APPROACHES TO REIMBURSEMENT FOR MEDICAL CARE WITHIN ANESTHESIOLOGY AND INTENSIVE CARE PROFILE DURING TRANSFER TO A NEW SYSTEM OF HEALTH CARE FUNDING

Abstract

A new federal model of in-patient medical care funding provides payment for treatment basing on the average costs estimated when evaluating "completed cases" of certain diseases grouped together due to their similarity and types of the provided medical care (CSG system). The lack of differentiation does not allow full reimbursement of expenses of in-patient units occurring during treatment of the severely ill in the intensive care wards. Goal: to estimate risks of financial losses of units providing medical care to the patients with high chances of a complicated course of the disease when medical care is reimbursed within the system described above (CSG system) and to propose improvement of this system. Results. The article presents the results of joint work of the experts from Organizational Economic Committee of the Association of Anesthesiologists and Intensive Care Physicians and workers of St. Petersburg Regional Fund of Mandatory Medical Insurance aimed at the improvement of the medical care funding system based on the so-called clinical statistic groups (CSG). It was suggested splitting up certain clinical statistic groups into subgroups considering the need of patients in the intensive care and its content. The coefficients reflecting the content of costs were calculated for the identified subgroups. The offered approach was piloted during the project in St. Petersburg through estimating costs for a completed case in parallel with estimation as per the existing method of reimbursement related to medical economic standards. The obtained results proved that the offered approach allowed achieving better differentiation due to re-distribution of funds from less severely ill patients who required no treatment in the intensive care departments to the more severely ill. The data were submitted to Center of Expertise and Monitoring of Medical Care Quality in order to prepare suggestions to amend guidelines on medical care reimbursement by the Russian Ministry of Health. Conclusion. The article describes specific practical outcomes – the model was developed to be introduced for reimbursement of the in-patient care as per CSG system within mandatory medical insurance.

Keywords

• mandatory medical insurance
• reimbursement for in-patient care
• clinical statistic groups
• intensive care unit