The results of the Federal Pilot Project in public health care in 2007-2008

In the Pilot Project, which was implemented in 19 subjects of the Russian Federation in the period from July 2007 through December 2008, a number of institutional transformations in the system of health care financing were tested.

The Federal Pilot Project in public health care was carried on in the following RF subjects (pilot regions): Astrakhan Oblast, Belgorod Oblast, Vladimir Oblast, Vologda Oblast, Kaliningrad Oblast, Kaluga Oblast, Krasnodar Krai, Leningrad Oblast, the Republic of Tatarstan, the Republic of Chuvashia, Perm Krai, Rostov Oblast, Samara Oblast, Sverdlovsk Oblast, Tver Oblast, Tomsk Oblast, Tiumen Oblast, Khabarovsk Krai, and Khanty-Mansi Autonomous Okrug.

The conditions for the Project’s implementation were determined by Decree of the RF Government, No 296 of 19 May 2007, “On approving the rules for financing, in the year 2007, the costs of implementing in subjects of the Russian Federation the Pilot Project designed to improve the quality of services in the sphere of public health care, and the list of subjects of the Russian Federation participating therein”, as well as by a number of normative documents issued by the RF Ministry of Health Care and Social Development and the Federal Fund for Compulsory Medical Insurance (CMI).

The Project was initially designed to last for 12 months – from July 2007 through July 2008. To its implementation, a total of 5.4 billion rubles was allocated from the federal budget, of which the actual expenditures in 2007 amounted to 2 billion rubles, and those on 2008 – to 3.4 billion rubles. The expenditures on the Project from the budgets of RF subjects amounted to 3 billion rubles.1 From July 2008, the Project was extended until the year’s end, without allocating any additional funding from the federal budget.

The Project tested the feasibility of transformations to be implemented in the following five areas:
  1. The switchover of health care institutions predominantly to one-channel funding through the CMI system. Within the Project’s framework, the share of state resources to be accumulated in the territorial CMI systems was made higher by means of increasing the size of contributions from the budgets of RF subjects to territorial CMI funds. As seen by the results of the year 2008, the actual share of CMI funding in the pilot regions increased by nearly 1.5 times – to 58%; however, the average target index envisaged for all the pilot regions (60%) was not achieved.  
  2. The implementation of medical care standards and the payment for in-hospital care in accordance with the norms established for financial costs calculated on the basis of these norms. In 14 regions, 678 federal medical care standards for providing care in various specific diseases (between 6 and 297, depending on a particular region) were implemented in the practice of hospitals and outpatient clinics, as well as 15,595 regional standards. The principal problem encountered in the implementation of these standards was their high cost. By comparison with the medical care costs calculated on the basis of the norms for funding the territorial programs of state guarantees, the costs involved in the provision of medical care in accordance with the standards were found to be much higher (for example, the treatment for heart failure – by 2.5 times, for acute myocardial infarction – by 4.7 times, for inborn pneumonia in preterm babies – by 24 times). In this connection, the bulk of costs is constituted by the costs of medications – up to 94% of the cost of a given standard. Thus, the Project’s implementation vividly demonstrated that the existing methodology for developing federal medical care standards and the procedure for the application as a base for estimating the payment tariffs for the medical care provided by hospitals and outpatient clinics, as envisaged in the Pilot Project, need to be thoroughly revised.
  3. The switchover to per capita funding of outpatient clinics, with some elements of fund-holding. At present, the predominant method of payment for outpatient medical care is the payment per visit. The testing of fund-holding method consisted in including in the composition of the per capita funding norms applied at 237 outpatient clinics of the funding allocated not only to the medical care proper provided by the institutions to the population serviced by them, but also of that allocated to the consultations of specialists and tests provided to the same population by other medical institutions. At 93 medical institutions, the mechanisms for inter-institution settlements between district general care departments and specialized departments were also implemented.
  4. The implementation of new systems for reimbursement of medical personnel based on volumes of care and performance was carried out in 14 regions. At 599 medical institutions, the salaries included additional payments designed to increase the dedication of medical personnel to the tasks of increasing the volumes and improving the quality of medical services provided by them. In this connection, the salary level of the medical personnel participating in the Project increased between July 2007 and December 2008 by 66.2%.
  5. Personified records of provided medical care were implemented in 18 regions and involved 95 % of all the medical institutions participating in the pilot study. The goal was to create a single information space within the regional health care administration system consisting of public health care administration bodies, medical institutions, and insurers.

In our opinion, the choice of study areas for the Project has been made quite correctly. Nevertheless, its organization had some flaws; thus, there was no testing of any alternative variants of the ongoing transformations in the study areas, no methodological base, and the timelines set for the Project were too narrow for a full-scale implementation of the planned tasks and for obtaining visible final results.

The shortness of the Project’s period makes it difficult to assess its results; however, there were indeed some positive achievements: thus, the scope of in-patient care – which in this country is excessive – was reduced, to be replaced by more outpatient care; the quality of medical care was improved – both through enhancing quality control (the number of expert’s estimations increased by 20 %) and through implementing the Project in its main directions; the population’s satisfaction with medical care, according to sociological surveys, rose from 61.6 % to 84.1 %.

On the whole, the results of the Pilot Project have confirmed the importance of large-scale reforming of the system for public health care financing in the selected areas, but at the same time they point to the need to revise and set more specifically the reforming goals and their differentiation by region across the country.

S. V. Shishkin – Doctor of Economic Sciences., Head of Department for the Economy of the Social Sector

1 Hereinafter the estimations are based on the data published by the Ministry of Health Care and Social Development and by the Federal Fund for Compulsory Medical Insurance.