Coronavirus jeopardizes the fulfillment of multibillion-dollar order for using CHI
Tatarstan doctors are making up for lost time due to COVID-19
In Tatarstan, the coronavirus pandemic has threatened to disrupt the 100% implementation of the compulsory health insurance (CHI) programme worth 57,6 billion rubles. The largest contractors of the state order — Republican Clinical Hospital, Republican Clinical Infectious Diseases Hospital, 7th and 16th city hospitals of Kazan, whose beds “went” under COVID-hospitals, only in early September, with a delay of several months, were able to resume conducting planned high-tech operations and receiving inpatient patients. As a result, every second person in need of such medical care did not receive it this year, doctors say. According to the Territorial Compulsory Health Insurance Fund (TFOMS), the current level of implementation of the high-tech medical care programme (VMP) was 56,2%. So after the quarantine is lifted, doctors need to make up for the amount of work under VMP by 4 billion rubles of federal subsidies. However, State Duma Deputy from Tatarstan, former head of the Tatarstan ministry of healthcare Ayrat Farrakhov does not consider these figures critical but agrees that the health budget must be fulfilled completely. Otherwise, the system's budget for 2021 will be “hacked”.
How COVID-19 “infected” the VMP programme
With the lifting of restrictions, the Tatarstan healthcare system began to return to the planned admission of patients. However, the implementation of the territorial CHI programme turned out to be under attack. According to the Territorial Fund of Compulsory Medical Insurance of the Republic (TFOMS RT), this year the rhythmic execution of the health budget has slowed down due to the COVID-19 pandemic.
As you know, since April, the largest hospitals and medical centres that implement the VMP programme have cancelled planned operations due to re-profiling for the treatment of patients with coronavirus. Other hospitals since the beginning of the epidemic introduced a ban on inpatient planned hospitalisation of patients, except in cases of threat to life. As a result, according to TFOMS, based on the results of 8 months, medical institutions provided medical care for 35,5 billion rubles, with an annual budget target of 57,6 billion rubles, or 61,8%. It is worth noting that the CHI programme is almost 80% funded from the federal budget. It includes 48 billion rubles of federal subventions, 32,4 billion rubles of which were implemented, according to data from TFOMS.
Every second patient was left without high-tech medical care
A particularly significant reduction in volumes occurred in the provision of high-tech medical care (VMP), hearing and dental prosthetics. According to TFOMS, the volume of the state order was implemented at 5 billion rubles, with a plan of 8,7 billion rubles. In other words, the implementation rate is 56,2%. It is important to note that only 0,5 billion rubles have been allocated from the federal budget, while the lion's share of 8,2 billion rubles is from the regional budget.
Nevertheless, for the remaining 4 months until the end of the year, the largest performing clinics of the VMP will have to make up for the volume of operations worth 4 billion rubles. First of all, this applies to cardiovascular operations — сoronary artery bypass surgery , stenting, which are traditionally performed in republican VMP performing clinics. These include Republican Clinical Hospital, Republican Clinical Infectious Diseases Hospital, 7th city hospital of Kazan, and recently the 16th city hospital of Kazan has received a large amount of VMP.
According to doctors of large clinics, during the pandemic, the number of surgical operations on various organs, interventions in orthopedics and traumatology, in gynecology has significantly decreased, and the number of patients in hospital treatment has fallen. “Everything that could have been cancelled has been postponed. Only emergency medical care has been provided," doctors admit. According to the chief cardiologist of the Volga Region, Albert Galyavich, over the past six months, almost half of those in need did not receive this medical care.
According to doctors, only cancer clinics worked nonstop. “Cancer patients could not be left without treatment, otherwise the death rate in the republic would have increased rapidly. This is the biggest risk group. They were fully provided with the necessary specialised care during the pandemic," one of the doctors of the Republican Cancer Dispensary told Realnoe Vremya.
In the remaining time after the restrictions are lifted, republican clinics will accept all patients in need, TFOMS hopes. “We can say that there are no special delays in financing. Everything is going roughly within the same boundaries as last year," they stated in the fund.
What types of medical care were stopped during the COVID-19 pandemic? In what areas did the greatest decline occur: traumatology, ophthalmology, internal organ surgery? In response to this question of Realnoe Vremya, TFOMS reported that more time is needed to identify the backlog, it is necessary to download data from the database in insurance companies, analyze: “As medical organisations hand over bills for August, in September a different picture will appear with the provision of medical services.”
What if there is still unimplemented money? Will they have to be returned?
Speaker of the Tatarstan Parliament Farid Mukhametshin spoke about the probability of failure of the CHI programme during a recent meeting of the government of the Republic of Tatarstan, where the ministry of economy and the ministry of Finance presented the forecast of socio-economic development and the draft consolidated budget of the Republic of Tatarstan for 2021-2023.
At the same time, the director of TFOMS, Alsu Miftakhova, made a report on the main parameters of the health system budget. She announced the following forecast indicators of the budget of the Territorial Compulsory Health Insurance Fund: for 2021 — 60,6 billion rubles, for 2022 — 63,5 billion rubles, for 2023 — 63,7 billion rubles. “The fund's expenditures for 2021, 2022 and 2023 are planned at the income level," she said. The main share of the fund's budget revenue is made up of subventions from the budget of the Federal MHI Fund. For 2021, the amount of the subvention of the Federal Compulsory Health Insurance Fund is calculated based on the standards approved by the current Programme of State Guarantees of Free Medical Care to Citizens in the amount of 51,2 billion rubles. Of these, 30% are deductions from the budget of the Republic of Tatarstan for compulsory health insurance of the unemployed population. Inter-budget transfers from the budget of the Republic of Tatarstan for 2021 are planned in the amount of 8,3 billion rubles.
“You show a budget surplus of 100,9% for this year," Farid Mukhametshin addressed the head of the MHI Fund. “If by the end of the year there is still unimplemented money, it will remain in the budget of the republic and will be transferred to the next year?
In response, Alsu Miftakhova noted that this option is excluded. “According to the budget code of the Russian Federation, unimplemented money in the absence of accounts this year is transferred back to the budget of the Federal MHI Fund and is not subject to refund," she warned.
“We shouldn't lose money. Are we implementing it badly?" Tatarstan President Rustam Minnikhanov became alarmed.
“Due to Covid-19, planned types of care, including hospitalisation, were suspended. In this regard, there is a slight non-implementation of volumes. But we think that we will master the funds by the end of the year," Alsu Miftakhova explained.
As a result, the president instructed the ministry of healthcare of the Republic of Tatarstan to speed up the resumption of planned inpatient medical care. But “not through false reporting, but by actual services rendered," he warned.
Routine examination regime from September
Indeed, only at the beginning of September, with a delay of several months, the largest contractors of the state order — Republican Clinical Hospital, Republican Clinical Infectious Diseases Hospital, 7th and 16th city hospitals of Kazan — resumed conducting planned high-tech operations and receiving inpatient patients. Their beds, along with the rest of the clinics, were repurposed as COVID hospitals. For example, operations were stopped at the Republican Clinical Hospital's Trauma Centre, his doctors said. The centre became operational in early September. In general, according to independent experts, hundreds of thousands of planned operations were postponed in Russia from mid-March, although there is no official data on this.
The resumption of planned inpatient treatment in Kazan became possible after the construction of the new building of the Republican Clinical Infectious Diseases Hospital was completed. It was opened on August 10, but it took time to remove infected patients and put the clinics in order. The hospital area is 15,000 square metres. It is designed for 232 beds, including 12 intensive care units. At the same time, it is possible to accommodate up to 500 beds in case of particularly dangerous infections. The hospital is planned to be equipped with modern high-tech medical equipment, including ventilators, computed tomography, x-ray, endoscopic and ultrasound equipment.
This is not a crisis of the state guarantee programme, but it will be difficult to catch up
However, Ayrat Farrakhov does not consider the current implementation of the programme of state guarantees for medical care to be critical.
“Today, I do not consider the current level of budget implementation to be critical. The main reason was due to that most of the high-tech medical centres in Tatarstan were closed for the creation of Covid hospitals, and this is understandable. Most of these hospitals are now closed, and clinics are beginning to resume the provision of high-tech medical care, restoring volumes. And a very large number of patients has received it. It's just that the accounts-registers have not been reported yet, and the fact of payment by the fund is not shown. If they were all shown and reflected, this figure would not be so critical," Farrakhov is convinced.
At the same time, he stressed that it is important to implement the entire volume. Why? “First of all, no one has such a volume of VMP, with the exception of Moscow. When drawing up the budget for the next year, it is important not to have any balances. This is critically important," he stressed. “I am sure that the money will be implemented. The main thing is that there is no second wave of Covid-19, which will again limit the volume of VMP. I hope that today we have learned how to treat these patients. The remaining volume is not so large, and it is quite possible to perform it. And finish the year with a sufficient volume of VPM.
Will doctors have to work three shifts? This is impossible to do. But in two shift — they worked earlier anyway. We should be happy that we have such a large amount of state orders," he said.
“No one expected that the year 2020 would be so critical. It will be unrealistic to catch up. I am afraid that if they cook the books, there will be complaints, medical errors, and various misunderstandings. I don't think they should do this. The situation is unprecedented. And you can't blame the doctors. Now we need to choose from the list of those patients who need help urgently," said Galyavich.