MINISTRY OF HEALTH/CHI
The Ministry of Health submitted a draft amendment on the application of clinical guidelines to the State Duma
The Ministry of Health forwarded to the State Duma a package of amendments to the legislation on the legal status of clinical guidelines. The key point is that national guidelines cannot be used to control the quality and safety of medical care activities or in quality-of-care assessments.
On December 9, Deputy Minister of Health Evgeny Kamkin sent to the Chairman of the State Duma Committee on Health Protection Sergey Leonov a draft order of the Russian Ministry of Health approving the procedure for applying clinical guidelines (a copy is in the possession of MV). Its authenticity was confirmed by the committee’s press service.
The document was developed by the ministry in connection with the preparation of draft federal law No. 646601-8 “On Amending Certain Legislative Acts of the Russian Federation” for consideration in the second reading. The letter says that “clinical guidelines are based on an analysis of scientific data available at the time of their preparation, are practice-oriented, and serve as a guide for the physician when providing medical care in specific situations.” At the same time, all medical organizations, regardless of ownership form or departmental affiliation, are required to follow them.
As was reported earlier, if it is impossible to perform a medical intervention provided for in the clinical guidelines (lack of a license for medical activity, for the works (services) indicated for the patient, medical devices, medicines, other consumables, other material stocks required to carry out the indicated medical intervention, or specialists with the required qualifications), the medical organization must redirect the patient within the referral system to another clinic participating in the territorial state-guarantee program that has such capability, or arrange for medical care using telemedicine technologies.
The prescription and use of medicines, medical devices, and specialized medical nutrition products not provided for by the relevant clinical guideline (CG) are permitted in the presence of medical indications (individual intolerance, on vital indications) by decision of the medical commission.
The most controversial point: CGs cannot be applied for federal state control (supervision) of the quality and safety of medical activity; they are not mandatory requirements and cannot be used in the examination of the quality of medical care (EQMC). In the opinion of Aleksey Starchenko, a member of the Public Council for the Protection of Patients’ Rights under Roszdravnadzor and president of the NP “National Agency for Patient Safety and Independent Medical Expertise,” professor, the draft in this form infringes patients’ constitutional rights to compensation for harm in civil proceedings.
“In the past three years, in similar cases, the Supreme Court of the Russian Federation has often accepted EQMC conclusions issued by insurance company experts as the main evidence of a medical organization’s guilt. The ban on referring to clinical guidelines means that patients are being deprived of the right to evidence so that there will be fewer lawsuits. What result will we get — an increase in the number of criminal cases against doctors, because patients deprived of tools of defense in civil proceedings will more often turn to the Investigative Committee,” he told MV.
According to sources at MV in the профиль committee, other members of the medical community also disagree with the Health Ministry’s position not to apply CGs in EQMC. The State Duma is waiting for the government’s version of amendments to the legislation regarding clinical guidelines.
The regulator does not plan to postpone the date of the full transition to providing medical care based on CGs to 2026, Kamkin said this week. According to him, the CHI system budget in 2025 will make it possible to fully implement the provisions of the clinical guidelines.
Last week, a message appeared on the United Russia website stating that following the meeting a decision was made to introduce the necessary changes to the law “On the Fundamentals of Health Protection of Citizens” to clarify the place and role of clinical guidelines in the system of organizing and providing medical care and to form a unified system of medical care quality. The party commission, together with deputies, was to study the amendments developed by the Health Ministry, which are to be introduced into the legislation already this year. If that does not happen, it was proposed to postpone the introduction of the norm on the mandatory application of CGs for another year — until January 1, 2026.
An up-to-date selection of opinions from insurers, chief physicians, and representatives of the patient community on clinical guidelines can be read here.
Murashko urged not to expect a return to the budgetary model with the launch of the payroll pilot
Health Minister Mikhail Murashko outlined priorities as part of the trial of the new sector-wide wage system. There are no plans to return to the budget-based financing model for medical organizations.
The introduction of a new remuneration model in healthcare does not imply restarting the budget financing model for medical organizations, since such an approach is not results-oriented, said Russian Health Minister Mikhail Murashko at the Plenum of the Healthcare Workers’ Union on December 12.
Increasing compensation for labor is impossible without taking into account labor productivity, efficiency, and the quality of medical care, the minister said. He noted that many regions are already following exactly this path — improving the use of human resources while increasing wages.
“By order of the president, we must move to a new remuneration model. It is important for us to build an efficient, fair and, most importantly, results-oriented system — patient health and accessibility of medical care. Such a system cannot exist without linkage to efficiency. On one of my recent trips to the CIS countries, I saw how a budget system can be demotivating. Medical staff simply have no desire to introduce something effective and modern,” Murashko emphasized.
At the same time, it is important that collective agreements are not set up around any populist decisions. First of all, they should be based on an understanding of the efficiency of each medical organization. “We have a budget, we must clearly understand our financial capabilities,” the minister warned.
President Vladimir Putin in April confirmed plans to launch a pilot project to introduce a new remuneration system in healthcare in 2025. It was to be tested in several regions, but so far neither the list of participants nor the project parameters are publicly available. As the Ministry of Labor press service told “MV” in early December, they do not have such data. During discussion of the Federal Compulsory Medical Insurance Fund budget, lawmakers noted that the expenses for implementing the pilot were not included.
The project to introduce a new remuneration system in healthcare is designed to reduce the significant gap in incomes and ensure adequate salaries for medical workers. It was originally planned to start in November 2021, but the ministries preparing the methodological justification — the Health Ministry and the Labor Ministry — postponed it twice, and then postponed it altogether until 2025. Since February 1, 2023, incomes of medical workers that were partially eroded by inflation have been compensated through special social payments (SSP).
Only a small share of doctors (9.6%) assess the chances of implementing the new sectoral remuneration system as high and expect a rapid increase in salaries, a “MV” survey showed. Many respondents were more pessimistic.
MISCELLANEOUS
Staff reserves: by how much do they plan to raise doctors’ salaries
Can saved funds become a resource for increasing medical workers’ incomes
Health Minister Mikhail Murashko spoke at the 10th Plenum of the Central Committee of the Russian Healthcare Workers’ Union. The event discussed the sectoral budget for 2025, as well as how to increase doctors’ salaries through proper work organization and savings. The issue becomes even more relevant because next year marks the planned launch of a pilot project to create a unified remuneration system for public-sector employees, including medical workers, which is supposed to operate nationwide starting in 2027. However, the list of clear project parameters and the regions that will take part in the testing has not yet appeared, and they were not announced during the plenum either. More on what medical workers can expect financially next year is in the Izvestia report.
How the healthcare budget is growing
In his speech, Mikhail Murashko said that since 2019 the budget of the Compulsory Medical Insurance Fund has increased by more than 2.2 times; investments in medical infrastructure within the national and federal projects also amounted to more than 1 trillion rubles.
Next year, the healthcare budget will increase across all three sources — compulsory medical insurance funds, the federal budget, and regional budgets — by a total of 13%, Guzel Ulumbekova, head of the Higher School of Healthcare Organization and Management, M.D., told Izvestia.
— That is an additional 865 billion rubles compared with 2024, she noted. — If we subtract inflation, for which the budget includes a forecast at the level of 4.5%, the increase will be 8%.
According to her, the additional money will go in part toward indexing the pay of medical workers by 13%, so that salaries meet the requirements of the president’s May decrees.
— The good news is that the budget is not being cut, but on the other hand, no funds have yet been allocated for the new remuneration system, which is supposed to launch nationwide in 2027, the expert emphasized.
When will the pilot project begin
At the plenary session, Mikhail Murashko reminded that the pilot project is due to start in 2025, and the full transition to the new wage system is set for 2027. According to the minister, this transition will be “discussed separately” with the participation of the trade union. When asked by an Izvestia correspondent when and in which regions the project would begin, the minister did not provide any additional information.
Marina Maslova, Director of the Department of Wages, Labor Relations and Social Partnership at the Russian Ministry of Labor, said in her speech at the plenary session that the work on developing new wage systems both in healthcare and in other sectors of the social sphere is “complex both in modeling and in subsequent implementation.”
As a reminder, the launch of the pilot project has been under discussion since 2021, but it has already been postponed several times for various reasons. Andrey Konoval, co-chair of the Deystviye trade union, told Izvestia that the project may not be launched until the fourth quarter of 2025.
The trade union of healthcare workers of the Russian Federation has a more optimistic view of the situation. Trade union chairman Anatoly Domnikov noted that the skeptics who doubted the project would be launched turned out to be wrong.
— Right now, at the federal level, there is discussion of how the concept that was previously approved but not implemented for a number of objective reasons will serve as the basis for developing a new version. And we, of course, will once again be taking the most active part in this process, — he said in his speech at the plenary session.
At the same time, the presidential directive to raise the share of base salary in medics’ pay to 50% in 2024 has by no means been fulfilled everywhere, the trade union notes, citing operational data.
— We conducted an anonymous blitz survey online on social media: out of 6.6 thousand respondents, almost a third noted a decrease in their wages as a result of changes in the mechanism for forming them, — Anatoly Domnikov said at the plenary session. — Even taking into account that these are unverified responses, it is important to emphasize that employees perceive the situation exactly this way. Therefore, it is necessary to explain the meaning of this work in detail and analyze it while interacting with managers at all levels.
What the Ministry of Health proposes
In his speech, Mikhail Murashko focused, in essence, on process management in healthcare: high-quality organization of activities at all stages will make it possible to save money, including for the salaries of medical staff, the minister emphasized.
He sees one reserve in the use of technologies in diagnostic and treatment centers.
— We are talking specifically about organizational principles. When medical care becomes highly efficient, high-throughput centers appear in the regions with no equipment downtime, where gastroscopy, colonoscopy, and other examinations are performed in a flow format, — the minister said. — If a digital framework is implemented in parallel, then the time of the doctor and nurse is used as efficiently as possible.
According to him, “lean technologies,” which minimize staff time costs, ultimately also affect the payroll fund.
The next aspect the official pointed to is minimizing the prices of medical products through the use of domestically produced medicines and devices.
— We have come to the point where 70% of the medicines on the list of vital medicines are domestic. This has already generated enormous savings in financial resources, — the minister said. — Efficiency is largely formed at the level of figures within 20%. Therefore, for us, the development of production and science is an economic component that affects, among other things, our wages, since we effectively use the resources of the procurement system. All of this ultimately is our wages.
The minister of health believes that treatment in accordance with clinical guidelines and centralized procurement of the medicines prescribed there will make it possible to save money. According to him, this will also help assess the efficiency of resource use and the “disciplinary performance” of medical institutions.
It should be noted that clinical guidelines, although they will be advisory in nature, have associated quality assessment criteria for medical care that remain mandatory. Guzel Ulumbekova explains that many in the medical community view these changes with caution, since this may lead to an increase in the number of lawsuits against them. In her opinion, when assessing the quality of medical care, it would be better to focus on final outcomes, as in all developed countries: health, survival and patient satisfaction, hospital complications, etc.
Mikhail Murashko also called in his speech for building a system for planning the need for medicines and equipment. According to him, the write-off of medicines “should be extremely rare,” and when ordering equipment, chief physicians must clearly understand what load it should have.
Another aspect that could have a positive effect on cost savings is the main emphasis on primary care, which will make it possible to stop the flow of patients at the subsequent stages of healthcare. The minister noted that the cost of treatment at the inpatient stage is currently being inflated, so the efficiency of the healthcare system drops sharply in the final indicators.
Is it possible to raise salaries through savings
Andrey Konoval believes that there are no longer any resources for a substantial salary increase within the existing healthcare system. According to him, the share of the wage fund in total spending on the healthcare sector is too large for saving the remaining funds to free up any serious money for bonuses to medical workers’ salaries. According to Guzel Ulumbekova, this figure is about 70%. She also believes that the saved money will not become serious support for solving the staffing issue, especially since it does not always go directly to medical workers: often problems have to be addressed with facility repairs, the purchase of additional medical devices, etc.
“Narodny Front. Analitika” expert Sergey Voityuk emphasizes that the budget of the Federal Compulsory Medical Insurance Fund (FOMS) is executed with a surplus every year, although a deficit is planned in advance. According to the results of 2023, the surplus amounted to 104.8 billion rubles instead of the planned deficit of 147.08 million rubles.
— These funds could go to the regions to raise healthcare workers’ salaries, but, according to the Audit Chamber of the Russian Federation, medical organizations in the regions annually receive less CHI funds than they should for the medical care provided due to the excess of medical care volumes allocated by the commission for developing the territorial CHI program, — he told Izvestia.
This may also be related to a hidden deficit in territorial CHI programs, he believes: “For example, in 2023, the total amount of excess volumes not paid to medical organizations amounted to 23 billion rubles.”
Experts emphasize that calls for efficient spending of funds are correct in themselves. However, according to Sergey Voityuk, the problem requires “not only local optimizations, but also a revision of federal policy on the distribution and use of budget funds.” In particular, increasing healthcare spending in Russia to at least 5% of GDP from the current level of about 3.5% of GDP, at which healthcare financing in Russia will be in 2025.
— To gradually increase this figure to 5% by 2030, it will be necessary to inject an additional 700 billion to 1 trillion rubles into the sector each year on top of inflation, — said Guzel Ulumbekova. — Of this, at least 500 billion rubles are needed to implement the new wage system.
The Audit Chamber reported insufficiently broad access to chemotherapy in a number of regions
The Audit Chamber presented data on regions with minimal access to chemotherapy for cancer patients. In inpatient hospitals, less than 15% of the approved regimens were prescribed in five constituent entities.
The Audit Chamber named the TOP5 regions with the lowest level of access to chemotherapy in cancer treatment in inpatient hospitals. The data were published in the operational report on the execution of the budget of the Federal Compulsory Medical Insurance Fund (FOMS) for 9 months of 2024, which MV reviewed.
The lowest number of treatment regimens used for antitumor therapy in inpatient hospitals was recorded in the Nenets Autonomous Okrug (29, or 5.2% of the total number of approved treatment regimens); the Chukotka Autonomous Okrug (37, or 6.7%); the Jewish Autonomous Region (68, or 12.3%); the Republic of Mari El (75, or 13.5%) and Sevastopol (82, or 14.8%).
On average across Russia, 554 treatment regimens were used in inpatient hospitals.
An average of 800 regimens were used in day hospitals. At the minimum level, this indicator was found in nine regions, where the range of available medicines did not exceed 15%. These values were lowest in the Chukotka Autonomous Okrug (three treatment regimens, 0.4% of the total approved), the Nenets Autonomous Okrug (31, or 3.9%), the Republic of Kalmykia (66, or 8.3%), the Republic of Altai (69, or 8.6%), the Republic of Ingushetia (72, or 9%), and the Jewish Autonomous Region (76, or 9.5%).
As explained by the Ministry of Health, low rates of use of antitumor therapy regimens are observed in constituent entities with a small population and, accordingly, a small contingent of cancer patients. At the same time, using the example of Kirov Region (1.1 million population), which has low indicators both in terms of the number of regimens used for antitumor therapy in a day hospital (14.5%) and the hospitalization frequency (3.46), there is a trend whereby constituent entities with approximately the same population achieve much higher indicators in the analyzed area, the auditors note in their conclusions.
According to their estimates, these facts require additional elaboration and analysis by the Ministry of Health and FOMS.
According to the Audit Chamber, the volume of medical care for patients with cancer in January–September of this year increased compared with the same period in 2023 by 17.8 billion rubles (297 billion rubles), or by 6%. The total number of paid cases of outpatient medical care increased by 15.8%, in day hospitals by 9.3%, and in inpatient hospitals by 1.3%.
Two-thirds (68%) of the oncologists surveyed report difficulties in prescribing treatment and link the problems to the unavailability of medications required by the patient under the clinical practice guidelines (CPG). Respondents most often pointed to problems with targeted therapy and immunotherapy drugs (60%), as well as supportive care therapy (29%) for cancer patients. 28% of those surveyed reported difficulties in prescribing the necessary chemotherapy, and 13% reported pain management issues, wrote MV.
The first reports of problems with the range of chemotherapy drugs in Outpatient Cancer Care Centers (OCCC) appeared in mid-2021. In the summer of 2022, oncologists asked for adjustments to therapy reimbursement rates, since the mandatory health insurance (MHI) standard used to finance OCCC did not take into account epidemiological data or the use of new anticancer drugs. According to monitoring by the relevant federal project, in 2020 the variety of anticancer drug therapy regimens in OCCC amounted to five or six items. Thus, only 5% of the therapy guaranteed under MHI was available to patients at such centers.
Doctors received only a third of the funds allocated for cancer vigilance
The change in the payment procedure in 2024 has so far not fundamentally changed the situation
Russian doctors over the first nine months of 2024 received 12.8 million rubles for detecting cancer during preventive checkups — only a third (33.7%) of the funds allocated for this purpose. These conclusions are presented in the Federal Treasury Chamber’s (FTC) operational report on the execution of the budget of the Federal Compulsory Medical Insurance Fund (FOMS).
In total, from January through September, FOMS allocated 37.9 million rubles to territorial mandatory health insurance funds (TFOMS). In two regions during this period, funds for payments for cancer vigilance were not used. These were Khabarovsk Krai and the Jewish Autonomous Region, a representative of the FTC press service clarified.
Since January 1, 2024, one medical worker instead of three, as before, receives a payment of 1,000 rubles for detecting cancer. Such a doctor must schedule the patient for a specialist consultation, diagnostic imaging, or laboratory tests. The payment is granted for each case of cancer first detected and confirmed by test results.
These indicators show a positive trend compared with the same period in 2023, the auditors conclude.
The procedure for making payments for detecting cancer changed only on May 7, 2024, so in effect it has been in force for seven months, not 11, a FOMS press service representative told Vedomosti. During this period, there has been a significant increase in the use of the funds allocated by the Fund for such payments. As of December 1, 2024, 33.7 million rubles had already been sent to medical organizations. By comparison, for 11 months of 2023, that amount was only 4.7 million rubles, he said.
Previously, for detecting a cancer diagnosis confirmed by tests, a payment of 1,000 rubles was provided. It was divided among the doctor who conducted the preventive checkup (500 rubles) and two other medical workers. The person who referred the patient to an oncologist was entitled to 250 rubles, and the same amount went to the person who timely established follow-up care for the patient.
This mechanism was ineffective. From January through September 2023, when this rule was still in force, hospitals spent only 13.8% of the funds received from FOMS by TFOMS on such payments to doctors (a total of 23.8 million rubles). At the same time, in 30 constituent entities, the allocated funding for this purpose was not used over the nine months of 2023.
The share of cancer detected at early stages (I–II, there are four stages in total) in Russia over the first nine months of 2024 was 61% of all newly diagnosed malignant neoplasms, according to the same FTC report.
From January through September last year, according to the auditors, the share of malignant neoplasms detected at stages I–II in the Russian Federation was 60.3%. In mid-November 2023, Health Minister Mikhail Murashko said that the ministry planned to increase the detection rate of tumors “at early stages, when the prognosis for treatment is most favorable,” from 60% to 80%. This indicator was increased from 54.9% in 2019 to 60.5% in 2023.
Cancer is the second leading cause of death in the Russian Federation after cardiovascular diseases. In 2023, nearly 198 people per 100,000 population died from neoplasms. According to the annual compilations “The State of Cancer Care for the Population of Russia,” cancers of the lip, bladder, and melanoma are most often detected at early stages; in women, cancers of the uterine body, breast, and cervix; in men, prostate cancer. At late stages, stomach and pancreatic cancer, pharyngeal cancer, lung cancer, and others are detected. Diseases that are poorly detected at an early stage are most often found already in an advanced stage, stage IV, and have high mortality in the first year after diagnosis.
Determining exactly which specialist first detected cancer in a person is difficult, and the complexity of the payment process for cancer vigilance discourages doctors from applying for such payments, Larisa Popovich, Director of the Institute for Health Economics at the HSE University, told Vedomosti. In addition, monetary incentives for cancer vigilance are quite small and do not motivate doctors, she noted.
As Alexander Safonov, Professor at the Financial University, pointed out, for this mechanism to work effectively, it is necessary to formalize checklists for detecting cancer more clearly, as well as strengthen the work of healthcare managers who would regularly remind doctors of this task.
In addition, doctors do not refer people for additional, sometimes expensive, examinations, since they do not always result in a confirmed diagnosis, he added. This happens because the inappropriate spending of funds is not supported by the financial management of medical institutions, Safonov explained.
The number of ambulance stations has decreased again in Russia
In Russia, emergency medical care departments and stations continue to be closed. By the end of 2023, there were 55 fewer of them. At the same time, the total number of medical organizations remained unchanged, while the number of polyclinics increased.
In 2023, more than fifty emergency medical care (EMS) departments and stations were closed in Russia. By the end of the year, there were 1,876 such organizations operating, compared with 1,931 in 2022, according to published Rosstat statistics on healthcare system indicators reviewed by MV.
For comparison: in 2020 there were 2,113 EMS departments in the country, and in 2021 there were 2,035. The downward trend in the ambulance service has been observed since 2001. At that time, there were 3,212 EMS organizations in the country. There is no regional breakdown statistics for this section in the report.
The total number of medical organizations remained unchanged last year at 5.2 thousand. As of the end of 2023, there were 5,177 hospitals. The 2022 figure was 5,167. A slight decrease in the number of hospital organizations was observed in the Far Eastern and Siberian federal districts, alongside an increase in their number in the Southern, Northwestern, and North Caucasian districts.
The total number of outpatient clinics and polyclinics increased to 22,719 (22,146 in 2022).
The results of a survey of 1,100 EMS workers from 74 regions showed a depressing state of the service in small towns and rural areas. Most respondents said they worked 1.5 positions or slightly less, and many teams were staffed with one medical worker instead of two, wrote MV, citing monitoring by the independent Action trade union, at the end of May.
Later, the Ministry of Health confirmed shortcomings in the financial support of the emergency medical care service in most regions. It was noted that actual EMS costs exceeded the standards calculated in accordance with the territorial compulsory health insurance program, and that target wage levels for medical workers involved in providing emergency care had not been achieved. Against the backdrop of problems in the EMS system, lawmakers asked the government to take “urgent management measures at all levels,” including raising salaries and regulating workloads in emergency services.
The number of specialists with higher medical education continues to decline in the ambulance service. In 2022, only 10.6% of those working at stations and departments of EMS were doctors. A presentation by Sergey Bagnenko, the chief freelance emergency medical care specialist of the Russian Ministry of Health, Rector of Pavlov First Saint Petersburg State Medical University, and Academician of the Russian Academy of Sciences, made at the “Emergency Medical Care 2022” congress, showed that the number of doctors (individuals) at EMS stations and departments has been steadily decreasing since 2012. At that time, the number of specialists reached 17,877 people, in 2020 it was 13,602, and in 2021 it was 13,070.
https://medvestnik.ru/content/news/V-Rossii-snova-sokratilos-chislo-stancii-SMP.html
Issues in the application of clinical guidelines will be discussed in an online marathon
Russia’s Ministry of Health has prepared a series of online meetings for doctors with leading healthcare specialists to discuss issues related to the application of clinical guidelines. Recall that the mandatory use of these guidelines is due to take effect next year, and this has raised many questions within the medical community. The ministry promised to provide explanatory work and said that from December 12 to 23, 2024, an educational online marathon, “Clinical Guidelines: Experts Explain,” will be held on the platform of the Russian Medical Academy of Continuous Professional Education, where the transition to clinical practice based on the new rules will be discussed.
“Knowledge of clinical guidelines allows doctors to choose the most effective and safe treatment methods for a specific patient with his or her individual characteristics. As part of the educational online marathon, issues related to clinical guidelines both in general and for individual areas of medical care will be discussed,” the Ministry of Health said.
The series of meetings will feature the chief freelance specialists of the Russian Ministry of Health; developers of clinical guidelines; and lawyers.
Any physician can participate in the educational project. To do so, you need to register in your personal account on the website webinars-rmanpo.ru, select one or more webinars in your field in the calendar, and confirm participation by clicking the “Registration” button. https://rg.ru/2024/12/11/voprosy-primeneniia-klinicheskih-rekomendacij-obsudiat-na-onlajn-marafone.html?utm_source=yxnews&utm_medium=desktop&utm_referrer=https%3A%2F%2Fdzen.ru%2Fnews%2Fsearch