In developed countries, insured health service has proved to be a very effective form of medical care for the population. On the one hand, it allows protection of the patient's interests in a medical institution (by means of control over the quality of medical care and the substantiation of costs), and on the other hand, the accumulation of considerable financial means used, among other things, for the development of this service.

In our conditions the transition from state free-of- charge (budget) health service to insured service cannot be carried out at once. The appearance of intermediate forms of budget-insured health service is quite natural.

Ways are proposed of solving one of the main problems of the transition to budget-insured health service, consisting in the transformation of the financing system from financing the overall medical network (bed- occupancy visits to a physician) to normative financing - per capita, taking in to account sex and age groups.

STAGES OF REORGANIZATION OF THE SECTOR

Calculations for each district of the Nizhni Novgorod region are made with the help of the staff of the medical institutes. The process of reorganization can be provisionally divided into three stages.

At the first stage the following procedure is adopted. General medical centres are advanced from the budget (for example, for a period of one month). Then the payment is made depending on the number of patients and the quality of medical treatment. For this, medical-economic standards have been established. At this stage it is necessary to launch a campaign aimed at encouraging enterprises to participate in voluntary insurance in order to attract non-budgetary sources of financing.

Specialized and socially significant services (obstetric, tubercular, psychiatric and other) are financed from the budget. Testing of medical personnel with consequent staff reduction is carried out.

At the second stage, specialized services are financed from the budget but the number of patients and the quality of medical treatment are taken into account. In the case of the development of voluntary and compulsory insurance, gradual (over 2-5 years) departure from the budget financing of large multi-specialty hospitals whose services will remain in fairly great demand.

At the third stage, medical centres which successfully functioned at the previous stages are transformed into enterprises with different forms of property - ranging from municipal and regional institutions to private enterprises of different kinds (joint-stock companies, private clinics, etc.).

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There must be a specific approach to defining the role of the network of district hospitals and medical-assistance and obstetric stations in the country. If the network is unprofitable it must be necessarily financed from the budget.

FUNDAMENTAL PRINCIPLES OF THE INSURANCE COMPANY "NIZHNI NOVGOROD"

The health insurance company "Nizhni Novgorod" is founded with the aim of providing citizens of the Nizhni Novgorod region with voluntary and compulsory insurance. In the case of illness all the insured can receive the complete extent of diagnostic and medical-preventive examination and treatment in conditions of maximum comfort and service.

The health insurance company uses the principle of return insurance. 75% of the insurance fees in the case of group or family return insurance are kept by the insured individuals if they did not request medical treatment over the year. The sum can be either transferred to the next year as the insurance fee, or received by the insured persons as a premium. The sum of the insurance fee for every insured person is fixed taking into account his or her state of health as established by a commission of qualified physicians.

The insurance fee is from 1,260 roubles to 4,300 roubles per person per year.

To assess the quality of medical care, the Insurance Company appoints an independent panel of experts which makes decisions concerning disputes between the medical centre and the insured person.

The insurance fee is paid by the insured person either at once for the whole year or monthly; the payment can be made by cash, bank transfer or postal money order.

When the term of the contract expires the remainder of the sum insured on the personal account of the insured person is paid to him or her as a premium.

RIGHTS AND OBLIGATIONS OF THE CLIENT

1. The Client has the right to choose and change the primary accredited doctor.

2. The Client has a medical file, insurance policy and a health card.

3. The Client with the insurance policy has the right to visit a doctor without queuing at any time, by previous arrangement.

4. The Client may send for a doctor.

5. Every client has information (address and telephone number) about all doctors working in clinics in different districts of the city and region.

6. The extent of medical examinations and medical treatment is defined by the attending physician. Control over the adequacy of treatment is carried out by an independent panel of experts.

8. If the client, in the case of return group health insurance, received medical advice very rarely, he or she is entitled to receive the remainder of his or her insurance fee.

9. If insurance coverage exceeds the sum insured, an additional payment is made to the account of the client.

10. Disputes concerning treatment and medical examination are considered by a panel of experts when appealed to by the client in writing. Costs of the examination of disputes are covered by the insurance company. In the case of the solution of the dispute in the client's favour, the costs of the improper medical examination and treatment are covered by the insurance company.

11. The Client is obliged:

- to follow prescriptions and recommendations of the doctors; and

- to observe the contract.

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RELATIONS BETWEEN THE PRIMARY DOCTOR AND THE CLIENT, MEDICAL CENTRE AND INSURANCE COMPANY

The primary accredited doctor:

- carries out the overall medical examination of the client with the aim of establishing his or her state of health as of the time of conclusion of the insurance contract between the client and the insurance company (determination of health group); -provides timely, qualified medical care at clinics and at the insured person's home; - carries out early diagnosis and qualified examination of patients with specific illnesses; -provides timely hospital services and treatment, and carries out medical examination of patients before admittance to hospital; - carries out the examination of patients with temporary disabilities, issues and extends sick leave certificates, makes recommendations concerning the working conditions of individuals who have to be transferred to a different workplaces, and directs patients to the Expert Council on Disability Certification; - carries out preventative health care and checkups of clients, with the aim of discovering unhealthy working conditions and work related illness; - provides clients with health information and health education; and - is in charge of registration and accounting documentation in accordance with the standards established by the insurance company.

RELATIONSHIP BETWEEN THE MEDICAL CENTRE, THE CLIENT AND THE INSURANCE COMPANY

1. Relations between the medical centre and the insurance company. 1.1. Relations between the medical centre and the insurance company are based on a bilateral contract.

The subject of the contract includes the following: - names of premises (offices, wards, departments) used by the insured health service;

- inventory of equipment, medicines and expendable materials used by the insured health service, in addition to the basic level;

- inventory of services (medical-diagnostic examinations, consultative) and the corresponding fees; -conditions for using wards (allocation of hospital beds or unused wards of the medical centre);

- conditions for drawing up and issuing sick leave certificates and other documentation are determined by the Instructions and a letter from the Health Service Department;

- conditions determining the relationship between doctors and other medical personnel accredited by the insurance company, and the administration of the medical centre and other employees of the medical centre, are defined by an internal agreement within the medical center;

- wages for doctors and medical personnel accredited by the insurance company are determined by an internal agreement within the medical centre;

- conditions determining relations between the medical centre and the panel of experts (assessment of the quality of medical care, and provision of medical documentation).

2. Relations between the medical centre and the client.

The client has the right to medical care from the personnel of the medical centre accredited by the insurance company. In necessary cases, accredited doctors attending to the client have the right to invite non-accredited doctors of the medical centre in order to provide the client with a service. All disputes arising between the client and the medical centre are considered by the insurance company.

PROCEDURE OF ACCREDITATION OF MEDICAL PERSONNEL

1. The Insurance company establishes the criteria for selection of the medical personnel working for the insurance company. 2. Accreditation of the medical personnel is carried out by the insurance company. The doctors receives Licenses from the insurance company.

The selection of employees of the medical centre for the accreditation is carried out by the insurance company together with the administration of the medical centre.

When considering the capability of the accredited individual to perform the work entrusted to him or her (in the case of unsatisfactory work), the insurance company has the right to revoke the license on the grounds of the decision made by the panel of experts.

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THE PANEL OF MEDICAL EXPERTS

1. A panel of experts is appointed by the Presidium of the Regional Soviet of People's Deputies.

2. The panel of experts reviews the quality of medical and diagnostic services the client is provided with at all stages of medical care.

3. The panel of experts concludes a contract with the insurance company and fulfills its assignments.

4. The membership of the panel of experts is established according to the Regulations of the Russian Independent Medical Board:

- specialist doctors; - representatives of the regional Soviet of trade unions; - representatives of social organizations of the insured individuals (in the case of group insurance).

FINANCES OF THE INSURANCE COMPANY IN THE CASE OF VOLUNTARY AND COMPULSORY HEALTH INSURANCE

The health insurance funds are formed by:

- budgetary funds (in the case of compulsory health insurance);

- voluntary insurance fees from enterprises and organizations;

- voluntary insurance fees from different groups of the population and individual citizens;

- charitable fees from enterprises and individual citizens.

TERMS FOR INSURANCE PAYMENTS MADE BY CLIENTS OF DIFFERENT CATEGORIES

1. Complete insurance payment made by an individual. 2. Complete insurance payment made by an enterprise or from budgetary funds.

3. Insurance payment shared by an individual and an enterprise or the State budget.

PAYMENT METHODS

1. The initial fee is no less than 70% of the sum insured at the time of concluding the insurance contract, with the subsequent distribution of the remainder over the course of the duration of the contract.

2. Immediate payment of the total sum insured at the time of concluding the insurance contract (for 1992).

FORMS OF PAYMENT TRANSACTIONS:

- cash payments made to the insurance company; - non-cash transfers from personal bank deposits of citizens; - non- cash transfers made by enterprises and organizations, including state-owned ones;

- non-cash foreign currency transfers made by organizations and individuals to the foreign currency account of the insurance company.

FINANCIAL RELATIONSHIP BETWEEN THE INSURANCE COMPANY AND THE MEDICAL CENTRE

- payment of the accounts of medical institutions and medical centres is made at the rates fixed by the insurance company, and is determined by the extent of services provided;

- the medical centre is financed by non-cash transfers upon submission of monthly accounts to the insurance company.

The administration of the medical centre can pay non- accredited specialists, as a bonus, part of the financial funds received for services provided.

LIABILITY OF THE PARTIES

Liability of the parties is determined by contracts between: - the insured party and the insurer; and - the insurer and the medical centre.

The parties are juridically and financially liable in accordance with the legislation in force and the terms of the contract.

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