Chief researcher, IMEMO Russian Academy of Sciences Yevgeny Gontmakher explained why attempts by the state to pass on to the Russians the cost of medicine is doomed to failure.
Chief researcher, Institute of world economy and international relations Russian Academy of Sciences Yevgeny Gontmakher explained the “Business weekly “Profile”,” why attempts by the state to pass on to the Russians the cost of medicine is doomed to failure.
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– How you consider, whether there will be after presidential election in 2018 reform of obligatory medical insurance?
– I think so. Unfortunately, immediately after the election, the conversation will talk about this in a practical way. We remember a phrase that Vladimir Putin said on 15 October in Sochi, the participants of the world festival of youth and students (“you need to think” about, “in what segments and in what amount” the state is obliged to “help for free”, and “where possible some co-financing”. – “Profile”). All it understood that it is necessary to share responsibility with the state in health care for the citizens too, it is time to pay. Now the contributions to the mandatory medical insurance Fund paid by employers (it receives 5,1% of payroll. – “Profile”) and regional budgets (for non-working population. – “Profile”). But the MMI system is unable to cope with the need for medical assistance, which really exists. We have low wages, so contribution of 5.1% is not enough.
So there are two options – either to subsidize these costs from the Federal budget like Pension Fund, but the government is never going to reduce the gosobyazatelstva.
The volume of population needed medical care to objectively grow. Good thing we have a longer lifespan, at least according to official statistics. But this automatically leads to increased demand for timely, specialized medical care. The second point is the transition to modern medicine, which is becoming more high-tech, and it is costly. Despite the fact that there are technologies that, on the contrary, to save budget money, for example, early warning, prevention of diseases, even chipping. But, unfortunately, the Russian health care system is a vortex which sucks any amount of money. It is beneficial as much as possible the number of patients for whom it receives money from the MLA.
The third factor is health care came in second or third place in the lives of all social problems, after poverty and rising prices.
And what specific ways of implementing this unpopular initiatives discussed by officials and experts?
– Preference is given to the introduction of co-payments by citizens. The only question is in what form. Discussion hidden, but happen public stuffing. Well, for example, the reports of the panel of experts from the Higher school of Economics, although there are different points of view. If you explain in a simplified way, a person comes to the clinic and pays at the entrance of 100 rubles, and then goes to the doctor and serviced free of charge. Of course, this is a relatively small amount of money, but the proposal itself may react, as his time on the monetization of benefits. Even according to official data, in the fourth year incomes fall. Although our citizens to touch hard, if you do, the reaction may be very sharp. Especially the poor, the elderly. Most likely, pensioners and disabled people will not be forced to pay extra. But even if the entire load will shift to running, it can cause resentment on the part of older people. The elderly are sensitive to what is happening with their children, and can be offended for them.
There is another point of view, which is inclined by the Ministry of Finance and economic development. We are talking about introduction of additional contributions that citizens will have to pay, like income tax, an additional 2% of salary on medicine.
The Ministry of health takes a more cautious stance, leaning more to the version of the MLA (a similar experiment in five regions actually fell. – “Profile”). The number of services that were funded CBOs will be reduced to the minimum, and the rest – by choice.
What do you think about this in the White house and in presidential administration, I don’t know. But Putin’s statement is the result of closed discussions there.
– The Central Bank recently published a report on improving the system of insurance and prior to November 17, collects comments to him. How do you feel about these proposals?
– Very carefully, because we are talking about patching the current system. We are hesitant to admit that the system is beyond repair. We need to build another. In the end, it all comes down to shifting part of the financial responsibility on the population, convinced the authorities that our people still suffer.
Private insurance companies exist to monitor the quality of services of health facilities. But if the medical institution and fined, mainly for inadequate documentation. As a rule, formal arraignment, because a private company is no time and opportunity to investigate specific cases, if the patient is incorrectly diagnosed, made a medical error etc. it is Necessary to change the system of incentives to private insurers, not the health insurance Fund, collecting contributions and accumulated them. That is, they were not a mediator between CBOs and the health facility, and really spent those 5.1% of the contributions. So they were looking for doctors, entered into contracts with clinics and hospitals, then maybe, just maybe, an incentive to control these funds. This should be competition. As, for example, in Israel, if you don’t like the way served in one insurance insurance, you go with your fee to another. But it is a completely different system, which we do not speak. Our medical insurance system that has repeatedly acknowledged, in their speeches and Vladimir Putin is quasistrategies. In OMS, there is not even personified, like in the Pension Fund.
– What can be the solution?
The only option is a transition period for 30-40-50 years, during which he had gradually to return to budget the health care system. Not Soviet, of course, there will not be returning. It is, rather, about the conditional, the Anglo-Saxon scheme, both in the UK, Canada, Australia, New Zealand, Sweden, and Italy. In a number of developed countries, this sector is financed from the budget. But there are contractual arrangements between the doctor/health facility and budget management, quality control system etc. These systems are considered to be at least not less efficient than the insurance system. There are countries with MHI, for example, the Netherlands, some of its elements is in Germany, but it is rare. By the way, Barack Obama wanted to make a version of OMS in the United States. We have this system exists on paper, it is not a product of the world experience. Our experience failed for example, those of 5.1% is economically not justified.
But discussions about the budget the financing of the repressed. It is believed that it is too radical an approach that requires a review of all current budget policies and politics in General. And she has other priorities – defense, homeland security. On the transfer of these funds for the development of human capital out of the question.
Turn to man has far-reaching consequences. This rejection of current foreign policy and a return to the decentralization of power, and revising the whole system of compulsory social insurance. But authorities are not ready to any major reform! Take any sphere – they are afraid, they need to maintain the status quo. They hope for the miracle, for the patience of the population. And not without reason: entered payments for the repair – people pay the real estate tax increased – the people are silent. Well, pay more for your health care.
– “No money, but you hold fast.” But it is clear that the population will not be able to pay for health care.
– Many understand perfectly. But it’s one thing when you suggest something to fix cosmetically, and the other when they say: let us military spending has decreased. Officials want to sit, so better to keep quiet. We have the responsibility delegated to one person. But if the President will say let’s reduce spending on the army and security, and the entire savings to send to their human capital, then everything will become supporters of this idea. Or, on the contrary, claim that education and health have enough money, and the people let him a little pay, officials once again agree. We have a policy of no internal conflict in the best sense of the word, which is the driver of any reforms. And when only one point of view, obviously no progress can not be.
Generally, the choice of a national model of health care as a social contract requires national debate. Real, not imitation as we like.
– Earlier it was rumored that discussed the issue of raising from 5.1% to 5.9% rate of contributions to the HIF.
– There is a constant trade, and 10% to do, but then our business generally will fall. Moreover, the RSPP, “Support of Russia”, Bulk – all require sharp decline in the so-called “load to payroll”. All “extremists” who call to cancel all insurance premiums. But the question arises, where to take the money, considering that with the same prices for oil and gas all is not well in the future.
– And how the budget system will be constrained by the unreasonable increase in the cost of health care and controlled costs gosmedakademii?
– The perfect scheme does not exist anywhere. Even in countries with the most successful health patients, in large part unhappy with the way they are treated. In developed countries, the healthcare system will always require a lot of money. In the US, including private spending, is spent almost 17% of annual GDP. This huge amount of money, the rest of the world can be cured. But Americans are still unhappy – it’s expensive, a lot of medical errors. Mechanisms limit the growth in spending is not created. But where they are, costs are rising. In the countries with the budget system in the UK too.
According to statistics, expenditure on health percentage of GDP increased in all countries. There are objective reasons: the aging, more expensive medicine, particularly high-tech. But there is an element of samoushenka. But there is this process in every way put a spoke in the wheel. In addition, when health care requires more money, respectively, it is necessary and doctors ‘ salaries to establish competitive, and purchasing equipment, etc.
This is a continuous work on quality control, have extensive experience on how to link costs with effectiveness. If there is excess treatment costs of the sick, investigation is made. There are plenty of control mechanisms, ranging from the Society for the protection of patients ‘ rights and ending the political opposition, which immediately starts to accuse the ruling party that it is wasting money for nothing.
– It turns out that when you save fiscal imbalance between military and social spending to go towards the development of the insurance model hopeless?
– Is futile. First, due to the budget constraints, because more money can not be printed. Second, our economy is not growing. If we had wages at least 2-3 times higher and distributed more evenly. And when the employer pays a fee to MLA with meager earnings, the money system is still lacking. But to oblige the person to give from the salary of 1-2% is generally unrealistic. It’s an extra ten rubles there. No prospects of higher wages, because nothing moves in the economy. If she reformed, created new jobs, would be at least some prospect, then people would have understood. In the 2000s, when there was rapid growth, it would be possible to persuade people. And now from what to pay in a falling trend?
– HIF deficiency, including the fact that some regions do not have enough funds on premiums. Some officials have proposed to oblige the “broken” working age by paying contributions (officially registered on the labour market 64% of the population of the Russian Federation).
– For the unemployed of working age in regions of OMS do not pay, only for the officially registered unemployed. However, such people are presented with a claim that they are not working, they are entitled to health insurance and maintained by contributions which are paid for other employers and the regions for their official unemployed. And because it is unfair, it is necessary to impose their kind of tax. But it is a very questionable proposal of the populist movement. Lukashenko introduced a similar exaction “law on social parasites”. And in the quiet of Belarus people came out to protest, after which the government was forced to suspend its action.
– What is the share of government spending on healthcare of GDP in Russia?
– 8-10 years ago, when there was a national project “Health”, it has grown to 4%. Now dropped to 3.3–3.4 per cent, and there is a tendency for further decrease. Despite the fact that in OECD countries, where we wanted to go, the standard of public megashadow percentage of GDP is 6-7%. And in fact, the gap is even larger given that they have a GDP per capita 3 times higher than ours. And we, failing to reach the level of developed countries begin to reduce health care costs! How to improve life expectancy?
The purpose of the state program “Development of health” – it will increase by 2025 to 76 years.
– Unreal! In moderately developed countries such as Russia, such a pattern – the less developed a country, the stronger the effect of health on life expectancy. But even these 76 years of XX century in developed countries, which they have long been passed. They now take 80+. Every year gain of life expectancy is a tremendous public health care costs, pension system, infrastructure. Because people have to live with more or less normal life at this age, not begging. At current trends, I don’t believe it.
– In Russia more than 50% of megashadow financed from private sources, in your opinion, what is the limit of growth in the share of private medicine in Russia?
– About half of all spending is mandatory insurance and the budget adds a little. The second half is also divided into two parts – the informal payments (bribes, gratitude) and what is officially paid by patients in cash.
The limit, which is reached in absolute terms this paid medical care is near. It is constrained by effective demand. If a person makes 10 thousand roubles, will he go to pay for the teeth? No wonder our people have bad teeth, including in children, as dentistry is terribly expensive, and free is almost none.
To treat or sustain life of cancer patients also need expensive medications. There is government funding, some free drugs. But the pharmacy might not be because the budget has no money for their purchase. Such situations are quite frequent. For example, they regularly occur with diabetics, when some regions do not deliver free insulin, which they are required to by law. Go to pharmacy – buy.
So the situation came to a region that is very bad. Everyone understands what the status of the health of the nation. And the government urge that citizens has implemented an innovative breakthrough in the XXI century.
