The situation in healthcare is becoming increasingly tense. This conclusion follows from a comprehensive sociological study commissioned by the All-Russian Union of Patients. Half (50.2%) of citizens say that the situation in healthcare will worsen in 2021.
Experts interviewed as part of the same study say that the system is beginning to acquire a reactive character. Patients who are ready to spend their time on complaints and appeals to various authorities receive the best help. However, as the survey data show, complaints to government agencies often do not give results.
The most effective practice of contacting insurance companies
According to the survey, the most effective practice was to appeal directly to the management of the medical organization where the rights of patients were violated, to insurance companies and to the prosecutor’s office. The head doctors and heads of the department were able to solve the problem in the majority (52.1%) of cases, in another 17.9% they gave valuable advice, but in 30% of cases they refused help. Insurers turned out to be the most responsive – they have the lowest share of refusals (24.6%). At the same time, they were able to help in 35.2% of cases, in another 40.2% of cases they helped with explanations and sent them to the right organization. The Prosecutor’s office was also able to help in 35.2% of cases, but the share ofAnswers to the question “where would you advise to contact a person whose rights to receive medical care are violated?”they were distributed in a similar way: first of all, patients call the head of the medical organization (68.3%) and the representative of the insurance company (46.6%). The relevant state agencies Rospotrebnadzor and FOMS were in the last places (2.7% and 2.1%, respectively).
So where should the patient go with problems? According to experts, it is necessary to use the advantages of CHI in the form of three responsible parties: the management of medical institutions, government departments and insurance companies independent of them.
“The effectiveness of the work of chief physicians with patient complaints is clear,” says General Secretary of the Russian Society of Surgeons, Professor Andrey Fedorov. —Where should patients of federal medical centers go?
However, now patients are increasingly finding themselves in a situation where persistent appeals to various authorities do not give any result. The author of the AIF recently managed to get acquainted with the history of one such patient. The patient was booked for a planned ophthalmological operation at the regional branch of one of the federal clinics and has already bought tickets for the route. However, on the eve of the operation, he was informed that the operationit is impossible due to lack of funding and offered to pay for an expensive operation from their own funds. The desperate patient contacted the insurance company, but the federal clinics are removed from the sphere of supervision of insurers, and they simply do not have the authority to influence this situation. Appeals to the Prosecutor’s Office, the Ministry of Health and other state authorities have not yet solved the problem.
This year, federal clinics are really experiencing a shortage of funds due to delays in paying for medical care, or due to the fact that the allocated annual volumes of compulsory medical insurance have ended. The media has repeatedly reported on increased cases of refusal of planned operations and other medical care in federal medical centers. Paradoxically, an acute shortage of funding for federal medical centers occurred as a result of the implementation of legislative innovations that were announced last year as a tool to increase and stabilize funding.federal medical centers: in 2021, the FOMS became the payer of medical care for federal medical centers instead of insurers. The FOMS also took away the function of protecting the rights of the insured from insurers. Who should the patient contact in such cases if the management of the federal medical center does not meet them halfway? In this case, the same state organization (FOMS), which does not give money to the medical center, which becomes the reason for the refusal of medical care, is engaged in protecting the rights of the patient in this case by law? It turns out that the stool was knocked out from under the patient?
According to Vice-President of the All-Russian Union of Insurers Dmitry Kuznetsov, insurance medical organizations continue to consider appeals regarding refusals to issue referrals, violation of the terms of hospitalization in federal medical centers. Some of these issues are solved at the level of an oral appeal to the call center. However, claims about the collection of funds for the provision of medical care or dissatisfaction with the quality of medical care (and almost half of such appeals) insurers are obliged to redirect to the FOMS, says Dmitry Kuznetsov.
The prosecutor’s office in this case is also most likely powerless:due to covid, the terms of planned hospitalization in many regions have been increased, and the problem of lack of funds cannot be solved by a prosecutor’s check. And appeals to the FOMS, as the survey data show, often remain unanswered.
“The number of complex issues, including those related to the refusal of medical care due to over-fulfillment of planned volumes by clinics, is really growing,” says Dmitry Kuznetsov. However, the vast majority of citizens’ appeals are resolved much faster, including directly when contacting the insurance company’s call center. In terms of appeals, examinations of the quality of medical care are carried out. Almost 80% of the problems identified during the examinationThis is non-compliance by medical workers with standards and clinical recommendations, 16.8% of violations of the conditions of medical care, including its expectations. At the same time, from January to July 2021, insurance medical organizations received 8 691 requests for medical care provided in federal clinics, of which 2,539 refused to issue referrals, hospitalization, violation of the terms of hospitalization and the right to choose a federal medical organization.