Health insurance fund development in stages. Health insurance. Main stages of MS development

In Russia, health insurance dates back to the time of the Russian Empire and is associated with the development at the end of the 19th century. zemstvo medicine, subsidized at the expense of the treasury, appropriations from provincial and district authorities. Didn't receive health insurance pre-revolutionary Russia widespread due to its agrarian nature and a very short period of post-reform capitalist development, as well as due to the lack of experience in the development of this industry at that time.

The emergence of elements of social insurance and insurance medicine in Russia began in the 18th - early 19th centuries. The first insurance partnership in Russia, which dealt with accident and life insurance, appeared in 1827 in St. Petersburg. G.V. Suleimanov. Social security and social insurance // M. 1998

The development and formation of the system of compulsory medical insurance in Russia took place in several stages. Starodubtsev V.I. Savelyeva E.N. Features of medical insurance in modern Russia // Russian medical journal. - 1996. - No. 1.

Stage 1. From March 1861 to June 1903 In 1861, the first legislative act was adopted, introducing elements of compulsory insurance in Russia. In accordance with this law, partnerships were established at state-owned mining plants, and auxiliary cash desks at partnerships, whose tasks included: issuing temporary disability benefits, as well as pensions to participants in the partnership and their families, accepting deposits and issuing loans.

Workers became participants in the auxiliary cash desk at mining plants, who paid fixed contributions to the cash desk (within 2-3% wages). In 1866, a law was passed, according to which employers, owners of factories and plants were required to have hospitals, the number of beds in which was calculated according to the number of workers in the enterprise: 1 bed per 100 workers. Opened in the 70-80s of the XIX century. in large factories, hospitals were small and could not provide for all those in need of medical care. In general, medical care for factory workers was extremely unsatisfactory.

Factory insurance offices began to be created at the beginning of the 20th century. mainly at large enterprises in Moscow and St. Petersburg. The principles of their organization and functioning were similar to Western European ones.

Stage 2. From June 1903 to June 1912. Of particular importance in the development of compulsory health insurance in Russia was the Law "On the remuneration of citizens who suffered as a result of an accident, workers and employees, as well as members of their families at factory enterprises" adopted in 1903. , mining and mining industry". Under this Law, the employer was liable for damage caused to health in case of accidents at work, the obligation of the entrepreneur and the treasury to pay remuneration to the victims or members of their families in the form of benefits and pensions was envisaged.
Stage 3. From June 1912 to July 1917. In 1912, the III State Duma did a lot for the social renewal of the country, including on June 23, 1912, the Law on Insurance of Workers in Case of Sickness and Accidents was adopted - the law on the introduction of compulsory medical insurance for working citizens.

In December 1912, the Insurance Council was established. In January 1913, Presences for Insurance Affairs were opened in Moscow and St. Petersburg. Since June-July 1913, sickness funds were created in many territories of the Russian Empire. In January 1914, insurance partnerships began to appear to provide workers in case of accidents. According to the law of 1912, medical assistance at the expense of the entrepreneur was provided to the participant of the sickness fund in four types:

1) initial assistance in case of sudden illnesses and accidents;
2) outpatient treatment;
3) obstetrics;
4) hospital (bed) treatment with the full content of the patient.

By 1916, there were already 2,403 sickness funds in Russia, with 1,961,000 members. Such cash desks existed before the revolution, and after the adoption of the ban on the introduction of a state monopoly in insurance, they lost not only their relevance, but also their legitimacy.

Stage 4. From July 1917 to October 1917. After the February Revolution of 1917, the Provisional Government came to power, which, from the first steps of its activity, began reforms in the field of compulsory health insurance (Novel dated 07/25/1917), including the following main conceptual provisions:
1) expansion of the circle of insured, but not for all categories of workers;
2) granting the right to sickness funds to unite, if necessary, into general funds without the consent of entrepreneurs and the Insurance Presence (county, citywide health funds);
3) increased requirements for independent health insurance funds in terms of the number of participants: they had to have at least 500 people;
4) full self-management of sickness funds by employees, without the participation of entrepreneurs.
Stage 5 October 1917 to November 1921 Soviet authority began its work on the reform of social insurance with the Declaration of the People's Commissar of Labor of October 30 (November 12), 1917 on the introduction of "complete social insurance" in Russia.

The main provisions of the Declaration were as follows:

1) the extension of insurance to all hired workers without exception, as well as to the urban and rural poor;
2) extension of insurance for all types of disability (in case of illness, injury, disability, old age, motherhood, widowhood, orphanhood, unemployment).
3) The reforms carried out by the Soviet government contributed to the implementation of full social insurance on the basis of complete centralization.
February 19, 1919 V.I. Lenin signed the Decree "On the transfer of the entire medical part of the former hospital funds to the People's Commissariat of Health", as a result of which the entire medical business was transferred to the People's Commissariat of Health and its local departments, cash medicine was abolished. The results of such a reform were a significant reduction in the incidence of social diseases (tuberculosis, syphilis, etc.), infant mortality, etc.
Stage 6 From November 1921 to 1929. Since 1921, the New Economic Policy (NEP) was proclaimed in the country, and the Government again turned to the elements of insurance medicine, as evidenced by the decisions of the Council of People's Commissars and the All-Russian Central Executive Committee for the period from 1921 to 1929.
On November 15, 1921, the Decree "On Social Insurance of Persons Employed in Wage Labor" was issued, according to which social insurance was reintroduced, covering all cases of temporary and permanent disability.

For the first time, this Decree established the procedure for collecting contributions, while the commissions for labor protection and social security became the main collectors. According to the Decree of the Council of People's Commissars No. 19, Article 124 of March 23, 1926, the following operating funds were formed from all social insurance funds:

1) Funds directly at the disposal of social insurance bodies.
2) Funds for medical assistance to the insured (FMPZ), which are at the disposal of the health authorities.
Stage 7. From 1929 to June 1991 This stage can be characterized as a period of public health care, during which, due to the objective political and economic situation, the residual principle of financing the health care system was formed.

In Soviet times, there was no need for health insurance, since there was universal free medical care, and the healthcare sector was completely supported by the state budget, state departments, ministries and social funds of the enterprises themselves.

Stage 8. June 1991 to present. With the adoption of the Law of the RSFSR "On the health insurance of citizens in the RSFSR" on June 28, 1991, we can begin to talk about a new stage in the development and further promotion of the socially significant idea of compulsory medical insurance in our country.

During the period of economic and social reforms, a sharp decline in living standards, and an acute shortage of budgetary and departmental funds for the maintenance of medical institutions, in 1991 a law was passed on the introduction of medical insurance for citizens in Russia in two forms: mandatory and voluntary. Moreover, all the provisions of this law that related to compulsory health insurance were put into effect only from 1993. Until that time, it was necessary to prepare an organizational and regulatory framework for managing and financing the new state insurance system. Grishin V. Federal Compulsory Medical Insurance Fund // Zdravookhraniye RF. - 2000. - No. 4 Borodin A.F. On health insurance // Finance. - 1996. - No. 12. It is from this moment that we can talk about a new stage in the development and further promotion of the socially significant idea of compulsory health insurance in our country.

Thus, compulsory health insurance has developed gradually, each stage brings with it some kind of improvement, various amendments are being adopted for the system of compulsory health insurance.

Health insurance.

The main stages in the development of MS.

(Instead of an introduction).

The provision of social assistance to citizens in case of illness has a fairly long tradition. Also in Ancient Greece and the Roman Empire, there were mutual aid organizations within the framework of professional colleges that collected and paid funds in the event of an accident, injury, disability due to a long illness or injury. In the Middle Ages, shop or craft guilds (unions) and the church were engaged in protecting the population in case of illness or disability.

However, social assistance in case of illness acquired the form of health insurance only in the second half of the 19th century. It was at this time that the labor union movement began to actively manifest itself, one of the most important results of which was the creation of health insurance funds in many European countries. The pioneers in the field of hospital insurance were England and Germany. It was in Germany in 1883 that the first state law on compulsory hospital insurance for workers was issued.

In Russia, the formation of a system of assistance to the population in case of illness is associated, first of all, with the development of zemstvo medicine at the end of the 19th century, subsidized at the expense of the treasury, appropriations from provincial and district authorities. However, health insurance in pre-revolutionary Russia was not as widespread as in Europe. Medical insurance developed mainly only at large enterprises in Moscow and St. Petersburg.

In 1912, the State Duma adopted a law on the introduction of compulsory medical insurance for working citizens.

After the revolution, insurance with the help of sickness funds turned out to be irrelevant due to the introduction of a state monopoly in insurance.

In 1991, Russia adopted a law on the introduction of medical insurance for citizens in two forms: mandatory and voluntary. Since that time, new rules and procedures in the MS began to be established. This is what will be the subject of my consideration in this work.

Compulsory health insurance (CHI).

CHI system in Russia.

Compulsory health insurance (CHI) is one of the most important elements of the system social protection of the population in terms of protecting health and obtaining the necessary medical care in case of illness. In Russia, CHI is state and universal for the population. This means that the state, represented by its legislative and executive bodies, establishes the basic principles for the organization of compulsory medical insurance, sets the rates of contributions, the range of insurers and creates special state funds for the accumulation of contributions to compulsory medical insurance. The universality of compulsory medical insurance is to provide all citizens with equal guaranteed opportunities to receive medical, medicinal and preventive care in the amounts established by state programs of compulsory medical insurance.

The main goal of CHI is to collect and capitalize insurance premiums and provide medical care to all categories of citizens at the expense of the collected funds on legally established conditions and in guaranteed amounts. Compulsory health insurance is part of the state system of social protection along with pension, social insurance and unemployment insurance. Also, thanks to the compulsory medical insurance system, additional financing of health care and payment for medical services is provided to budgetary appropriations. It should be noted that compensation for earnings lost during illness is already carried out within the framework of another state system - social insurance and is not the subject of compulsory medical insurance.

Medical care within the framework of compulsory medical insurance is provided in accordance with the basic and territorial programs of compulsory medical insurance developed at the level of the Federation as a whole and in the subjects of the Federation. The basic CHI program for Russian citizens contains the main guarantees provided under the CHI. These include outpatient and inpatient care provided in health care institutions, regardless of their organizational and legal form, for any diseases, with the exception of those whose treatment must be financed from the federal budget (expensive types of medical care and treatment in federal medical institutions) or budgets of subjects of the Russian Federation and municipalities (treatment in specialized dispensaries and hospitals, preferential drug provision, prevention, emergency medical care, etc.).

The main indicators of the program are the standards for the volume of medical care provided by healthcare institutions:

1) the standard of visits to outpatient clinics - 8173 visits per 1000 people;

2) the standard for the number of days of treatment in day hospitals - 538 days per 1000 people;

3) the standard for the volume of inpatient care - 2006.6 bed-days per 1000 people;

4) the average duration of hospitalization - 11.4 days.

The financial resources of the state compulsory medical insurance system are formed at the expense of obligatory target payments of various categories of insurers.

The collected funds are managed by independent state non-commercial financial and credit institutions specially created for these purposes - federal and territorial (for the constituent entities of the Russian Federation) CHI funds.

Direct provision of insurance services within the framework of compulsory medical insurance is carried out by medical insurance organizations that have a license to conduct compulsory medical insurance and have concluded relevant agreements with territorial funds of compulsory medical insurance. They are called upon to pay for the medical services provided to citizens at the expense of funds allocated to them for these purposes by territorial funds, and to control the correctness and amount of medical care provided.

Insurers in the CHI system.

CHI insurers, i.e. those entities that pay insurance premiums to provide all citizens with health insurance are employers and local executive authorities.

Employers are required to pay insurance premiums for the working population. The rate of insurance premiums is set by federal law and currently amounts to 3.6% of the wage fund. In accordance with the Instruction on the procedure for collecting and accounting for insurance premiums for CHI, insurance premiums for CHI funds are required to be paid by all business entities, regardless of ownership and organizational and legal forms of activity.

Exempted from paying insurance premiums for CHI public organizations persons with disabilities and enterprises and institutions owned by them, created for the implementation of the statutory goals of these organizations.

Insurance premiums are charged in relation to the accrued wages for all reasons in cash and in kind, including under civil law contracts. There is no need to pay contributions from compensation payments, social benefits, lump-sum incentive payments, prize awards, dividends and some others.

The amounts of accrued contributions are paid to the CHI funds monthly, no later than the 15th day of the next month. The amount of contributions in the amount of 3.4% of the wage fund is transferred to the account of the territorial MHIF, and 0.2% - to the account of the Federal MHIF. On a quarterly basis, policyholders are required to submit to the territorial MHIF (at the place of registration) reporting statements on the accrual and payment of insurance premiums no later than the 30th day of the month following the reporting quarter.

Policyholders are responsible for the correct calculation and timely payment of insurance premiums. For violation of the procedure for paying insurance premiums, various financial sanctions are applied to them:

1) for refusal to register as an insured, a fine in the amount of 10% of insurance premiums due;

2) for failure to submit the payroll for insurance premiums within the specified time limits - a fine in the same amount from the amount of contributions accrued for the quarter;

3) in case of concealment or underestimation of the amounts on which insurance premiums are to be charged, - a fine in the amount of the insurance premium from the understated or concealed amount, charged in excess of the due payment of premiums, taking into account penalties;

4) for late payment of insurance premiums - penalties for each day of delay.

For the non-working population, insurance premiums for compulsory medical insurance are required to be paid by executive authorities, taking into account the volume of territorial compulsory medical insurance programs within the funds provided for in the relevant budgets for health care. The non-working population includes: children, students, the disabled, pensioners, the unemployed.

Executive authorities are obliged to transfer funds to compulsory medical insurance of the non-working population on a monthly basis, no later than the 25th, in the amount of 1/3 of the quarterly amount of funds provided for these purposes.

The transfer of funds to the territorial CHI funds should be carried out according to the standard, which is established based on the cost of the territorial CHI program. However, today the obligations of local administrations to pay insurance premiums are very uncertain. If for policyholders - economic entities the tariff is established by federal law, then for executive authorities only guidelines prepared by the MHIF itself.

Insurers in the CHI system.

According to the law "On the health insurance of citizens in the Russian Federation", there are three groups of subjects for managing the organization and financing of CHI. These entities enter into contracts for the implementation of CHI, collect and accumulate insurance premiums, send funds to pay for medical services. From the point of view of insurance, they act as insurers, but they have significant differences and have strictly delimited powers to carry out specific insurance operations.

The 1st level of insurance in the CHI system is represented by the Federal Fund CHI (FFOMS), which carries out the general regulatory and organizational management of the CHI system. He himself does not carry out insurance operations and does not finance the compulsory medical insurance system of citizens. The Fund was created to implement the state policy in the field of health insurance, and its role in the MHI is reduced to the general regulation of the system, which is achieved both through the regulatory regulation of the main provisions of the MHI in the territory of the Russian Federation, and through financial regulation of the implementation of medical insurance for citizens in the constituent entities of the Russian Federation .

The MHIF is an independent state non-profit financial and credit institution, accountable to the Legislative Assembly and the Government of the Russian Federation. The budget of the fund and the report on its implementation are approved annually by the State Duma.

The financial resources of the fund are formed by:

parts of insurance premiums of enterprises, organizations and other economic entities (0.2% of FOP);

contributions from territorial CHI funds for the implementation of joint programs;

appropriations from the federal budget for the implementation of republican compulsory medical insurance programs;

income from the use of temporarily free funds of the fund by placing these funds on bank deposits and in highly liquid government securities.

The functions of the Federal MHIF include:

financing of targeted programs within the framework of CHI;

approval of model rules for compulsory medical insurance of citizens;

development of regulatory documents;

participation in the development of the basic CHI program for the entire territory of the Russian Federation;

participation in the organization of territorial CHI funds;

international cooperation in the field of MS;

implementation of financial and credit activities to fulfill the tasks of financing CHI;

carrying out research work and training of specialists for CHI.

The fund's activities are managed by its board and permanent executive directorate. The board includes representatives of federal executive bodies and public associations.

2nd level of organization of compulsory health insurance represented by territorial funds of the MHIF and their branches. This level is the main one in the system, since it is the territorial funds that collect, accumulate and distribute the financial resources of the MHI.

Territorial MHIFs are created in the territories of the constituent entities of the Russian Federation, are independent state non-profit financial and credit institutions and are accountable to the relevant representative and executive authorities.

The financial resources of the TFOMS are state-owned, are not included in budgets, other funds, and are not subject to withdrawal. They are formed by:

parts of insurance premiums paid by enterprises, organizations and other business entities for compulsory medical insurance of the working population;

funds provided in the budgets of the constituent entities of the Russian Federation for compulsory medical insurance of the working population (3.4% of the payroll);

income received from the use of temporarily free funds by investing them in bank deposits and government securities;

funds collected as a result of the presentation of recourse claims against insurers, medical institutions and other entities;

funds received from the application of financial sanctions against policyholders for violating the procedure for paying insurance premiums.

The main task of the TFOMS is to ensure the implementation of compulsory medical insurance in each territory of the constituent entities of the Russian Federation on the principles of universality and social justice. The TFOMS is entrusted with the main work to ensure the financial balance and sustainability of the compulsory medical insurance system. TFOMS performs the following functions in the CHI organization:

collect insurance premiums for CHI;

carry out financing of territorial CHI programs;

enter into agreements with health insurance organizations (HIOs) to finance CMO programs for CHI according to the differentiated per capita standards approved by the TFOMS;

carry out investment and other financial and credit activities, including providing loans to insurance medical organizations with a justified lack of financial resources;

form financial reserves to ensure the sustainability of the functioning of compulsory medical insurance, including a normalized insurance reserve in the amount of a two-month amount of financing for territorial programs (now the reserve has been reduced to ½ of the monthly volume);

carry out the alignment of the conditions for financing compulsory medical insurance in the territories of cities and regions;

develop and approve the rules for compulsory medical insurance of citizens in the relevant territory;

organize a data bank for all insurers and exercise control over the procedure for calculating and timely payment of insurance premiums;

participate in the development of tariffs for payment of medical services;

interact with federal and other territorial funds.

The TFOMS activities are also managed by the board and executive directorate. The chairman of the board is elected by the board, and the executive director is appointed by the local administration.

To perform its functions TFOMS create branches in cities and districts. Branches carry out the tasks of the TFOMS in collecting insurance premiums and financing insurance medical organizations. In the absence of insurance medical organizations in the given territory, branches are allowed to carry out CHI of citizens themselves, i.e. and accumulate insurance premiums, and make settlements with medical institutions.

The 3rd level in the implementation of compulsory medical insurance is represented by medical insurance organizations. It is they who, by law, are given the direct role of the insurer. HMOs receive financial support for the implementation of CHI from the TFOMS according to per capita standards, depending on the size of the age and sex structure of the population insured by them, and make insurance payments in the form of payment for medical services provided to insured citizens.

According to the regulation on insurance medical organizations providing compulsory medical insurance, a legal entity of any form of ownership and organization provided for by Russian law and having a license to conduct compulsory medical insurance issued by the department of insurance supervision can act as an HMO.

CMOs have the right to simultaneously carry out mandatory and voluntary insurance of citizens, but are not entitled to carry out other types of insurance activities. At the same time, financial resources for compulsory and voluntary insurance are accounted for by HMOs separately. HMOs do not have the right to use the funds transferred to them for the implementation of MHI for commercial purposes.

HMOs build their insurance activities on a contractual basis, concluding four groups of contracts:

1. Insurance contracts with enterprises, organizations, other business entities and local administration. According to such contracts, the contingent of insured persons in this HMO is determined.

2. Agreements with TFOMS for financing compulsory medical insurance of the population in accordance with the number and categories of the insured. Financing is carried out according to a differentiated average per capita standard, which reflects the cost of the territorial CHI program per inhabitant and the sex and age structure of the insured contingent.

3. Contracts with medical institutions to pay for services provided to citizens insured by this HMO.

4. Individual MHI agreements with citizens, i.e. compulsory medical insurance policies, according to which free medical care is provided within the framework of the territorial compulsory medical insurance program.

All relationships within the compulsory medical insurance system are regulated on the basis of the territorial rules of compulsory medical insurance, which must comply with the model rules of compulsory medical insurance dated 01.12.93, approved by the Federal Fund for Compulsory Medical Insurance and agreed with Rosstrakhnadzor.

Thus, the activities of the CMO represent the final stage in the implementation of the provisions of the MLA. Its main task is to pay for insured events. In this regard, the main functions of the SMO are:

participation in the selection and accreditation of medical institutions;

payment for medical services provided to the insured;

monitoring the volume and quality of medical services provided, including filing recourse claims and lawsuits against medical institutions on the fact of violation of the terms of compulsory medical insurance or causing damage to the insured;

formation of insurance reserves: a reserve for payment of medical services, a reserve for financing preventive measures and a reserve reserve;

investing temporarily free cash in bank deposits and government securities.

The amount of funds transferred monthly by the territorial fund of an insurance medical organization to pay for medical services to the insured is determined by the number of insured persons in this organization and the average per capita funding standard (Nf), calculated in the manner approved by the Federal Compulsory Medical Insurance Fund and agreed with the Ministry of Health of the Russian Federation and the Ministry of Finance of the Russian Federation.

1) The average per capita funding standard Nf is defined as the quotient of the amount of funds collected by the fund for the month, minus deductions to replenish the normalized insurance reserve (its maximum value is twice the cost of providing medical care for the previous month) and the cost of doing business by the population territory. If the fund has additional funds, Nf is multiplied by the indexation coefficient (Kin), agreed by the fund with executive authorities, associations of insurance medical organizations and professional medical associations.

2) The differentiated average per capita standard (Nfd) for the branches of the fund, used to equalize compulsory medical insurance funds within the territory, is calculated as the product Kin * Nf * Kpz, where Kpz is the coefficient of previous costs, determined in relative units based on financial reports on the execution of health budgets assigned to the branch for the last three years.

3) The differentiated average per capita standard (Nsd) for financing insurance medical organizations is calculated as the product of Nfd * Kpv, where Kpv is the average coefficient of sex and age costs for the contingent insured by the organization, determined on the basis of the cost coefficient for each of the sex and age groups relative to the reference (usually insured at the age of 20 - 25 years) and the share of each of the sex and age groups in the insured contingent.

Currently, several methods are used to pay for medical services. To pay for treatment in hospitals apply:

payment according to the cost estimate (financed 11.2% of hospitals at the beginning of 1996);

the average cost of a treated patient (7.5%);

for the treated patient according to clinical and statistical groups (CGS) or medical and economic standards (MES) (50.4%);

number of bed-days (29.4%);

combined payment method (1.5%).

Payment for treatment in outpatient clinics is made by:

according to cost estimates (20.3% of polyclinics);

according to the average per capita standard (16.6%);

for certain services (29.5%);

for the treated patient (27.6%);

combined payment method (6%)

Currently, there is no unified system of payment for medical services in the CHI system. This situation is typical for the transitional period in the organization of CHI. Most effective way payment for medical services today, experts consider payment for a treated patient, i.e. completed treatment.

The above mechanism for the functioning of CHI reflects the principles of organization and financing of the system, which were laid down by the legislation on medical insurance of citizens.

However, the practice of introducing compulsory medical insurance in the constituent entities of the Russian Federation shows that at present, the functioning territorial systems of compulsory medical insurance do not fully comply with the requirements of the legislation. To date, there are four options for organizing CHI in various subjects of the Russian Federation.

The first option basically corresponds to the legislative base and most fully takes into account the principles of the implementation of state policy in the field of MS. According to this option, all required subjects work in the MHI system. Funds from insurers (enterprises and executive authorities) are credited to the TFOMS account. The Fund accumulates the collected funds and, upon conclusion of agreements with CMOs, transfers to these organizations the shares due to them for financing CHI. HMOs work directly with medical institutions and the public. The greatest problems with such an organization of compulsory medical insurance arise when concluding contracts for insurance of the population. The legislation lays down two principles for concluding such contracts: either with the local administration or with employers. Unfortunately, at present, the conclusion of industrial insurance contracts directly between employers and HMOs has not received due distribution. Basically, representatives of the local administration are engaged in the conclusion of insurance contracts, which removes the main payers of insurance premiums - employers from the sphere of control over the implementation of compulsory medical insurance and the choice of medical institutions for their employees. According to the first option, compulsory medical insurance systems operate in 19 constituent entities of the Russian Federation, covering more than 30% of the population: the cities of Moscow, St. Petersburg, Volgograd, Moscow, Kaliningrad, Novosibirsk, Kemerovo regions, Stavropol region and some others.

The second option is a combined CHI system. This means that insurance of citizens (issuance of policies and financing of medical institutions) is carried out not only by HMOs, but also by TFOMS branches. This is the most common scheme for organizing CHI, which covers 36 constituent entities of the Russian Federation, or 44.8% of the population.

The third option is characterized by the complete absence of CMOs in the compulsory health insurance system. Their functions were taken over by TFOMS and their branches. Such an organization of CHI has developed in 17 subjects of the Russian Federation and covers 15% of the population. The performance of TFOMS of all functions within the CHI is proposed by many experts as the main principle of a possible reform of the CHI. However, at present, there are no significant improvements in the field of medical care in these subjects. Rather, on the contrary, such an organization of CHI is associated with the weak socio-economic development of the region.

The fourth option is characterized by the absence in the regions of compulsory health insurance as such in principle. In these constituent entities of the Russian Federation, compulsory medical insurance is carried out only in terms of collecting insurance premiums for the working population. Local health authorities manage the collected funds, directly financing medical institutions. This situation is typical for 17 regions and covers 9.2% of the country's population: the republics of the North Caucasus, the East Siberian region, Smolensk, Kirov, Nizhny Novgorod regions, etc.

Voluntary medical insurance (VMI).

VHI is similar to mandatory and pursues the same social goal - providing citizens with a guarantee of receiving medical care through insurance financing. However, this common goal is achieved by the two systems by different means.

Firstly, VHI, unlike CHI, is not a social, but a commercial insurance industry. VHI, along with life insurance and accident insurance, belongs to the field of personal insurance.

Secondly, as a rule, this is an addition to the compulsory medical insurance system, which provides citizens with the opportunity to receive medical services in excess of those established in compulsory medical insurance programs or guaranteed within the framework of state budgetary medicine.

Thirdly, despite the fact that both systems are insurance, compulsory medical insurance uses the principle of insurance solidarity, and VMI uses the principle of insurance equivalence. Under the VHI agreement, the insured person receives those types of medical services and in the amounts for which the insurance premium was paid.

Fourthly, participation in VHI programs is not regulated by the state and fulfills the needs and capabilities of each individual citizen or professional team.

Voluntary private health insurance is present to a greater or lesser extent in almost all countries, occupying leading positions in the national insurance markets. This is explained by the fact that the state or mandatory insurance financial resources allocated for the development of medicine are currently insufficient to provide medical care to the population at the level of the most modern medical standards.

From an economic point of view, VHI is a mechanism for compensating citizens for expenses and losses associated with the onset of an illness or accident.

According to global standards, MS covers two groups of risks arising from the disease:

the cost of medical services for the restoration of health, rehabilitation and care;

loss of labor income caused by the inability to carry out professional activities, both during the illness and after it with the onset of disability.

In case of insurance coverage of medical expenses, the insurer reimburses the actual costs associated with the implementation of treatment and restoration of the ability to work. Thus, medical expenses insurance is damage insurance and protects the client's condition from sudden expenses.

In case of loss of income insurance coverage, the insurer pays the insured person the monetary compensation for the day of illness. The amount of the indemnity and the start date of its payment are agreed in the contract and depend on the income received by the insured person and the day established by the labor legislation or the current social insurance system, until which the loss of income due to illness is covered either by the employer or is obligatory by health insurance. Thus, insurance for the loss of earned income is sum insurance. It serves to protect the personal income of the insured in a similar way to life insurance.

In Russia, VHI differs from that adopted abroad by the lack of insurance coverage associated with the loss of labor income as a result of illness.

The Law of the Russian Federation “On Health Insurance of Citizens in the Russian Federation” defines “insurable risk associated with the costs of providing medical care in the event of an insured event” as an object of the MC. At the same time, the Law states that VMI “provides citizens with additional medical and other services in excess of those established by compulsory medical insurance programs.”

In terms of licensing insurance activities in Russia, Rosstrakhnadzor of the Russian Federation specified the concept and defined MC only as “a set of types of insurance that provide for the insurer’s obligations to make insurance payments in the amount of partial or full compensation for additional expenses of the insured caused by the insured applying to medical institutions for medical services, included to the MS program.

The fact that there is no income loss insurance in the domestic MS is due to two factors. First, in Russia, the loss of labor income during illness compensates for social insurance, which until recently extended to the entire employed population. Secondly, at the time of the adoption of legislative acts regulating the organization of MS, potential consumers did not have a need for such guarantees, and domestic insurers did not have sufficient financial and actuarial base for the relevant proposals.

AT modern conditions Supplementing VHI with income loss insurance is becoming increasingly important as the number of individual entrepreneurs and freelancers who are not subject to compulsory social insurance and who lose their personal income in the event of illness is growing. In addition, serious losses in labor income are observed among part-time workers, for whom the loss of income within the framework of social insurance is compensated only at the main place of work, leaving additional earnings without compensation.

The economic prerequisites for the emergence of VMI are the following facts:

Firstly, VMI appears and successfully develops where and when there is a need to pay for medical services. If medical care is provided free of charge and fully funded by the state or the CHI system, then there is no need for additional health insurance;

secondly, the periodicity of the onset of the risk of a disease during the life cycle of a person makes it possible to attribute this risk to the number of insured risks by equalizing its consequences for large groups of the population. The risk of the disease really affects every person, but at the same time, a stable statistical pattern has been revealed that makes it possible to divide a person’s life into four periods characterizing the frequency of the onset of the disease:

1) from birth to 15 years of age - the period of childhood diseases, characterized by a fairly high level of morbidity:

2) from 15 to 40 - a period of stability, characterized by the lowest incidence:

3) from 40 to 60 years - a period of gradual increase in risk;

4) after 60 years - the period of the highest risk of morbidity.

Such dynamics of risk made it possible to distribute it evenly in society with the help of insurance using insurance premiums for different age groups.

Thirdly, the need for VHI does not directly depend on the extent to which the risk of disease is covered by compulsory MI systems.

Fourthly, the demand for private health insurance is determined in many cases by the desire to receive a guarantee of not only treatment, but also a high level of service in a medical institution (private room, nurse, treatment by leading specialists and some other services).

Fifthly, the need for VHI becomes very relevant when traveling abroad, especially to those countries where it is impossible to obtain a visa without presenting medical insurance for the duration of the trip.

In the law of the Russian Federation "On medical insurance of citizens in the Russian Federation", the main goal of medical insurance is formulated as follows: "..to guarantee citizens, in the event of an insured event, the receipt of medical care at the expense of accumulated funds and to finance preventive measures."

Based on the general goals, several specific tasks can be distinguished.

Social tasks:

public health protection;

ensuring the reproduction of the population;

development of the medical service sector.

Economic tasks:

financing of health care, improvement of its material base;

protection of income of citizens and their families;

redistribution of funds used to pay for medical services between different groups of the population.

The social and economic significance of VHI lies in the fact that it supplements the guarantees provided within the framework of social security and social insurance to the highest possible standards in modern conditions. This applies primarily to expensive types of treatment and diagnostics; application of the most modern medical technologies; providing comfortable conditions for treatment; the implementation of those types of treatment that are included in the scope of "medical care for vital indications".

In the Russian Federation, collective forms of insurance at the expense of employers currently prevail in the VMI system. This is facilitated by sufficiently favorable economic and legal conditions for the financial resources of the enterprise to pay for the health insurance of its employees.

First, as for some other types of insurance, premiums for VHI can be attributed by the enterprise to the cost of production in the amount of 1% of gross turnover.

Secondly, the amounts of insurance payments paid by the enterprise in favor of employees under VHI agreements concluded for a period of at least one year are not subject to taxation of contributions to off-budget funds.

Thirdly, the amounts of insurance premiums for VHI paid by employers in favor of their employees are not subject to income tax as part of the total annual income of employees.

Fourthly, the amounts of payment for medical expenses of insured persons under VHI agreements concluded by the enterprise in favor of its employees are not included in the total taxable income.

The main types of DMS. Types of VHI are distinguished depending on the consequences of the onset of the disease, both economic and medical and rehabilitation in nature; the amount of insurance coverage; type of insurance rate; degree of supplementation of the CHI system.

According to the economic consequences for a person, there are two types of insurance:

insurance of costs associated with treatment, restoration of health;

insurance for loss of income associated with the onset of the disease.

According to the medical and rehabilitation consequences, the types of insurance are distinguished depending on the type and methods of the necessary treatment. Usually, the following types of insurance for medical care expenses are distinguished:

for outpatient treatment and family doctor;

for inpatient treatment;

for dental care;

for specialized diagnostics of diseases;

for the purchase of medicines;

to visit medical specialists;

for prosthetics;

for the purchase of glasses, contact lenses;

for the costs associated with pregnancy and childbirth;

for service costs;

for patient care costs.

Naturally, the set of guarantees is expanded or narrowed by each individual insurance company, depending on which VMI programs it prefers to work with. Therefore, it is customary to single out the main types of health insurance and additional types (options).

The former include insurance for the costs of outpatient and inpatient medical care. These guarantees compensate for the cost of basic medical treatment necessary for life reasons.

The second group includes types of insurance that cover the costs of related services or specialized medical care (dentistry, obstetrics, prosthetics, spa treatment, and some others).

Depending on the amount of insurance coverage, there are:

full medical expenses insurance;

partial insurance of medical expenses;

insurance costs for only one risk.

Comprehensive health insurance guarantees coverage of costs for both outpatient and inpatient treatment. Unlike full insurance, partial insurance covers the costs of either outpatient or inpatient or specialized treatment at the choice of the insured.

According to the types of insurance rates applied, medical insurance is classified as follows:

at full (combined) tariff;

at the rate with the insured's own participation;

at the rate with the limit of liability of the insurer;

with dynamic rates.

Full rate insurance involves the payment by the insured of a premium for guaranteeing coverage of all costs of outpatient and/or inpatient treatment, including additional payment for selected options.

Insurance based on the principle of the insured's own participation implies a deductible, depending on which medical expenses are covered either starting from the amount agreed in the contract, or in each insured event, the insured independently pays the part of the treatment costs agreed with the insurer.

Tariffs with a liability limit allow the insurer to limit its participation in the coverage of the insured's medical expenses to the amount for which the insured is able to pay a premium and which corresponds to his needs. The liability limit can be set in two ways:

1) the amount of insurance coverage for the year is agreed, within which the insurer pays the medical expenses of the insured;

2) limits on the amount of coverage for certain types of medical services are established;

3) the share of participation of the insurer in covering the medical expenses of the insurant is determined.

Depending on whether there is an imposition of two types of health insurance - compulsory and voluntary for the same risk, we can distinguish:

additional private health insurance;

independent private health insurance.

Since the majority of the population is covered by certain CHI systems in many countries, insurers have developed such types of VHI that would allow citizens participating in CHI to fully cover the costs of those medical services that are partially paid for by the CHI program, or to improve conditions of their medical care under compulsory health insurance. Additional voluntary health insurance provides coverage for expensive surgeries, for attracting leading specialist doctors, choosing a hospital and a doctor, creating comfortable treatment conditions, providing care, and some others.

Independent medical involves medical policies: for citizens who do not participate in compulsory medical insurance; certain groups of the population with special treatment (children, women and some others); for treatment in private clinics and private practitioners; to provide medical insurance when traveling abroad.

Daily allowance insurance, which covers loss of income due to illness, is offered by insurers in three options:

daily allowance insurance while staying in the hospital;

insurance of daily payments for the day of illness;

daily allowance insurance for days in need of care.

In Russia, insurance of daily payments for health insurance is not carried out.

Rules and programs VMI.

The subject of VHI is the costs of medically necessary medical care of the insured person in case of illness or accident. Based on the capabilities of modern medicine and the needs of customers, insurance organizations develop insurance rules, and then specify them, compiling various VHI programs.

The VHI rules contain general insurance conditions:

determination of the object of insurance, insured event, sum insured;

the procedure for concluding and maintaining an insurance contract;

conditions for payment of insurance compensation;

a list of standard exclusions from insurance coverage.

As an object of VHI, the risk of incurring medical costs for the insured is usually indicated.

Under the insured event in VHI is understood the insured person's appeal to a medical institution (doctor) for medical help. An insured event is considered settled when, for medical reasons, the need for further treatment disappears. The number of insured events under the rules of VHI can be unlimited.

Insurance coverage for VHI is determined by:

1) either a fixed sum insured, within which the annual volume of specific medical expenses of the insured person is paid;

2) either a list of cases in which full payment for treatment is guaranteed;

3) or a list of medical expenses with a limit of liability of the insurer for each type.

Full VHI coverage guarantees payment of the following expenses.

Costs associated with outpatient treatment:

medical assistance (visiting a doctor, examinations, consultations of specialists, performing surgeries on an outpatient basis);

laboratory tests and diagnostics;

medicines;

medical means of a different nature (physiotherapy, massage, optics, prostheses, devices for the analysis of cardiac stimulation, wheelchairs, etc.).

Costs associated with inpatient treatment:

medical care, including operations;

delivery to the clinic;

diagnostic costs;

medicines and other medicinal products.

The cost of dental services.

The definition of insurance coverage also includes the conditions for extending the content of the contract to the insured. They usually include guarantees for additional types of medical expenses and conditions for the application of other tariff steps.

In the rules of VHI insurance, similarly to other types of insurance, a standard set of exclusions from insurance coverage is provided. The insurance payment is not made by the insurer if:

1) the disease was the result of an accident due to military operations or military service;

2) the disease has occurred as a result of the intentional actions of the insured;

3) the treatment was carried out by methods not recognized by official medicine or in clinics that do not have official accreditation or license.

If the VHI rules contain the main economic and legal aspects of the health insurance offered by the insurer, then the VHI programs contain:

list of medical services included in the insurance coverage;

the scale of sums insured within which an insurance contract can be concluded;

limits of liability of the insurer for certain types of medical services;

options indicating the size of the additional insurance premium;

the scale of insurance premiums corresponding to the scale of the proposed sums insured;

a list of medical institutions serving this program;

insurance period.

The procedure for concluding and maintaining a VHI agreement.

The procedure for concluding and maintaining a VHI insurance contract has general and special features in comparison with other damage and amount insurance contracts.

Like any insurance contract, it begins with the submission of an insurance application by the insured. The application can be drawn up for the insured himself, for his family members or, in case of collective insurance, for employees.

In the application, the policyholder provides the following information: age, gender, marital status, profession, place of residence, state of health at the time of filling out the application, the presence of chronic diseases, injuries, physical indicators, a list of past diseases. In the case of contracts with high guarantees, the insurer may ask in the application to indicate the presence of hereditary diseases, the life expectancy of parents, the data of basic laboratory tests, predisposition to certain diseases, as well as require an additional medical examination or provide extracts from the medical history. When concluding collective insurance agreements, no data on the health status of potential insured persons is required. Since a large group of people undergoes additional risk equalization, this allows the insurer not to make an individual risk assessment and, saving on operating costs, conclude collective health insurance contracts at reduced rates.

Upon receipt of the application, the insurer may:

accept the risk for insurance under normal conditions for a given age and sex;

accept under special conditions, i.e. at an increased rate or with limited liability in the event of certain diseases;

refuse insurance.

When submitting an application, the period of validity of the insurance contract is specified. The VHI agreement can be concluded:

for a certain period - as long as the policyholder has an interest in continuing the contract, subject to regular payment of the premium;

for a certain period - from one year to 10 years;

for a specific short-term period - for the duration of a foreign trip.

The calculation of premiums in health insurance, as well as in other types of commercial insurance, is based on the principle of equivalence.

The amount of the insurance payment for VHI can be calculated using the following method.

1. The first (permanent) component of the net payment:

C n1 = C n1p + C n1st + C n1sp, where C n1p, st, cn are the average costs per insured person of applying for medical care, respectively, to an outpatient clinic, a hospital and a specialized medical institution under the VHI program under consideration during the term of the contract.

Each of the constant components of the net payment is calculated by the formula:

C n1 = sum (Q i * C p i), where i = (1; M), M - the number of types of insured events (diseases) provided for by the VHI program; Q i - the mathematical expectation of the number of calls to the relevant medical institutions per one insured person for the i-th type of insured events during the term of the contract; C p i - the cost of providing medical and service services for the i-th type of insured events.

For a large (several thousand) contingent of insured persons, Q i values can be taken from statistical reference books published annually in each region with the main indicators of the activities of health authorities and institutions, providing relevant data per 1000 people. For small groups of insured persons, it is expedient to estimate the values of Q i by expert means according to the data of a preliminary medical examination of the insured persons by a trusted physician of the insurance organization.

The cost of providing medical and service services is accepted on the basis of tariff agreements (contracts) concluded with medical institutions.

2. The second (risk) component of the net payment, taking into account annual fluctuations in the number of people seeking medical care:

C n2 \u003d r * C p * S (sum Q i), where i \u003d (1; M); r is the coefficient of variation, taken depending on the stability of the change in Q i over the previous period of 5-10 years. With sufficient accuracy for practice, it is recommended to take r = 1 ... 2; S(sum Q i) - standard deviation of the total number of insured events under the considered VHI program for the previous period of 5-10 years; C p i - cost of providing medical and services, averaged by types of insured events:

C l \u003d (sum (Q i * C p i)) / sum (Q i), where i \u003d (1; M).

3.Total cost of the policy (gross payment):

C b \u003d (C n1 + C n2) * K load * K prib, where K load is the load factor, including the costs of the insurance organization for doing business, including the creation of a reserve of preventive measures, if the latter is provided for by the VHI program (usually it is equal to 1.1 - 1.3); K prib - the coefficient of profit from health insurance operations planned by the insurance organization (usually it is 1.0 - 1.05).

The described methodology can also be used to calculate the real cost of a compulsory medical insurance policy, provided that the risk premium is adjusted in accordance with the regulatory requirements for the amount of the reserve and the profit coefficient is excluded.

The progress of medicine, the growing costs in health care, the growth of morbidity make it necessary for insurers to annually review insurance rates and premiums in the direction of their increase.

Unlike other insurance contracts, VHI has several stages of insurance guarantees being put into effect:

Stage 1 - the formal beginning of the contract, which is the signing of the contract by the insured and the insurer and is determined by the date the contract is filled. At this stage, an agreement is confirmed on the scope, conditions and terms of providing insurance coverage.

The 2nd stage is the material beginning of insurance protection, which is expressed in the payment of an insurance premium and the issuance of an insurance policy.

Stage 3 - the technical beginning of insurance protection, which is expressed in the fact that, starting from this moment specified in the contract, the insurer bears full responsibility for the obligations assumed.

In health insurance, the material and technical principles of the insurance contract do not coincide. The insurer introduces the so-called pre-contractual period, the duration of which is specified in the contract. The essence of this period is, firstly, to avoid cases of concluding contracts with a deliberate goal - to pay for the treatment of a disease that the insured is already expecting, and secondly, to provide the insurer with a certain period of accumulation of funds under the contract for making subsequent payments.

Usually, a pre-contractual period is assigned for all illnesses, except for the consequences of an accident. It can range from one month to a year. The longest pre-contractual periods are set for childbirth, dentistry and orthopedics, psychiatry, chronic diseases and pathologies. The pre-contractual period may be canceled subject to payment of a higher premium or presentation of a medical certificate.

The policyholder has the right to make changes or additions to the contract during the course of the contract. Insurers usually allow the policyholder to:

increase the amount of insurance coverage;

expand the list of insured medical services.

Naturally, both that, and another the insurer carries out for an additional payment.

The settlement of an insured event in VHI also has significant features compared to other types of insurance.

Firstly, the insured event under VHI is extended in time and coincides with the period of incapacity for work of the insured.

Secondly, the duration of the insured event is determined by the method of treatment and is established by a medical institution or a private practitioner.

Thirdly, medical services must be provided by medical institutions or doctors accredited by the insurer, and medicines and other medicines prescribed by prescription.

Medical care can be paid for in a variety of ways.

1. The most simple and traditional method can be described as follows: the medical institution issues an invoice to the client, who in turn pays and submits it to insurance company, which compensates him for the cost of treatment, or the client, having received an invoice, sends it to the insurer for payment.

Currently, insurers have begun to use deferred settlements with clients according to the following scheme for paying for medical services. The insurer starts accepting invoices for payment only when the amount specified in the insurance contract is reached. This condition allows the insurer to save the cost of doing business and not divert the amount of reserves from the capitalization process.

2. More common is the method of paying for medical services without the participation of the insured client, when the medical institution sends an invoice for payment for the services provided directly to the insurance company. Moreover, invoices can be issued for the periods agreed upon by the insurer and the medical institution for entire groups of treated clients insured by this insurance company.

With this payment scheme, great importance is given to the calculation of the cost of medical services. Typically, each country has tariff plans for medical services that are used in the calculation of social security and compulsory medical insurance. Private health insurance uses them as a basis for payment, setting payment systems at 100% Social Security (or CHI), 150%, or even 300%, depending on the specific insurance program chosen by the insured. In Russia, there are Rules for the provision of paid medical services to the population, approved by the Government Decree of 13.01.96. No. 27.

3. Recently, in connection with the emerging trend of a steady rise in the cost of medical services and the observed increase in unprofitability in the MC for direct insurance operations, completely new systems of payment for medical services began to appear. The leader in this direction was the United States, where the private MS makes up the vast majority of the entire national MS. In the United States, health insurance with control over the future use of insurance funds has become increasingly common.

4. Another way to reduce the unprofitability of VHI is the development of such a private type of insurance as the payment by the insurer of all the medical services necessary for the insured during the year, followed by additional payment (at the end of the calendar year) of the overspending of accumulated funds of insurance premiums for certain types of treatment. The insurance contract under such conditions includes payment for dental care, services of medical specialists, and expensive diagnostic examinations.

5.Sometimes insurers, in order to increase the attractiveness of VHI policies, include in them the conditions for making insurance payments to the client in advance, before the occurrence of an insured event. Such an opportunity is provided when a client is referred for treatment in an expensive private clinic or abroad.

Termination of the insurance contract. The VHI insurance contract can be terminated similarly to other insurance contracts on the initiative of both the client and the insurer.

The policyholder may terminate the insurance contract in case of violation by the insurer of the obligations assumed - an increase in the amount of insurance premiums.

The insurer may terminate the contract in case of non-payment of insurance premiums on time, in case of violation by the insured of the obligation to provide complete and honest information about himself in the application, in case of violation of medical prescriptions, use of the medical policy by other persons.

In addition, the contract terminates: upon expiration of the term of the contract; by agreement of the parties, in the event of the death of the insured; By the tribunal's decision; upon liquidation of the insurer.

The occurrence of an insured event is not a reason for terminating the contract before the end of the period specified in the contract.

In case of early termination of the contract, the insurer returns to the policyholder a part of the insurance premiums, in proportion to the unexpired term of the contract, minus the expenses incurred by the insurer.

Conclusion.

Despite the fact that medical insurance, like all other types of insurance in Russia over the past 10 years, has made a huge step forward, we still lag behind developed countries in this indicator. And therefore, as for many other sectors of the economy that came to us after perestroika, huge opportunities for development are opening up for insurance in Russia. Health insurance is also very importance for the development of the domestic system of health care and medicine.

In conclusion, I also want to say that: unfortunately, I did not manage to fit in this work everything that I wanted to describe in this work initially in the process of developing the plan for this work. Namely:

1) the question of which other insurance services (life insurance, accident insurance, disability insurance) are used in combination with MC;

2) also in this work, almost no word is said about such a specific type of MI as insurance of citizens traveling abroad;

3) Reinsurance in MS.

4) Russian health insurance market.

List of used literature:

1. Fundamentals of insurance activities T.A. Fedorova

2. Insurance business B.Yu. Serbinovsky, V.N. Garkusha

3. Insurance: Practice and Principles compiled by David Bland

4. Actuarial calculations in non-state health insurance E.M. Chetyrkin.

Regulations:

Civil Code of the Russian Federation, Chapter 48 "Insurance".

Decrees of the Government of the Russian Federation of July 15, 1999 No. 805.

Decrees of the Government of the Russian Federation of December 11, 1998 No. 1488.

Decrees of the Government of the Russian Federation of May 31, 2000 No. 420.

Tax code of the Russian Federation part 2.

Letter of the Ministry of the Russian Federation on taxes and fees dated November 9, 1999 No. ДЧ-9-07/360.

In Russia, the formation of a system of assistance to the population in case of illness is associated, first of all, with the development at the end of the 19th century. zemstvo medicine, subsidized at the expense of the treasury, appropriations from provincial and district authorities. Medical insurance was not widely used in pre-revolutionary Russia due to its agrarian nature and a very short period of post-reform capitalist development.

The emergence of elements of social insurance and insurance medicine in Russia began in the 18th - early 19th centuries, when the first mutual aid funds appeared at the first capitalist enterprises that arose. The workers themselves began to create at their own expense (without the participation of employers) mutual aid societies - the forerunners of sickness funds. The first insurance partnership in Russia, which dealt with accident and life insurance, appeared in 1827 in St. Petersburg.

The development and formation of the system of compulsory medical insurance in Russia took place in several stages.

Stage 1. From March 1861 to June 1903 In 1861, the first legislative act was adopted, introducing elements of compulsory insurance in Russia. In accordance with this law, partnerships were established at state-owned mining plants, and auxiliary cash desks at partnerships, whose tasks included: issuing temporary disability benefits, as well as pensions to partnership participants and their families, accepting deposits and issuing loans.

Workers became participants in the auxiliary cash desk at mining plants, who paid fixed contributions to the cash desk (within 2-3% of wages). In 1866, a law was passed providing for the establishment of hospitals at factories and plants. According to this Law, employers, owners of factories and factories were required to have hospitals, the number of beds in which was calculated according to the number of workers in the enterprise: 1 bed per 100 employees.

Opened in the 70-80s of the XIX century. in large factories, hospitals were small and could not provide for all those in need of medical care. In general, medical care for factory workers was extremely unsatisfactory.

Stage 2 . From June 1903 to June 1912. Of particular importance in the development of compulsory health insurance in Russia was the Law "On the remuneration of citizens who suffered as a result of an accident, workers and employees, as well as members of their families at factory enterprises" adopted in 1903. , mining and mining industry". Under this Law, the employer was liable for damage caused to health in case of accidents at work, the obligation of the entrepreneur and the treasury to pay remuneration to the victims or members of their families in the form of benefits and pensions was envisaged.

Stage 3. From June 1912 to July 1917. In 1912, the III State Duma did a lot for the social renewal of the country, including on June 23, 1912, the Law on Insurance of Workers in Case of Sickness and Accidents was adopted - the law on the introduction of compulsory medical insurance for working citizens.

initial assistance in case of sudden illnesses and accidents;
ambulatory treatment;
obstetrics;
hospital (bed) treatment with the full content of the patient.

Stage 4. From July 1917 to October 1917. After the February Revolution of 1917, the Provisional Government came to power, which, from the first steps of its activity, began reforms in the field of compulsory health insurance (Novel dated 07/25/1917), including the following main conceptual provisions:

expansion of the circle of the insured, but not for all categories of workers (since it was technically impossible to do it all at once, the categories of the insured were singled out);
granting the right to sickness funds to unite, if necessary, into general funds without the consent of entrepreneurs and the Insurance Presence (county, citywide health funds);
increased requirements for independent health insurance funds in terms of the number of participants: they had to have at least 500 people;
full self-management of sickness funds by employees, without the participation of entrepreneurs.

The provisional government adopted four legislative acts on social insurance, which seriously revised and corrected many of the shortcomings of the Law adopted by the Third State Duma in 1912.

Stage 5 From October 1917 to November 1921, the Soviet government began its activities on the reform of social insurance with the Declaration of the People's Commissar of Labor of October 30 (November 12), 1917 on the introduction of "complete social insurance" in Russia.

The main provisions of the Declaration were as follows:

the extension of insurance to all hired workers without exception, as well as to the urban and rural poor;
extension of insurance for all types of disability (in case of illness, injury, disability, old age, motherhood, widowhood, orphanhood, unemployment).

The reforms carried out by the Soviet government contributed to the implementation of full social insurance on the basis of complete centralization.

The logical continuation of the initiated policy of merging the People's Commissariat of Health and insurance medicine was the adoption of the Decree of October 31, 1918, which approved the "Regulations on the social security of workers." In the new Regulation, the term "insurance" was replaced by the term "security". This was in line with the concept of the Soviet government that a year after the October Revolution, capitalism had already been eliminated and Russia had become "socialist" and, therefore, the capitalist institution of social insurance had to give way to the socialist institution of social security. The content of the Decree of October 31, 1918 fully corresponded to this.

February 19, 1919 V.I. Lenin signed the Decree "On the transfer of the entire medical part of the former hospital funds to the People's Commissariat of Health", as a result of which the entire medical business was transferred to the People's Commissariat of Health and its local departments. Thus, by this Decree, cash medicine was abolished. The results of such a reform at first in the fight against infectious diseases were convincing enough. The incidence of social diseases (tuberculosis, syphilis, etc.), infant mortality, etc., have significantly decreased.

Stage 6 From November 1921 to 1929. Since 1921, the New Economic Policy (NEP) was proclaimed in the country, and the Government again turned to the elements of insurance medicine, as evidenced by the decisions of the Council of People's Commissars and the All-Russian Central Executive Committee for the period from 1921 to 1929.

On November 15, 1921, the Decree "On Social Insurance of Persons Employed in Wage Labor" was issued, according to which social insurance was reintroduced, covering all cases of temporary and permanent disability. For the organization of social insurance in case of illness, insurance premiums were established, the rates of which were determined by the Council of People's Commissars and differentiated depending on the number of people employed at the enterprise and working conditions.

1) Funds directly at the disposal of social insurance bodies.

2) Funds for medical assistance to the insured (FMPZ), which are at the disposal of the health authorities.

Stage 7. From 1929 to June 1991 This stage can be characterized as a period of public health care, during which, due to the objective political and economic situation, the residual principle of financing the health care system was formed.

Stage 8. June 1991 to present. And only with the adoption of the Law of the RSFSR "On the health insurance of citizens in the RSFSR" on June 28, 1991, can one begin to talk about a new stage in the development and further promotion of the socially significant idea of compulsory medical insurance in our country.

At present, a multi-subject system of health care financing has developed. However, the vast majority of funds for medicine are provided by budget allocations for compulsory health insurance.

List of used literature

1. Law "On health insurance of citizens in the Russian Federation".
2. Borodin A.F. About health insurance//Finance.-1996.- No. 12.
3. Grishin V. Federal fund of obligatory medical insurance//Zdravookhraniye RF.-2000.- №4.
4. Starodubtsev V.I. Savelyeva E.N. Peculiarities of health insurance in modern Russia//Russian Medical Journal.-1996.-No. 1.

5. Federal fund of obligatory medical insurance//Analytical review.-2001
6. G.V. Suleimanova. Social security and social insurance - M.1998
7. Magazine "Expert". - 2001.- No. 9 and the magazine "Insurance Business". -2001.- No. 4.

Health insurance.
The main stages in the development of MS.
(Instead of an introduction).
The provision of social assistance to citizens in case of illness has a fairly long tradition. Even in Ancient Greece and the Roman Empire, there were mutual aid organizations within the framework of professional colleges that collected and paid funds in the event of an accident, injury, disability due to a long illness or injury. In the Middle Ages, shop or craft guilds (unions) and the church were engaged in protecting the population in case of illness or disability.
However, social assistance in case of illness acquired the form of health insurance only in the second half of the 19th century. It was at this time that the labor union movement began to actively manifest itself, one of the most important results of which was the creation of health insurance funds in many European countries. The pioneers in the field of hospital insurance were England and Germany. It was in Germany in 1883 that the first state law on compulsory hospital insurance for workers was issued.
In Russia, the formation of a system of assistance to the population in case of illness is associated, first of all, with the development of zemstvo medicine at the end of the 19th century, subsidized at the expense of the treasury, appropriations from provincial and district authorities. However, health insurance in pre-revolutionary Russia was not as widespread as in Europe. Medical insurance developed mainly only at large enterprises in Moscow and St. Petersburg.
In 1912, the State Duma adopted a law on the introduction of compulsory medical insurance for working citizens.
After the revolution, insurance with the help of sickness funds turned out to be irrelevant due to the introduction of a state monopoly in insurance.
In 1991, Russia adopted a law on the introduction of medical insurance for citizens in two forms: mandatory and voluntary. Since that time, new rules and procedures in the MS began to be established. This is what will be the subject of my consideration in this work.

Compulsory health insurance (CHI).
CHI system in Russia.
Compulsory health insurance (CHI) is one of the most important elements of the system of social protection of the population in terms of protecting health and obtaining the necessary medical care in case of illness. In Russia, CHI is state and universal for the population. This means that the state, represented by its legislative and executive bodies, establishes the basic principles for the organization of compulsory medical insurance, sets the rates of contributions, the range of insurers and creates special state funds for the accumulation of contributions to compulsory medical insurance. The universality of compulsory medical insurance is to provide all citizens with equal guaranteed opportunities to receive medical, medicinal and preventive care in the amounts established by state programs of compulsory medical insurance.
The main goal of CHI is to collect and capitalize insurance premiums and provide medical care to all categories of citizens at the expense of the collected funds on legally established conditions and in guaranteed amounts. Compulsory health insurance is part of the state system of social protection along with pension, social insurance and unemployment insurance. Also, thanks to the compulsory medical insurance system, additional financing of health care and payment for medical services is provided to budgetary appropriations. It should be noted that compensation for earnings lost during illness is already carried out within the framework of another state system - social insurance and is not the subject of compulsory medical insurance.
Medical care within the framework of compulsory medical insurance is provided in accordance with the basic and territorial programs of compulsory medical insurance developed at the level of the Federation as a whole and in the subjects of the Federation. The basic CHI program for Russian citizens contains the main guarantees provided under the CHI. These include outpatient and inpatient care provided in health care institutions, regardless of their organizational and legal form, for any diseases, with the exception of those whose treatment must be financed from the federal budget (expensive types of medical care and treatment in federal medical institutions) or budgets of subjects of the Russian Federation and municipalities (treatment in specialized dispensaries and hospitals, preferential drug provision, prevention, emergency medical care, etc.).
The main indicators of the program are the standards for the volume of medical care provided by healthcare institutions:
1) the standard of visits to outpatient clinics - 8173 visits per 1000 people;
2) the standard for the number of days of treatment in day hospitals - 538 days per 1000 people;
3) standard for the volume of inpatient care - 2006.6 bed-days per 1000 people;
4) the average duration of hospitalization - 11.4 days.
The financial resources of the state compulsory medical insurance system are formed at the expense of obligatory target payments of various categories of insurers.
The collected funds are managed by independent state non-commercial financial and credit institutions specially created for this purpose - federal and territorial (for the constituent entities of the Russian Federation) CHI funds.
Direct provision of insurance services within the framework of compulsory medical insurance is carried out by medical insurance organizations that have a license to conduct compulsory medical insurance and have concluded relevant agreements with territorial funds of compulsory medical insurance. They are called upon to pay for the medical services provided to citizens at the expense of funds allocated to them for these purposes by territorial funds, and to control the correctness and amount of medical care provided.

Insurers in the CHI system.
CHI insurers, i.e. those entities that pay insurance premiums to provide all citizens with health insurance are employers and local executive authorities.
Employers are required to pay insurance premiums for the working population. The rate of insurance premiums is set by federal law and currently amounts to 3.6% of the wage fund. In accordance with the Instruction on the procedure for collecting and accounting for insurance premiums for CHI, insurance premiums for CHI funds are required to be paid by all business entities, regardless of ownership and organizational and legal forms of activity.
Public organizations of the disabled and enterprises and institutions owned by them, created to implement the statutory goals of these organizations, are exempted from paying insurance premiums for compulsory medical insurance.
Insurance premiums are charged in relation to the accrued wages for all reasons in cash and in kind, including under civil law contracts. There is no need to pay contributions from compensation payments, social benefits, lump-sum incentive payments, prize awards, dividends and some others.
The amounts of accrued contributions are paid to the CHI funds monthly, no later than the 15th day of the next month. The amount of contributions in the amount of 3.4% of the wage fund is transferred to the account of the territorial MHIF, and 0.2% - to the account of the Federal MHIF. On a quarterly basis, policyholders are required to submit to the territorial MHIF (at the place of registration) reporting statements on the accrual and payment of insurance premiums no later than the 30th day of the month following the reporting quarter.
Policyholders are responsible for the correct calculation and timely payment of insurance premiums. For violation of the procedure for paying insurance premiums, various financial sanctions are applied to them:
1) for refusal to register as an insured, a fine in the amount of 10% of insurance premiums due;
2) for failure to submit within the specified period of the payroll for insurance premiums - a fine in the same amount from the amount of contributions accrued for the quarter;
3) in case of concealment or underestimation of the amounts on which insurance premiums are to be charged, - a fine in the amount of the insurance premium from the understated or concealed amount, charged in excess of the due payment of premiums, taking into account penalties;
4) for late payment of insurance premiums - penalties for each day of delay.
For the non-working population, insurance premiums for compulsory medical insurance are required to be paid by executive authorities, taking into account the volume of territorial compulsory medical insurance programs within the funds provided for in the relevant budgets for health care. The non-working population includes: children, students, the disabled, pensioners, the unemployed.
Executive authorities are obliged to transfer funds to compulsory medical insurance of the non-working population on a monthly basis, no later than the 25th, in the amount of 1/3 of the quarterly amount of funds provided for these purposes.
The transfer of funds to the territorial CHI funds should be carried out according to the standard, which is established based on the cost of the territorial CHI program. However, today the obligations of local administrations to pay insurance premiums are very uncertain. If for policyholders - business entities the tariff is set by federal law, then for executive authorities only methodological recommendations prepared by the Compulsory Medical Insurance Fund itself are used.

Insurers in the CHI system.
According to the law "On the health insurance of citizens in the Russian Federation", there are three groups of subjects for managing the organization and financing of CHI. These entities enter into contracts for the implementation of CHI, collect and accumulate insurance premiums, send funds to pay for medical services. From the point of view of insurance, they act as insurers, but they have significant differences and have strictly delimited powers to carry out specific insurance operations.
1st level of insurance in the CHI system represents the Federal Compulsory Medical Insurance Fund (FFOMS), which provides general regulatory and organizational management of the compulsory medical insurance system. He himself does not carry out insurance operations and does not finance the compulsory medical insurance system of citizens. The Fund was created to implement the state policy in the field of health insurance, and its role in the MHI is reduced to the general regulation of the system, which is achieved both through the regulatory regulation of the main provisions of the MHI in the territory of the Russian Federation, and through financial regulation of the implementation of medical insurance for citizens in the constituent entities of the Russian Federation .
The MHIF is an independent state non-profit financial and credit institution, accountable to the Legislative Assembly and the Government of the Russian Federation. The budget of the fund and the report on its implementation are approved annually by the State Duma.
The financial resources of the fund are formed by:

parts of insurance premiums of enterprises, organizations and other economic entities (0.2% of FOP);

contributions from territorial CHI funds for the implementation of joint programs;

appropriations from the federal budget for the implementation of republican compulsory medical insurance programs;

income from the use of temporarily free funds of the fund by placing these funds on bank deposits and in highly liquid government securities.

The functions of the Federal MHIF include:

financing of targeted programs within the framework of CHI;

approval of model rules for compulsory medical insurance of citizens;

development of regulatory documents;

participation in the development of the basic CHI program for the entire territory of the Russian Federation;

participation in the organization of territorial CHI funds;

international cooperation in the field of MS;

implementation of financial and credit activities to fulfill the tasks of financing CHI;

carrying out research work and training of specialists for CHI.

The fund's activities are managed by its board and permanent executive directorate. The board includes representatives of federal executive bodies and public associations.
2nd level of organization of compulsory health insurance represented by territorial funds of the MHIF and their branches. This level is the main one in the system, since it is the territorial funds that collect, accumulate and distribute the financial resources of the MHI.
Territorial MHIFs are created in the territories of the constituent entities of the Russian Federation, are independent state non-profit financial and credit institutions and are accountable to the relevant representative and executive authorities.
The financial resources of the TFOMS are state-owned, are not included in budgets, other funds, and are not subject to withdrawal. They are formed by:

parts of insurance premiums paid by enterprises, organizations and other business entities for compulsory medical insurance of the working population;

funds provided in the budgets of the constituent entities of the Russian Federation for compulsory medical insurance of the working population (3.4% of the payroll);

income received from the use of temporarily free funds by investing them in bank deposits and government securities;

funds collected as a result of the presentation of recourse claims against insurers, medical institutions and other entities;

funds received from the application of financial sanctions against policyholders for violating the procedure for paying insurance premiums.

collect insurance premiums for CHI;

carry out financing of territorial CHI programs;

enter into agreements with health insurance organizations (HIOs) to finance CMO programs for CHI according to the differentiated per capita standards approved by the TFOMS;

carry out investment and other financial and credit activities, including providing loans to insurance medical organizations with a justified lack of financial resources;

carry out the alignment of the conditions for financing compulsory medical insurance in the territories of cities and regions;

develop and approve the rules for compulsory medical insurance of citizens in the relevant territory;

organize a data bank for all insurers and exercise control over the procedure for calculating and timely payment of insurance premiums;

participate in the development of tariffs for payment of medical services;

interact with federal and other territorial funds.

The TFOMS activities are also managed by the board and executive directorate. The chairman of the board is elected by the board, and the executive director is appointed by the local administration.
To perform its functions TFOMS create branches in cities and districts. Branches carry out the tasks of the TFOMS in collecting insurance premiums and financing insurance medical organizations. In the absence of insurance medical organizations in the given territory, branches are allowed to carry out CHI of citizens themselves, i.e. and accumulate insurance premiums, and make settlements with medical institutions.
3rd level in the implementation of CHI represent health insurance companies. It is they who, by law, are given the direct role of the insurer. HMOs receive financial support for the implementation of CHI from the TFOMS according to per capita standards, depending on the size of the age and sex structure of the population insured by them, and make insurance payments in the form of payment for medical services provided to insured citizens.
According to the regulation on insurance medical organizations providing compulsory medical insurance, a legal entity of any form of ownership and organization provided for by Russian law and having a license to conduct compulsory medical insurance issued by the department of insurance supervision can act as an HMO.
CMOs have the right to simultaneously carry out mandatory and voluntary insurance of citizens, but are not entitled to carry out other types of insurance activities. At the same time, financial resources for compulsory and voluntary insurance are accounted for by HMOs separately. HMOs do not have the right to use the funds transferred to them for the implementation of MHI for commercial purposes.
HMOs build their insurance activities on a contractual basis, concluding four groups of contracts:
1. Insurance contracts with enterprises, organizations, other business entities and local administration. According to such contracts, the contingent of insured persons in this HMO is determined.
2. Agreements with TFOMS for financing compulsory medical insurance of the population in accordance with the number and categories of the insured. Financing is carried out according to a differentiated average per capita standard, which reflects the cost of the territorial CHI program per inhabitant and the sex and age structure of the insured contingent.
3. Contracts with medical institutions to pay for services provided to citizens insured by this HMO.
4. Individual MHI agreements with citizens, i.e. compulsory medical insurance policies, according to which free medical care is provided within the framework of the territorial compulsory medical insurance program.
All relationships within the compulsory medical insurance system are regulated on the basis of the territorial rules of compulsory medical insurance, which must comply with the model rules of compulsory medical insurance dated 01.12.93, approved by the Federal Fund for Compulsory Medical Insurance and agreed with Rosstrakhnadzor.
Thus, the activities of the CMO represent the final stage in the implementation of the provisions of the MLA. Its main task is to pay for insured events. In this regard, the main functions of the SMO are:

participation in the selection and accreditation of medical institutions;

payment for medical services provided to the insured;

formation of insurance reserves: a reserve for payment of medical services, a reserve for financing preventive measures and a reserve reserve;

investing temporarily free cash in bank deposits and government securities.

The composition and standard of expenses for doing business under compulsory medical insurance, as well as the norms of insurance reserves as a percentage of the financial resources transferred to insurance companies for conducting compulsory medical insurance, are determined by the TFOMS. The excess of income over expenses is directed to replenish the reserves for CHI in the manner and amount determined by the TFOMS.
The amount of funds transferred monthly by the territorial fund of an insurance medical organization to pay for medical services to the insured is determined by the number of insured persons in this organization and the average per capita funding standard (Nf), calculated in the manner approved by the Federal Compulsory Medical Insurance Fund and agreed with the Ministry of Health of the Russian Federation and the Ministry of Finance of the Russian Federation.
1) The average per capita funding standard Nf is defined as the quotient of the amount of funds collected by the fund for the month, minus deductions to replenish the normalized insurance reserve (its maximum value is twice the cost of medical care for the previous month) and the cost of doing business by the population territory. If the fund has additional funds, Nf is multiplied by the indexation coefficient (Kin), agreed by the fund with executive authorities, associations of insurance medical organizations and professional medical associations.
2) The differentiated average per capita standard (Nfd) for the branches of the fund, used to equalize compulsory medical insurance funds within the territory, is calculated as the product of Kin * Nf * Kpz,
where Kpz is the coefficient of previous costs, determined in relative units on the basis of financial reports on the execution of healthcare budgets assigned to the branch for the last three years.
3) The differentiated average per capita standard (Nsd) for financing insurance medical organizations is calculated as the product of Nfd * Kpv,
where CPV is the average age-sex cost ratio for the contingent insured by the organization, determined on the basis of the cost coefficient for each of the age-sex groups relative to the reference (usually insured aged 20-25 years) and the share of each of the age-sex groups in the insured contingent.
Currently, several methods are used to pay for medical services. To pay for treatment in hospitals apply:

payment according to the cost estimate (financed 11.2% of hospitals at the beginning of 1996);

the average cost of a treated patient (7.5%);

for the treated patient according to clinical and statistical groups (CGS) or medical and economic standards (MES) (50.4%);

number of bed-days (29.4%);

combined payment method (1.5%).

Payment for treatment in outpatient clinics is made by:

according to cost estimates (20.3% of polyclinics);

according to the average per capita standard (16.6%);

for certain services (29.5%);

for the treated patient (27.6%);

combined payment method (6%).

Currently, there is no unified system of payment for medical services in the CHI system. This situation is typical for the transitional period in the organization of CHI. Today, experts consider payment for the treated patient to be the most effective way to pay for medical services. completed treatment.
The above mechanism for the functioning of CHI reflects the principles of organization and financing of the system, which were laid down by the legislation on medical insurance of citizens.
However, the practice of introducing compulsory medical insurance in the constituent entities of the Russian Federation shows that at present, the functioning territorial systems of compulsory medical insurance do not fully comply with the requirements of the legislation. To date, there are four options for organizing CHI in various subjects of the Russian Federation.
The first option basically corresponds to the legislative base and most fully takes into account the principles of the implementation of state policy in the field of MS. According to this option, all required subjects work in the MHI system. Funds from insurers (enterprises and executive authorities) are credited to the TFOMS account. The Fund accumulates the collected funds and, upon conclusion of agreements with CMOs, transfers to these organizations the shares due to them for financing CHI. HMOs work directly with medical institutions and the public. The greatest problems with such an organization of compulsory medical insurance arise when concluding contracts for insurance of the population. The legislation lays down two principles for concluding such contracts: either with the local administration or with employers. Unfortunately, at present, the conclusion of industrial insurance contracts directly between employers and HMOs has not received due distribution. Basically, representatives of the local administration are engaged in the conclusion of insurance contracts, which removes the main payers of insurance premiums - employers from the sphere of control over the implementation of compulsory medical insurance and the choice of medical institutions for their employees. According to the first option, compulsory medical insurance systems operate in 19 constituent entities of the Russian Federation, covering more than 30% of the population: the cities of Moscow, St. Petersburg, Volgograd, Moscow, Kaliningrad, Novosibirsk, Kemerovo regions, Stavropol Territory and some others.
The second option is a combined CHI system. This means that insurance of citizens (issuance of policies and financing of medical institutions) is carried out not only by HMOs, but also by TFOMS branches. This is the most common scheme for organizing CHI, which covers 36 constituent entities of the Russian Federation, or 44.8% of the population.
The third option is characterized by the complete absence of CMOs in the compulsory health insurance system. Their functions were taken over by TFOMS and their branches. Such an organization of CHI has developed in 17 subjects of the Russian Federation and covers 15% of the population. The performance of TFOMS of all functions within the CHI is proposed by many experts as the main principle of a possible reform of the CHI. However, at present, there are no significant improvements in the field of medical care in these subjects. Rather, on the contrary, such an organization of CHI is associated with the weak socio-economic development of the region.
The fourth option is characterized by the absence in the regions of compulsory health insurance as such in principle. In these constituent entities of the Russian Federation, compulsory medical insurance is carried out only in terms of collecting insurance premiums for the working population. Local health authorities manage the collected funds, directly financing medical institutions. This situation is typical for 17 regions and covers 9.2% of the country's population: the republics of the North Caucasus, the East Siberian region, Smolensk, Kirov, Nizhny Novgorod regions, etc.

Conclusion.
Despite the fact that medical insurance, like all other types of insurance in Russia over the past 10 years, has made a huge step forward, we still lag behind developed countries in this indicator. And therefore, as for many other sectors of the economy that came to us after perestroika, huge opportunities for development are opening up for insurance in Russia. Health insurance is also very important for the development of the national healthcare system and medicine.

List of used literature:
1. Fundamentals of insurance activities T.A. Fedorova
etc.................

During the period of crisis phenomena in the economy and subsequent market transformations, as a rule, the existing one is reformed or the new system social protection of the population. The ways of creating and developing a social protection system are based on the requirements of the time, the current level of socio-economic development of society, the existing systems of medical and social assistance to the population, and the emerging social policy of the state.

The combination of all factors in the process of interaction ensures the formation of the basic principles, priority tasks and mechanisms for implementing the social policy of the state.

The emergence of compulsory health insurance in Russia has deep historical roots. Since the 10th century, in connection with the sharp stratification of society into rich and poor serfs or semi-serfs, there was an urgent need to provide minimal social protection to the broad masses of the population. The solution to this problem was found in the formation and development of an obligatory charitable system of church and state charity.

Charity was obligatory for church ministers, princes and boyars. Charity was carried out by distributing alms, food on holidays or during famine and wars, providing shelter to wanderers, the poor, the crippled and orphans in monasteries, in princely and boyar courts. For these purposes, the church and the propertied strata of the population had to allocate "tithes", i.e. 1/10 of all their income.

Beginning in 1701, the Monastic Order constantly allocated funds for the maintenance of hospitals, almshouses, assistance to the poor and the payment of "assistance to the wives, widows and children of service people", as well as to pay for the maintenance of doctors in the public service.

The charity system has developed from century to century, the number of hospitals, almshouses, educational and penitentiary houses has grown, but in general there have been no radical changes leading to its improvement and transfer to a new qualitative level. Only the changes in the administration of the territories of the Russian Empire, carried out by Catherine II at the end of the 18th century, radically affected the existing system of charity. In 1775, a special state institution for the social protection of the population was created to manage local improvement - the all-class "Order of public charity for charity and public education."

When creating the Orders, the OP was allowed to provide them with a subsidy from the province's income in the amount of 15,000 rubles, and later they were transferred to self-financing. The orders of the OP had the right to give loans, place funds at interest in a bank, attract charitable capital, accept private and state deposits, conduct economic activities, rent out their real estate, participate in certain monopoly business areas: sale playing cards, organization of pharmacies.

Until 1860, medical care for the population of Russia was carried out by medical institutions, mainly subordinate to the Ministry of Internal Affairs, incl. Order of the OP, and to some extent to the Ministry of State Property. Hospitals and other medical institutions of the Order of the OP made up the vast majority of all medical institutions in the country.

At the end of the 19th century, there was a significant transformation of the organizational structure and sources of financing of the Orders of the OP.

From self-financing, the Orders of the OP were transferred to the state content. Since 1869, the credit part of the capital of the Orders of the OP came under the jurisdiction of the Ministry of Finance, which divided them into provinces to finance social charity organizations. Permanent state subsidies were also introduced for the Orders of the OP, but at the same time, elements of self-financing remained, and they used income from both their direct economic activities and from investment operations.

In the service of the Ministry of Internal Affairs were: in 1856 - 1134 doctors, and in 1863 - 2135 doctors, of which 800 physicians practiced in the capitals. There were significant differences in the provision of doctors and pharmacies to the population in the provinces of Russia. Thus, the ratio of the number of doctors and the population served varied in the central and outlying provinces from 1: 2300 (St. Petersburg province) to 1: 70000 (Orenburg province), i.e. in the central provinces, the availability of doctors was 20-30 times higher than in the outskirts of the empire. Pharmacies opened mainly in major cities, which clearly characterizes their small number in various provinces: from 2 pharmacies in the Astrakhan province to 70 pharmacies in the St. Petersburg province.

Initially, during the formation of medical and social insurance in industry, it was implemented through voluntary insurance of employees of individual enterprises and factories against accidents and was carried out by small private (commercial) insurance organizations. The growth and development of industry in Russia led to the emergence of ever larger enterprises and factories and the involvement in the production process of ever wider sections of the population, the formation of new insurance risks. Voluntary insurance did not develop so rapidly, but the increase in the volume of insurance risks and the number of people exposed to them necessitated the introduction of compulsory insurance for employees of enterprises and their families.

The hospitals that opened in the 70s and 80s of the 19th century at large factories were low-capacity and could not provide medical care to all the needy workers of the factory or plant. The medical assistance provided to factory workers was extremely unsatisfactory and covered only 20-30% of all industrial workers. By 1907, medical care was organized in only 38% of all plants and factories in the country. The rest of the workers, like the rest of the population, used the city and zemstvo medical institutions on a common basis, and they were charged a hospital fee.

As a result of a stubborn political struggle for the rights of the working class, insurance legislation was further improved and the socially significant idea of compulsory state medical and social insurance for workers was put into practice. On June 23, 1912, the "Law and Regulations on Insurance of Workers against Accidents" was adopted, the 45th article of which obliged employers to provide medical care to workers: outpatient treatment and assistance in case of sudden illnesses and accidents, both in factory hospitals and in other medical institutions. Russia joined the ranks of the most developed countries that had state social legislation.

A new organizational structure, not typical for compulsory insurance, has appeared - the sickness (insurance) fund, i.e. insurance organization. Health insurance funds were formed at individual large enterprises or at several small enterprises in terms of the number of operating enterprises. They carried out insurance for employees of the enterprise in case of illness, injury, disability, death and medical care.

The emergence of insurance organizations (sickness funds) determined the creation for the first time in Russia of insurance supervision bodies: a factory inspection and insurance presences, in which officials were appointed by the state and representatives from sickness funds were elected. The supreme body of insurance supervision was the Workers' Insurance Council. It consisted of 26 members, including 5 representatives of workers, members of sickness funds; 14 major officials; 5 representatives of entrepreneurs; 2 representatives of the Zemstvo and the Duma.

The funds of the health insurance fund were used to provide benefits in the amount of the full earnings of the insured person. Namely: due to illness for the entire period of disability and on the occasion of childbirth within 8 weeks before and 8 weeks after childbirth; allowances to family members, dependents of the insured person in case of loss of a breadwinner; allowances and benefits for breastfeeding workers to reimburse the costs of providing medical care to insured persons. Federal Law No. 255-FZ of December 29, 2006

On November 15, 1921, the Decree of the Council of People's Commissars "On the Social Insurance of Persons Engaged in Wage Labor" was adopted, in accordance with which the compulsory medical and social insurance of hired workers was reintroduced or revived. Insurance organizations - insurance cash desks - begin to be created.

From January 1, 1922, all organizations, enterprises, institutions and farms of any form of ownership became insurers of employees and paid certain insurance premiums by law. The amount of insurance premiums was approved by the government of the country and formally depended on the danger and harmfulness of this production, affecting the health and working capacity of employees.

Discounts and surcharges of up to 25% of the tariff for compliance with or violation of labor rules were applied to insurance tariffs. In 1922, the insurance rate for the first category was 21.0%, for the fourth category - 28.5% of the wage fund, and in 1923 its size decreased by 1.3 times and amounted to 16.0% and 22.0%, respectively. % of the payroll fund.

Medico-social insurance applied to all wage laborers employed in state, public, cooperative, concession, mixed or private enterprises, institutions, farms or individuals, regardless of the nature and duration of work and methods of remuneration. Persons employed in seasonal and temporary jobs were subject to insurance. And also: laborers and laborers; working at home; those who are in the service and work for free hire in the institutions of the military and naval departments; artel workers; pupils working at enterprises, in the small handicraft and handicraft industry, studying at the schools of factory studies; students undergoing internship; elected persons; literary workers. It should be specially noted that medico-social insurance applied only to hired workers and practically did not affect the non-working urban population and the vast majority of rural residents, both self-employed and united in collective farms.

In 1924, there were only 956 sickness funds, which was 2.5 times less than in 1916. But the volume of insured persons increased by 3 times in 1924, while the average number of participants in sickness funds increased by 7.2 times, that is, during the NEP period, large sickness funds prevailed and the number of insured persons increased significantly. By 1928, medical and social insurance covered more than 9 million people, i.e. there was a positive trend in the increase in the coverage of the country's hired population with medical and social insurance.

From February 1925, the management of the fund for medical (medical) care for insured persons was transferred to the People's Commissariat of Health of the RSFSR and its subdivisions. Namely, the People's Commissariat of Health of the Autonomous Republics and Gubernia Health Departments through the departments of medical care for insured persons created under them, and the management of the fund of pensions and other benefits was transferred to the direct disposal of the social insurance bodies of the People's Commissariat of Labor. The expenses for the work of the department of medical assistance to insured persons amounted to up to 3% of the amount of insurance premiums collected by the insurance authorities.

Difficulties experienced by healthcare, including those in the organization and conduct of medical care for insured persons, were primarily due to the low level of budget financing. For 38 administrative territories of the country in 1926-1927, budgetary funds accounted for only 30.9% of the funds used to pay for medical care for insured persons, and compulsory medical insurance funds, respectively, 69.1%. Medical expenses for insured transport workers were covered by 82.4% from medical insurance funds. There was a situation when public health care was financed mainly at the expense of compulsory health insurance.

Until 1991, the state health care system operated in the country, and there was no compulsory medical insurance of the population or its individual groups in any form.

Since the 1930s, the development of Soviet health care has been based on state planning and budget financing. Five year development plans National economy countries included targets for all sectors, incl. and healthcare. Quantitative indicators that the industry must achieve by a certain point were rigidly determined.

At the beginning of its development, the public health system achieved excellent indicators of providing the population with medical care, but by 1985 the growth of quantitative indicators had exhausted itself, without ensuring the transition to qualitative indicators. This led to the need for fundamental changes in the health care system. They are based on the transition from planned to market mechanisms of industry management and are aimed at providing social guarantees to citizens in protecting health and at providing quality medical care to the entire population.

With absence market mechanisms four economic experiments in health care carried out from 1967 to 1988 did not ensure intra-industry reform and transfer of the medical industry to economic management methods.

CHI Models

The main goal of CHI is to collect and capitalize insurance premiums and provide medical care to all categories of citizens at the expense of the collected funds under legally established conditions and in guaranteed amounts. Therefore, the CHI system should be considered from two points of view. On the one hand, it is an integral part of the state system of social protection, along with pension, social and unemployment insurance. On the other hand, compulsory medical insurance is a financial mechanism for providing additional funds to budget allocations for financing health care and paying for medical services. This is the economic significance of CHI. In the Russian Federation, only medical care for the population is included in the scope of compulsory medical insurance. Compensation for earnings lost during illness is already carried out within the framework of another state system - social insurance and is not the subject of compulsory medical insurance.

Medical care within the framework of compulsory medical insurance is provided in accordance with the basic and territorial programs of compulsory medical insurance, developed at the level of the federation as a whole and in the subjects of the federation.

The basis of each model of the compulsory medical insurance system is the procedure for the movement of funds from the insured to medical institutions to reimburse the costs of the latter, for the medical care provided during

occurrence of an insured event1

In the second option, the financial flow is divided, as it were, the financing of medical institutions is carried out both through medical insurance organizations and directly by the territorial fund. The universality of insurance is provided by branches of territorial funds.

In the third option, financing of medical institutions is carried out only by the territorial fund. In this case, the functions of the insurer are performed by branches of the territorial CHI funds.

Thus, the movement of financial flows is predetermined by the functional and organizational structure of the CHI system.

The diverse order of financial interaction in the compulsory medical insurance system that has developed in various territories determines the basis of the model of the compulsory medical insurance system.

The next functional and organizational subsystem, subject to strict observance of antimonopoly measures, which predetermines the model of the compulsory medical insurance system, are medical insurance organizations (HIOs). Their inclusion in the CHI system ensures the consistent implementation of a competent state policy in protecting public health. HIOs, acting in the interests of the insured, control the volume and quality of medical care provided, actively influence the transformation and streamlining of the activities of medical institutions.

Sometimes the fund loses its independence, ceding the reins of government to an insurance medical organization or, more rarely, to a health management body.

Under such conditions, the formation of a model of the compulsory medical insurance system occurs according to the type:

health management authority (OHM);

insurance medical organization (SMO).

This is done through a direct strong vertical connection coming from the authority (administration) of the territory or the board of the territorial fund, i.e. bodies authorized to manage the territorial fund.

The “Health Management Authority” model has the least financial stability, since the technology of implementing the CHI system pursues the interests of the territory's health management authority. At the expense of compulsory medical insurance, the problems of budget financing are solved: the inclusion in the Territorial program of volumes and types of medical care that should be financed from the budget, the purchase of expensive equipment, transport, the provision of targeted programs, the inclusion in the cost of medical services provided under the compulsory medical insurance program, almost all costs according to budget items.

21 constituent entities of the Russian Federation use a mixed CHI model. In case of insufficiency of insurance medical organizations, branches of territorial funds also carry out compulsory medical insurance. At the same time, ensuring the universality of insurance remains with the branches of territorial funds, which also finance the provision of medical care to the population (for example, in the Rostov region there are 8 licensed HMOs, 6 of them participate in compulsory medical insurance, but 30% of the population is insured by branches of the territorial fund).

In 24 constituent entities of the Russian Federation, the functions of an insurer are performed only by branches of territorial CMI funds (for example, the Saratov Regional CHI Fund, despite the presence of 14 licensed insurance organizations, or Ryazan, where there are 8 licensed CMOs).

At first glance, it seems that this is an economical and simple model of the compulsory medical insurance system for administrative expenses and taxation. However, it practically repeats the previously existing state inefficiency, which in providing citizens with free affordable qualified assistance was the basis for reforms in healthcare. It does not allow to fully realize the possibilities of independent protection of the interests of insured citizens.

The variety of models of the compulsory medical insurance system is also determined by: the size of the insurance tariff for the working and non-working population; the system of remuneration of medical workers providing medical and preventive care to the insured; methodology for the examination of the quality of medical care.

The stable functioning of the compulsory medical insurance system is ensured by its financial stability. The financial stability of the compulsory health insurance system is influenced by: the amount of contributions for the working and non-working population; volume of registration of payers; scope of the CHI program and its cost; size of regional differentiated per capita standards; cost (cost of medical services); coefficients of indexation of tariffs for medical services; methods of payment for medical care; the volume, types and technologies of medical care provided; the effectiveness of the credit and investment activities of the fund, insurance medical organizations; the amount of insurance reserves, the procedure for their accumulation and use; the amount of financial resources used for the intended purpose; the frequency of occurrence of an insured event.

Therefore, for the stable functioning of the compulsory medical insurance system, it is necessary to develop measures aimed at strengthening the influence of the Federal Fund, Rosstrakhnadzor on compliance legislative framework Compulsory medical insurance in the formation of various models of the compulsory medical insurance system in the course of the implementation of the Law “On health insurance of citizens in the Russian Federation of July 18, 2009 No. 185-FZ” corresponds to their economic policy of the state and guarantees the financial sustainability of the compulsory medical insurance system.