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Problems of private medical organizations involved in the implementation of the program of obligatory medical insurance (OMS)

Jan. 29, 2018, midnight

Problems of private medical organizations involved in the implementation of the program of obligatory medical insurance (OMS)


Federal law of 29.11.2010 № 326 – FZ "On mandatory medical insurance in the Russian Federation" (further – FZ "On compulsory medical insurance") establishes the provisions under which medical assistance program the OMS is carried out by included in the relevant register as the state and municipal health care institutions, and commercial healthcare companies. Thus, at first glance, the state actually put on the same level and given equal opportunities both to the implementation of this direction of medicine. However, in practice the same state by the actions of state and municipal structures infringe upon the rights and interests of private healthcare companies, and creates discriminatory conditions for their work within the framework of the OMC, which often compels the latter having the best material equipment and qualified personnel, to refuse such activity.

What are the difficulties faced by commercial medical organisations working in system OMS, and in what ways to overcome some of the difficulties?

FZ on compulsory health insurance stipulates that free medical care is available in the territory of the RF subject on the basis of the territorial program OMS, which contains the methods of payment for health care provided to insured persons, the tariff structure for payment for medical care, the register of medical organizations involved in its execution, defines the conditions for providing medical assistance to them, as well as the target values of criteria of availability and quality of medical care. This program is developed and approved by the relevant territorial Commission (p. p. 6 – 9 of the Federal law "On compulsory medical insurance"). In addition, this Commission performs the functions of distribution of volumes of health care provision between health insurance organizations and between health organizations, the review of tariffs and the formation of tariff agreements, etc. it is thus provided that the Commission on a parity basis, together with representatives of territorial health ministries, social security funds, insurers, state and municipal health care institutions should include representatives of private medical organizations (p. 3, 4 of the Regulations on the Commission on the development of the territorial program of obligatory medical insurance, approved by order of the health Ministry of Russia dated 28.02.2011 No. 158 h).

However, as practice shows, in fact, this rule is not enforced. Almost none of the subjects of the Russian Federation established the Commission did not include in its membership individuals of commercial structures in this area (Decree of the Government of Moscow dated 10.07.2012 No. 364 – RP resolution of the Government of the Kirov region dated 13.02.2012 No. 139/67, the resolution of the Government of the Omsk region from 01.02.2012 № 16 – p). Thus, private medical organizations involved in the implementation of the territorial program OMS, denied the right to Express an opinion during the discussion and voting on the important issues of their activities. In our view, these circumstances allow to doubt in the performance of the main principle of the formation of the Commission of equality of the parties, which in turn "gives rise" to thinking about its legality and legitimacy, the legitimacy of its decisions.

As, perhaps, a "sore" problems in the commercial healthcare companies, providing services on the OMS, it should be noted the refusal, or "cuts" Commission for the development of the territorial program of obligatory medical insurance of volumes of granting of medical aid on obligatory medical insurance of the population. Usually this happens due to "covert" protect the interests of the public health institutions, including members of this Commission, by storing them unnecessarily larger volume of medical services under the program of compulsory medical insurance, than they actually are or can be provided. This Commission often is not taken into consideration the rationale for the designated private health providers of medical care capacities, allocation is necessary to meet the needs of those who appeal to them insured persons formed taking into account the information on the annual number of medical services provided in corresponding directions. Thus, the Commission does not actually take into account the interests and choices of citizens who annually use medical help in such companies, indicating a her including obstacles to the implementation of fixed in FZ "On compulsory medical insurance" the right to the patient's choice of medical organization.

As a result of unjustified and unlawful decisions of the Commission on refusal of the allocation of volumes of medical aid or reducing commercial medical companies fall into the "financial hole". The reason is that, on the one hand, knowing that direct funding is not provided, they have to provide medical services to insured persons at the expense of own means, as to refuse to provide medical care they are entitled to. Subsequently, to conduct a protracted litigation with the insurance medical organisations on the recovery of spent funds for provided medical service, which is also not always resulted in success. On the other hand, the private medical companies need to "close" loans, which were purchased expensive medical equipment, had operated the payment of wages to employees, etc., as arranged at their own expense this kind of activity is quite difficult. Accordingly, this creates a situation where commercial medical organizations are forced to "tolerate" losses as a result of illegally taken by the Commission on the development of the territorial program OMS decision on the distribution of medical care, while the public sector is "idle" and not learn in full the quotas for medical care in OMS.

It appears that similar phenomena often "thrive" in the subjects of the Russian Federation because:

  • commercial medical companies – participants of the MLA is not entitled to request information and to familiarize yourself fully with the Commission's consideration of documentation when making decisions about the distribution of medical care, and the Commission has not established an offsetting duty at its results;
  • there is no clear and transparent legal regulation in the MHI system, including the formation of the Commission, consideration of the validity of the claimed amounts and their distribution, etc.

In such "cramped" conditions, in order to "stay afloat" private medical organizations can not do without the inclusion in the system of measures for development and protection of business legal solutions to problems, both administrative and in court. For example, you can pay to the Antimonopoly body with the statement for infringements of the legislation on protection of competition unlawful actions of bodies of Executive power of a subject of the Russian Federation in the establishment of the Commission for the development of territorial program OMS or of the Commission when deciding on the distribution of medical assistance (resolution of the Federal 21.12.2016 from G. in the case N 4-14.9-1107/00-18-16). Protection in court, usually done by challenging the Commission's decisions on the development of the territorial program OMS on distribution of volumes of rendering of medical aid (the Decision of the Nineteenth arbitration court of appeal dated 14.10.2014 according to case number A36-6671/2013).

In summary, we believe that the mandatory medical insurance system needs serious improvements, both in organizational and legal sectors. Clear regulation of relations on the problems at the legislative level will help to create optimal conditions for healthy competition between state and municipal healthcare institutions and private medical companies. In turn, competition can serve as a key to improving the level and quality of medical care received by citizens under the program of the MLA.