autonomous repub- lic or region) or by local organs with a man- date from the organs of the subjects of the Russian Federation. If the conditions of the activities of the medical organizations do not correspond to the standards established for licensing, no license is granted and an exist- ing license can be revoked (2). Private health care The private health care system includes a number of medical institutions with individ- uals conducting private medical practice and private pharmacy operations. It is permitted for citizens with a medical diploma from a nurses’ college or medical institution of high- er education to conduct private medical prac- tice. The local administration grants permis- sion for private practice in agreement with a commission composed of medical experts. In the law ”On enterprises and on the activities of enterprisers” of the Russian Federation there is a stipulated list of the kinds of medical activities, which the representatives of private medicine are not permitted to conduct, which are the exclusive prerogative of government medical organizations. These activities in- clude care of patients suffering from particu- larly dangerous infections, cancerous diseases, preparation and sale of narcotic and toxic pharmacological preparations, removal and preparation of organs for transplantation, medical sterilization, forensic medicine and psychiatric expertise, and biomedical research on volunteers. The basic programme of obligatory medi- cal insurance of the citizens of the Russian Federation was ratified in 1993 by the Gov- ernment and it defines the scope and condi- tions for providing medical assistance and medication. On the basis of this basic pro- gramme of the republics and regions of the Russian Federation, the cities of Moscow and S:t Petersburg, territorial programmes of ob- ligatory medical insurance are developed and ratified, in accordance with which the scope of services granted cannot be less than the scope stipulated by the basic programme. Guaranteed free assistance The provision of free primary medical and sanitary assistance (including emergency medical care), diagnostics and care in out- patient clinics, implementation of prophylactic measures against illness (for example, vacci- nation), inpatient care is guaranteed to the citizens of the Russian Federation. A detailed list of quotas of the population, illnesses, prophylactic, medical and diagnostic meas- ures, constituting the basic programme are developed and ratified by the Ministry of Health of the Russian Federation in agree- ment with the Ministry of Finance of the Russian Federation and with the participation of trade union organs. The scope and condi- 143 tions of medication assistance are defined by the territorial programmes for obligatory medical insurance. Payment for medicaments at hospitals in connection with provision of emergency medical care is come from the insurance premiums for obligatory medical insurance, in polyclinics it is at the citizen’s own expense. The insurance company is obliged to pay the account for medical services provided no later than one month from the moment of presentation of the relevant docu- mentation for reimbursement. The medical insurance company has the right not to com- pensate the medical institution for services rendered to the insured party due to a claim arising through his own fault, if he came to the institution in connection with trauma or ill- ness caused by alcoholic, narcotic or toxic intoxication, as a result of deliberately com- mitting a crime, attempted suicide or causing himself bodily injury. New principle for Federal law The Federal law from July 24, 1998 ”On obligatory social insurance against accidents in the workplace and occupational disease”, rests on new principles to regulate the com- pensation of loss of health attributable to labour activities of citizens of the Russian Federation (5). This law provides for a change from compensation directly through employ- ers for injury to citizens suffering work related handicaps, occupational disease, or other dam- age to health connected with fulfilment of occupational obligations, to a compensation for injury according to the principles of social insurance. Payments will be made by the single insurer from insurance premiums paid by the employers. Collection of insurance premiums, and the function of the making insurance payments to indemnify victims will be done by the organs of the Social Insurance Fund of the Russian Federation, defined as the insurer by Federal law. The premiums will be paid by the insured parties, proceeding from insurance tariffs, differentiated according to the industry and the class of professional risk. Conclusion According to this structure, it is possible to conclude that in the Russian Federation the new system of medical assistance to the pop- ulation is based on the principles of medical insurance. The process of change is proceed- ing with considerable difficulty due to the difficult financial situation of the nation, the extent of corruption in various entities in- volved in the process, the irrational use of the positive qualities of the earlier system of free health care and the insufficient knowledge and experience of contemporary Western sys- tems of medical insurance. In our opinion, one of the most effective levers for successful development of the models of medical insur- ance in the Russian Federation is the teaching of Russian specialists using the examples of Western nations with extensive and useful experience of developing and introducing varied systems of medical insurance in order to create connections for the exchange of experience and results. References 1. Law of the Russian Federation 1993 ”On Insur- ances”. 2. Collection of Laws of the Russian Federation 1998 Moscow. 3. Y. P. Lisitzyn, V.I. Starodybov, E.N. Saveleva. Medical Insurance. Moscow 1995. ”Meditzi- na”. 4. Insurance. Accounting. Taxation. Moscow, 1998. Prior Publishing. 5. Law ”On obligatory social insurance against accidents on the work place and occupational disease” 1998. Moscow.