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Analysis of sources of financing of medical care in the Russian Federation

Balynin Igor' Viktorovich

PhD in Economics

Associate Professor, Department of Public Finance, Faculty of Finance, Financial University under the Government of the Russian Federation

125468, Russia, Moscow, Leningradsky ave., 49

igorbalynin@mail.ru
Other publications by this author
 

 
Ragozin Andrei Vasil'evich

PhD in Medicine

Director of the Center for Problems of Organization, Financing and Interterritorial Relations in Health Care of the Institute of Regional Economics and Interbudgetary Relations, Financial University under the Government of the Russian Federation

125468, Russia, Moscow, Leningradsky ave., 49

AVRagozin@fa.ru
Other publications by this author
 

 
Grishin Vladimir Vadimovich

Doctor of Economics

Chief Researcher at the Center for Problems of Organization, Financing and Interterritorial Relations in Health Care, Institute of Regional Economics and Intergovernmental Relations, Financial University under the Government of the Russian Federation

125468, Russia, Moscow, Leningradsky ave., 49

VVGrishin@fa.ru
Other publications by this author
 

 
Safonov Aleksandr L'vovich

Doctor of Economics

Professor, Deputy Director of the Institute of Interbudgetary Relations and Regional Economics, Department of Psychology and Human Capital Development, Financial University under the Government of the Russian Federation

125468, Russia, Moscow, Leningradsky ave., 49

ALSafonov@fa.ru
Other publications by this author
 

 

DOI:

10.25136/2409-7802.2023.3.44030

EDN:

ZERKBU

Received:

14-09-2023


Published:

05-10-2023


Abstract: The subject of the study is the sources of financial support for state guarantees of free medical care to citizens in the Russian Federation. Particular attention is paid to the analysis of the composition and structure of the financial support of state guarantees of free medical care to citizens (including the volume of contributions received by the budget of the Federal Compulsory Medical Insurance Fund for working citizens and for non-working citizens). The authors also assessed the potential volume of MHIF budget revenues from the payment of insurance premiums and compared the results obtained with actual data. Research methods used: structural and dynamic analysis, synthesis, comparison, as well as graphical presentation of the results obtained. Based on the results of the study, it was revealed that contributions for the non-working population are paid from regional budgets. Taken together with the use of funds from the federal budget for the implementation of the program of state guarantees for the provision of free medical care to citizens, this allows us to conclude that the budgetary financial mechanism is predominantly used in financial support for the implementation of state guarantees of free medical care to citizens in Russia. In order to maximize the volume of funds for solving problems in the field of healthcare, as well as ensuring their more efficient use, the authors propose expanding the list of objects subject to insurance premiums, as well as a more reasonable approach to establishing various preferential regimes that reduce the volume of budget revenues of the Federal Compulsory Health Insurance Fund. The author’s calculations showed that the actual revenues of the MHIF budget are approximately half of the potential ones.


Keywords:

healthcare, health financing, budget financial mechanism, social development, social sphere, health financing models, insurance financial mechanism, health, free medical care, medical care

This article is automatically translated. You can find original text of the article here.

Introduction

The relevance of the study of issues related to the financial provision of medical care in the Russian Federation is beyond doubt for several reasons.  Firstly, the duration and quality of life of Russians depends on it: in the conditions of a developed healthcare system, citizens receive high-quality medical care. Secondly, the achievement of the national development goals of our state depends on solving the problems related to the financial provision of medical care in the Russian Federation. Thirdly, it also contributes to economic development due to a higher level of economic activity of the population.  

In recent years, the issues of financial support of the healthcare system have been raised repeatedly in the scientific literature. Of course, the increased interest in these issues was especially evident against the background of the coronavirus pandemic [5]. First of all, the authors consider the models of healthcare financing used in Russia and abroad [4,15,16], which make it possible to determine recommendations for improving Russian practice.  It is valuable that the authors focus on the importance of more active use of financial control tools [18], as well as improving the administration of budget revenues of the budgetary system of the Russian Federation [11], which will expand the state's financial support capabilities for the healthcare system. It should be noted that despite the fact that scientific research on the modernization of the compulsory health insurance system [1,7, 12,13,14] raises issues of its improvement, focusing on a number of important problems (for example, in terms of the specifics of the formation of sources of financial support for state guarantees of free medical care to citizens for the unemployed population, with reduced rates of insurance premiums, informal employment, etc.) is not produced.

Research results

The existing program of state guarantees of free medical care to the population in Russia involves the implementation of a large list of measures, the financial support of which is carried out from several sources. Thus, Table 1 presents data on the composition and structure of sources of financial support for the implementation of the program of state guarantees of free medical care to citizens of the Russian Federation.

Table 1 – Composition and structure of sources of financial support for the implementation of the program of state guarantees of free medical care to citizens of the Russian Federation  

Sources of financing

2015

2017

2019

2021

billion

rub.

%

billion

rub.

%

billion

rub.

%

billion

rub.

%

Total expenses for the State Guarantees Program

2467,04

100

2600,94

100

3342,48

100

x

x

Insurance premiums from economic entities

 

 

The volume of insurance premiums, in billions of rubles

 

921,35

37,35

1059,89

40,75

1322,9

39,58

1532,8

x

Insurance premiums for the unemployed population

 

 

The volume of insurance premiums, in billions of rubles

616,29

24,98

618,66

23,78

720,1

21,54

783,3

x

Other sources of financial support for the implementation of the program of state guarantees of free medical care to citizens of the Russian Federation

MBT from FB

23,8

0,96

27,39

1,05

78,98

2,36

293,07

h

Federal budget

429,9

17,43

351,4

13,51

502,3

15,03

x

h

Budgets of the constituent entities of the Russian Federation

475,7

19,28

543,6

20,90

718,2

21,49

x

x

Source: compiled and calculated by the authors on the basis of reports of the FOMS and the Accounts Chamber of the Russian Federation [electronic resources: 4,5,6,8,10].

As you know, in the Russian Federation, there is mandatory medical insurance, which involves the payment of insurance premiums: for working citizens – by employers, for non–working - by the executive authorities of the subjects of the Russian Federation. On the one hand, the total amount of insurance premiums in the FOMS budget is more than 60%. However, if we take into account the fact that these insurance premiums for non-working citizens imply the implementation of expenditures of regional budgets, then their insurance nature becomes controversial. Thus, the share of insurance premiums for the working population throughout the study period is in the region of 37-40%%. This suggests that the financial mechanism mainly used in the financial support of the implementation of state guarantees of free medical care to citizens in Russia is more budgetary than insurance.  The authors believe that the situation in which the insurance financial mechanism is formally declared, but in fact the budget mechanism is used, is a source of problems for management. This does not allow it to be adequately filled with "general taxes", nor to receive the benefits of insurance management, avoiding the problem of political vulnerability of the redistribution of funds in the budget.  At the same time, unlike developed OECD countries, where the transition to general taxes as the main source of health care income is usually caused by a purposeful state policy due to the benefits of this approach, the predominantly "budgetary" nature of healthcare financing in the Russian Federation is not a political choice: adherence to insurance principles is regularly proclaimed.  It seems that such inconsistency of the Russian healthcare financing system does not allow taking advantage of insurance or budgetary financial mechanisms. At the same time, this regularly causes problems associated with the accumulation of shortcomings of both financial mechanisms. In other words, the historically established system of financing the Program of state guarantees of free medical care to citizens in the Russian Federation does not have the advantages of insurance management and cannot be filled with more efficiently collected "general taxes", but at the same time it faces the political vulnerability of the tax system and the vulnerability of the insurance system to economic risks.

It seems that such an overestimated share of "general taxes" in the formal insurance financing of the Program of state guarantees of free medical care to citizens of the Russian Federation and the predominantly "budgetary" nature of its financing are due to the shortcomings of the MHI income system.

Firstly, this is due to the non–solidary nature of the compulsory health insurance system - exemption from payment of compulsory health insurance contributions of individuals' income from capital and rent. Unlike the OECD countries with an insurance model, where medical insurance premiums are usually withheld at the same rate not only from the salaries of the formally employed, but also from the income of individual entrepreneurs and self-employed, as well as from income from capital and rent, in Russia, capital owners and rent recipients are exempt from contributions to compulsory health insurance. Meanwhile, profit and rent account for about 40% of the GDP of the Russian Federation – which reduces the base of contributions of the compulsory medical insurance by about 40%. The exemption of income of capital owners and rent recipients from participation in the joint financing of compulsory medical insurance is one of the reasons why compulsory medical insurance in Russia can hardly be called social insurance.

Secondly, it should be noted the "stowaway problem" caused by the large-scale shadow economy, high informal employment and the shortcomings of the historically established system of compulsory health insurance of the so-called unemployed population.

According to the FOMS, there are significantly more so-called unemployed citizens in the Russian Federation than working: in 2021, out of 145 million, only 63.8 million were formally employed. Meanwhile, a significant part of the so-called "unemployed" today are workers of the shadow economy, living on criminal income and income from capital and rent, informally employed (including those registered as unemployed), as well as non-working family members of formally employed workers, who in OECD countries with an insurance model are insured by contributions from the working head of the family. Therefore, the compulsory medical insurance of all these citizens – formally not employed, but often with high incomes – is paid for at the expense of the budgets of the constituent entities of the Russian Federation (in fact, at the expense of "general taxes").

Thirdly, the tariff of the insurance premium for the compulsory health insurance for an employee is underestimated for a country with an insurance model, which does not allow insuring his non-working members together with him, transferring them to the status of "self-employed".

Fourth, the rate of contribution to the compulsory health insurance or its fixed size for individual entrepreneurs and self-employed in the Russian Federation is underestimated for a country with an insurance model. In developed OECD countries, this tariff is calculated as a percentage of the income of an individual entrepreneur and self-employed and is usually equal or comparable to the tariff of contributions from an employee for hire.

Fifthly, the process of providing benefits and special tax regimes for the payment of compulsory health insurance contributions to a wide range of employers by industry and territory is impersonal - not tied to a specific employee. Benefits for the payment of social health insurance contributions are infrequently provided in developed OECD countries and are often of an individual nature - tied to a specific employee – which ensures a full-fledged planned and managed replenishment of the decrease in insurers' income (the exact amount of the required budget transfer) and thereby limits the presentation of benefits.

On the contrary, in the Russian Federation, the provision of benefits is carried out in an impersonal form on an industry and territorial basis, which does not allow us to accurately calculate the required size of the inter-budget transfer to the FOMS budget to compensate for these benefits and thus does not place significant restrictions on their provision.  

The analysis of available sources suggests that the development and adoption of draft laws on the provision of preferential payment regimes by employers for compulsory health insurance contributions to entire industries and territories often does not provide for the calculation of the losses of the FOMS budget and the amount of the inter-budget transfer necessary for their compensation. 

 

Table 2 presents an estimate of the potential amount of income of the FOMS budget from the payment of insurance premiums 

Table 2 – Estimation of the potential volume of the FOMS budget revenues from the payment of insurance premiums  

Year

 

Remuneration of employees, billion rubles

The potential revenue of the budget of the Federal Migration Service is 5.1% of the wages of employees, billion rubles

 

Contributions received in the FOMS budget for the working population,

billion rubles

 

Inter-budget transfer

the budget of the Federal Migration Service to compensate for the loss of income at reduced rates of contributions of the Compulsory Medical Insurance (MBT), billion rubles

The difference between the actual and potential revenues of the budget of the Federal Migration Service in the form of contributions for the working population, taking into account the MBT, billion rubles

The ratio of the volume of actual revenues of the FOMS budget, taking into account the MBT, to the potentially possible, %

2017

43989,2

2243,45

1059,89

27,39

- 1156,17

48,46

2018

47379,3

2416,34

1200,57

32,19

- 1183,58

51,02

2019

51344,3

2618,56

1322,9

8,98

- 1286,68

50,86

2020

52770,5

2691,30

1388,9

11.96

- 1290,44

52,05

2021

53786,7

2743,12

1532,8

35,47

- 1174,85

57,17

2022

59914,5

3055,64

1599,4

47,50

- 1408,74

53,90

Average value

– 1250,08

52,24

Compiled by the authors on the basis of Rosstat data, FOMS reports and Federal Treasury data [electronic resources: 1-3,6-11].  

 

Analysis of data from open official sources suggests that the budget of the Federal Migration Service may annually receive up to 50% of insurance premiums from employers for the working population annually.

 

Conclusion

Thus, based on the results of the study, it is possible to draw the following conclusions.

1.                 The existing approaches to financial support for the implementation of state guarantees of free medical care are quite contradictory and have great potential for their improvement.

2. These studies show a significant untapped potential for increasing the effectiveness of the CHI system and financing the Program of state guarantees of free medical care to citizens of the Russian Federation as a whole.

3.                 The most effective measures are:

- collection of insurance premiums for compulsory health insurance from income from capital and rent, including from financial transactions to offshore companies;

- revision of the system of benefits and special tax regimes for the payment of compulsory health insurance premiums with the unification of the tariff and payment regime;

- defragmentation and centralization of the system: consolidation of numerous channels of financing the Program of state guarantees of free medical care to citizens of the Russian Federation into a centralized system of a single payer.

Source of funding.

The article is based on the results of research carried out at the expense of budgetary funds under the state assignment of the Financial University under the Government of the Russian Federation.

Electronic resources: 

1. Unified portal of the budget system of the Russian Federation. URL: https://budget.gov.ru/Главная-страница (accessed: 11.09.2023)

2. Federal State Statistics Service. URL: https://rosstat.gov.ru / (accessed: 11.09.2023)

3. Federal Tax Service. URL: https://www.nalog.gov.ru/rn77 / (accessed: 08/23/2023)

4. Analysis of the sources (structure) and dynamics of the volume of financial support for territorial compulsory medical insurance programs (including in terms of the basic compulsory medical insurance program), as well as changes in the volume and structure of medical care paid for at the expense of subventions for 2015-2019 and the expired period of 2020. URL:  https://ach.gov.ru/upload/iblock/fa4/fa412e5db73d7355f85a2c05de4eb4a3.pdf (accessed: 08/31/2023)

5. Report on the activities of the FOMS in 2015. URL: https://www.ffoms.gov.ru/upload/iblock/91b/91b96b3174f25702b769e8ced881ab2e.pdf (accessed: 08/29/2023)

6. Report on the activities of the FOMS in 2017. URL:https://www.ffoms.gov.ru/upload/iblock/636/6363feb19b121cc76865461aa67512b4.pdf (accessed: 08/29/2023)

7. Report on the activities of the FOMS in 2018. URL: https://www.ffoms.gov.ru/upload/medialibrary/6a0/6a027028c1820b87bc18a3f8d280b029.pdf (accessed: 08/29/2023)

8. Report on the activities of the FOMS in 2019. URL: https://www.ffoms.gov.ru/upload/iblock/3c0/3c0366b4c5a490209ba93c22922c8701.pdf (accessed: 08/29/2023)

9. Report on the activities of the FOMS in 2020. URL:https://www.ffoms.gov.ru/system-oms/about-fund/fund-activities/1_ОТЧЕТ_о_результатах_деятельности_ФОМС_за_2020_год.pdf (accessed: 08/29/2023)

10. Report on the activities of the FOMS in 2021. URL: https://www.ffoms.gov.ru/system-oms/about-fund/fund-activities/ОТЧЕТ_ФОМС_за_2021_год_28.11.2022.pdf (accessed: 11.09.2023)

11. Report on the activities of the FOMS in 2022. URL: https://www.ffoms.gov.ru/upload/docs/2023/ОТЧЕТ_2022_18.05._2023.pdf (accessed: 11.09.2023)

 Electronic recsources:

1.Unified portal of the budget system of the Russian Federation. [Electronic resource]. Retrieved from https://budget.gov.ru/Home page (access date: 09.11.2023)

2.Federal State Statistics Service. [Electronic resource]. Retrieved from https://rosstat.gov.ru/ (access date: 09/11/2023)

3.Federal Tax Service. [Electronic resource]. Retrieved from https://www.nalog.gov.ru/rn77/ (access date: 08/23/2023)

4. Analysis of the sources (structure) and dynamics of the volume of financial support for territorial compulsory health insurance programs (including the basic compulsory health insurance program), as well as changes in the volume and structure of medical care paid for using subvention funds for 2015-2019 and the expired period of 2020. [Electronic resource]. Retrieved from https://ach.gov.ru/upload/iblock/fa4/fa412e5db73d7355f85a2c05de4eb4a3.pdf (access date: 08/31/2023)

5. Report on the activities of the Compulsory Medical Insurance Fund in 2015. [Electronic resource]. Retrieved from https://www.ffoms.gov.ru/upload/iblock/91b/91b96b3174f25702b769e8ced881ab2e.pdf (access date: 08.29.2023)

6. Report on the activities of the Compulsory Medical Insurance Fund in 2017. [Electronic resource]. Retrieved from https://www.ffoms.gov.ru/upload/iblock/636/6363feb19b121cc76865461aa67512b4.pdf (date of access: 08/29/2023)

7. Report on the activities of the Compulsory Medical Insurance Fund in 2018. [Electronic resource]. Retrieved from https://www.ffoms.gov.ru/upload/medialibrary/6a0/6a027028c1820b87bc18a3f8d280b029.pdf (access date: 08.29.2023)

8. Report on the activities of the Compulsory Medical Insurance Fund in 2019. [Electronic resource]. Retrieved from https://www.ffoms.gov.ru/upload/iblock/3c0/3c0366b4c5a490209ba93c22922c8701.pdf (access date: 08.29.2023)

9. Report on the activities of the Compulsory Medical Insurance Fund in 2020. [Electronic resource]. Retrieved from https://www.ffoms.gov.ru/system-oms/about-fund/fund-activities/1_REPORT_on_the_results_of_the_MHIF_activities_for_2020_year.pdf (date of access: 08/29/2023)

10. Report on the activities of the Compulsory Medical Insurance Fund in 2021. [Electronic resource]. Retrieved from https://www.ffoms.gov.ru/system-oms/about-fund/fund-activities/FOMS_REPORT_for_2021_28.11.2022.pdf (date of access: 09.11.2023)

11. Report on the activities of the Compulsory Medical Insurance Fund in 2022. [Electronic resource]. Retrieved from https://www.ffoms.gov.ru/upload/docs/2023/REPORT_2022_18.05._2023.pdf (access date: 09/11/2023)

 

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Peer Review

Peer reviewers' evaluations remain confidential and are not disclosed to the public. Only external reviews, authorized for publication by the article's author(s), are made public. Typically, these final reviews are conducted after the manuscript's revision. Adhering to our double-blind review policy, the reviewer's identity is kept confidential.
The list of publisher reviewers can be found here.

The scientific article submitted for review on the topic: "Analysis of sources of financing of medical care in the Russian Federation" is an actual study of the issues of financing medical care in the Russian Federation. This scientific article has a scientific novelty and meets, in general, the requirements for this type of scientific work. The article is of substantial scientific and reader interest and, we believe, will most likely be quite useful for the target readership. The article is structured into several sections and includes an introduction with a definition of the relevance of the study and the problem being solved, the results of the study, accompanied by tabular material, data from foreign and Russian studies, and a conclusion. The article is based on the results of research carried out at the expense of budgetary funds under the state assignment of the Financial University under the Government of the Russian Federation. Meanwhile, it should be noted that the reviewed scientific article does not contain a specially highlighted methodological section in the text itself. The authors of the article do not present the research methodology, including the methods and approaches used for the study. However, when analyzing the reviewed text of the article, it is still possible to draw a conclusion about the author's design of the study, which includes all the necessary elements for the implementation of this study. The style of the article has a scientific character. The text is logical and consistent in its presentation. It is written in an accessible and understandable language for the readership. The author's choice of the source base of modern, mainly scientific literature of the study, made it possible to prepare a decent scientific article. It should also be noted that the article was prepared taking into account the use of data from a variety of analytical sources (Report, Analysis), which qualitatively enhanced the value of this scientific work. The article also uses data from Rosstat, FOMS reports and data from the Federal Treasury. The elements of the scientific discussion are not presented in the article. We believe, with that said, that this circumstance does not affect the quality of scientific work as a whole. Meaningfully, the authors rightly assume that the financial mechanism mainly used in the financial support of the implementation of state guarantees of free medical care to citizens in Russia is more budgetary than insurance. The authors believe that a situation in which an insurance financial mechanism is formally declared, but in fact a budgetary one is used, is a source of problems for management. The authors formulated the main disadvantages of the MHI income system and suggested that the development and adoption of draft laws to provide often entire industries and territories with preferential payment regimes for MHI contributions by employers often does not provide for calculating the losses of the MHI budget and the amount of inter-budgetary transfer necessary for their reimbursement. The author/authors have quite competently drawn conclusions. However, unfortunately, the relevant recommendations are not provided. The article is recommended for publication.
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