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First year of health insurance implementation: Results and goals for 2021

Wednesday, 20 January 2021, 21:10:25

2020 was a difficult year for everyone, especially for the healthcare system of our country. At the same time, the first year of the implementation of the health insurance system coincided with the coronavirus pandemic. At the online briefing, Chair of Social Medical Insurance Fund NJSC Bolat Tokezhanov, Director of the Department for Monitoring the Quality of Medical Care Lazzat Shomanova and Director of the Department for Work with Legal and Physical Persons Zabir Orazaliev said what are the results of the Social Health Insurance Fund for 2020 and what tasks have been set for 2021.

As Tokezhanov noted in his speech, the main task of the fund is continuous financing of medical organizations and material support of medical workers involved in the fight against CVI.

“The Fund has fully fulfilled this task. To ensure readiness for the growth of morbidity, several important steps were initiated and implemented,” Tokezhanov noted.

So, according to him, during the pandemic, the role of primary health care was strengthened — mobile teams were created, day hospitals at home were organized, and the provision of medical services in a remote format was started. In addition, the capacity of the laboratory service for PCR diagnostics has been increased. The fund provided access to this assistance for the entire population, regardless of its participation in the health insurance system.

According to the speakers, despite the force majeure conditions, the results of the first year of the implementation of the compulsory health insurance indicate that the health insurance system is fully operational. It allowed to inject over 500 billion tenge into the health care system. These funds have significantly increased the volume of medical services — consultations of narrow specialists, diagnostics, examinations, day hospital services. Finally, access to medical rehabilitation has appeared, including for patients with postcoid syndrome.

In addition, it became possible to finance more high-tech operations and reduce the priority for this kind of medical services.

 

WHO IS COVERED BY HEALTH INSURANCE SYSTEM?

As the chair of the board of the Fund noted, according to the results of last year, 85% of the population are participants in the system — this is 15.9 million people.

Even despite the quarantine measures, the insolvency of businesses during this period managed to increase the number of participants in the compulsory health insurance system during the first year by 1 million people: from 14.9 million people in January 2020 to 15.9 million people in January this year.

Currently, more than 3 million Kazakhstanis remain outside the compulsory health insurance system. But, according to Tokezhanov, they have the right to receive medical services at any time within the guaranteed volume of free medical care.

The Fund, together with akimats and relevant ministries, will continue systematic work to involve the population in the Compulsory Social Health Insurance.

In the form of contributions and deductions for the CSHI in 2020, 550 billion tenge were received. The largest amount of receipts was made by the state contributions for privileged categories of citizens - 297.6 billion tenge, or 54% of all receipts. Thus, the state continues to maintain its social obligations to the population. Deductions from employers for their employees in total left 162.6 billion tenge (30%). The share of contributions from individuals was 16%.

 

MEDICAL HELP THROUGH CSHU: WHAT POPULATION RECEIVED

As noted by Tokezhanov, all funds received from the CSHI are directed to pay for medical assistance to the population. Last year, the plan for the procurement of medical services of the Fund amounted to 1.8 trillion tenge, and in comparison with 2019 it increased by one and a half times. Financing of the guaranteed volume of medical care amounted to 1.2 trillion tenge, compulsory health insurance — 569 billion tenge.

“A significant increase in funding made it possible to increase the volume of medical care for the population. As before, financing of outpatient and polyclinic care remains a priority for us,” noted Tokezhanov.

Last year, about 215 million services were provided to the population at the outpatient level.

This is more than:

  • 110 million appointments, including about 33 million appointments of narrow specialists;
  • 65 million laboratory diagnostics services;
  • about 28 million procedures and manipulations;
  • 11 million diagnostic services, including 454 thousand CT / MRI, 2.8 million ultrasound, 13.5 thousand PET diagnostics.

At the same time, according to the chairman of the board of the Fund, the bulk of all consultative and diagnostic services provided through polyclinics are paid for through medical insurance.

Last year, more than 1 million hospitalizations were carried out in a day hospital, of which 508 thousand hospitalizations within the guaranteed volume of medical care and 578 thousand hospitalizations within the compulsory health insurance system.

About 2.7 million patients received treatment in 24-hour hospitals.

“It is important to note that the cases of emergency hospitalization have significantly decreased, although in the general structure of hospitalizations, emergency care is still 62%,” said Tokezhanov.

According to the speaker, emergency hospitalization indicates that the patient was admitted with complications or with a late diagnosis. This poses a threat to human life and health. Whereas planned hospitalization involves early detection of the disease and its timely treatment.

The preliminary results of 2020 show a trend towards an increase in the availability of planned hospitalization by reducing the waiting time. Last year, 86% of patients were routinely hospitalized in a period of one to ten days, only 5% of patients waited for hospitalization for more than 30 days, while back in 2019 their number was 12%.

At the expense of medical insurance funds, about 10 thousand expensive, high-tech operations were carried out. The average cost of each case was over 3 million tenge

The number of operations performed on patients in the areas of angiosurgery, ophthalmology, cardiac surgery, neurosurgery, traumatology and orthopedics has increased.

“There is an increase in the use of endovascular (minimally invasive) expensive surgeries for cardiac arrhythmias. For example, the implantation of an automatic cardioverter / defibrillator increased by 1.5 times. The average cost of such an operation is more than 6 million tenge, over 1,200 such operations were carried out last year,” Tokezhanov informed.

Also, according to the chair of the Board of the Fund, more operations were carried out for children with disabilities at the expense of health insurance funds. Operations for the treatment of retinopathy in premature infants and the number of implantations of an electromagnetic hearing aid increased by one and a half times. The cost of one such service is on average 5.5 million tenge.

“No one can guarantee that we or our loved ones will not need medical assistance at any time. The role of health insurance at such moments is especially clear, and it should work according to the principles of sociality, accessibility, and not accumulation,” Tokezhanov stressed.

 

CSHI: FINANCING OF REHABILITATION INCREASED 9 TIMES

Another initiative of health insurance was to increase the availability of rehabilitation for the population. In 2020, funding for rehabilitation increased 9 times compared to 2019, to 56 billion tenge.

This stimulated the opening of new rehabilitation centers, departments and rehabilitation rooms in medical organizations. In 2020, compared to 2019, the number of providers of these services increased from 64 to 559 medical organizations.

And the coronavirus pandemic has shown how important rehabilitation is and how timely this initiative was implemented.

Now in these centers and departments, patients with complications from coronavirus infection are undergoing rehabilitation.

Since the beginning of last year, medical organizations have provided rehabilitation services worth more than 31 billion tenge, including 132 thousand cases of rehabilitation in inpatient conditions. The largest number of them fell on the last quarter of last year. This also includes the rehabilitation of patients who have suffered from Covid-19 and coronavirus infection.

 

ROLE OF THE FUND IN THE FIGHT AGAINST CORONAVIRUS

In 2020, funding for measures to combat coronavirus infection amounted to 187.7 billion tenge, including the projected amounts for December:

  • over 110 billion tenge was allocated for bonuses to health care workers;
  • for medical care and services to prevent the spread of CVI — 53.9 billion tenge,
  • 384 thousand people were hospitalized and treated in provisional, quarantine and infectious diseases hospitals;
  • 19.7 billion tenge was allocated for PCR diagnostics services, more than 1.9 million PCR tests were carried out; for mobile brigade visits - 3.2 billion tenge, about 550 thousand visits were carried out.

Also, according to the speakers, business representatives are exempted from paying fees.

“Thanks to government measures, we have restored their insurance status to citizens who find themselves in difficult life situations. Since the main values ​​of the fund are the health of people, the Fund, despite significant financial losses, has reached such an important compromise," Tokezhanov said.

As he further informed, during 2020, medical workers were provided with the payment of allowances for participation in anti-epidemic measures. About half a million health care workers received risk-based pay increases. In March-December, the Social Health Insurance Fund allocated more than 110 billion tenge for these purposes.

“Recently it was decided that incentive bonuses will be paid in the first half of 2021 as well. Depending on the epidemiological situation in the country, the contingent and the group of recipients may change,” said Tokezhanov.

 

PLANS FOR 2021

“In 2020, due to the pandemic, we were not able to fully implement some of our initiatives. But we are not abandoning them, and we will continue to implement them this year. First of all, this is an increase in access to medical services through an increase in funding at the level of outpatient care, school medicine, inpatient care, expansion of rehabilitation, and others,” said Tokezhanov.

At the beginning of December, the Fund announced the procurement for the bulk of medical services under the guaranteed medical insurance and compulsory health insurance packages for 2021.

“As previously reported, the Fund, as a single strategic purchaser, has switched to an electronic format for purchasing medical services. For this, together with JSC Center for Electronic Finance, a web portal for the procurement of medical services was launched. The electronic format allows to ensure the transparency of the procedure, and also minimizes the risk of errors, excludes paperwork. All this simplifies the procurement procedures both for the Fund and for medical organizations,” said Tokezhanov.

The amount of the main purchase amounted to about 1.5 trillion tenge. This amount is forecast to increase by an average of 20% by the end of the year.

According to the results of the procurement for 2021, the Fund's suppliers are currently 1,373 medical organizations, of which 704 are state-owned (51%), 669 are private (49%).

Taking into account the increased needs of the population and the epidemic situation in the country, the volume of procurement of medical care has been increased. In the guaranteed volume of medical care package, this concerns medical care for patients with infectious diseases, patients with oncology, palliative services.

For the insured population, the volume of specialized medical care, including in rural areas, of expensive high-tech services has been increased. It is also planned to raise the salaries of doctors up to 30% and nurses up to 20%.

The increase in the availability of medical services in rural areas has not been ignored either; the volume of funding in this area will grow by 20%. Last year, to increase the availability of medical services in rural areas, 100 mobile medical complexes were purchased and transferred to the regions. They make it possible to provide advisory, specialized medical care, diagnostic studies to the population in remote rural districts.

It is important to note that the number of IVF services has been increased sevenfold on the instructions of President Kassym-Jomart Tokayev. If in 2020 just over 1,000 families used the chances to experience the joy of motherhood and fatherhood, then in 2021 their number will grow to 7,000.

Work is underway to improve the tariff policy. The Fund made proposals to the Ministry of Health in terms of changing the financing of the anti-tuberculosis service by bringing the tariff to the average republican level. In addition, proposals were made for the transfer of payment for services of the oncological service from a complex tariff to clinical-cost groups.

 

FOUNDATION FOR PROTECTING PATIENTS

''The Fund, as a hearing organization, stands for the protection of patients and pays the main attention to feedback through all its channels of communication," said Tokezhanov.

According to him, the bulk of requests and complaints are received through the free contact center 1406. These requests go through a three-tier processing model. At the 1st level, the operator is consulted. At the 2nd level, the appeal is transmitted by medical organizations and branches of the Fund. At the 3rd level, the quality control of the responses of medical organizations and the analysis of the reasons for calls is carried out.

The Qoldau mobile app is distributed 24/7, through which you can also send your appeal, check the status in the CSHI system. Last year, more than 22 thousand applications were received through it. Taking into account the fact that the number of users is increasing, it is planned to expand the capabilities of the application.

“Over the past year, we have received and processed about 720 thousand requests. More than 95% are consultations on participation in the compulsory health insurance system, obtaining medical care, on the coronavirus,” said Tokezhanov.

Of these appeals, about 8 thousand complaints were addressed to medical organizations that have an agreement with the Fund. Measures were taken on all complaints and answers were given to the applicants. Of the indicated number of complaints, the Fund monitored the quality and volume of medical care for 214 appeals.

Most often, the population complains about the inaccessibility of consultative and diagnostic services (lack of equipment, waiting time, failure to issue referrals, staff shortages), rude attitude and incompetence of medical workers, quality medical care, referral to paid services, refusal of hospitalization, long waiting time for KDU, etc.

They relate, first of all, to the correct organization of medical care for the population, the issues of which must be resolved locally by medical organizations and health departments.

Despite the fact that the Foundation consistently fulfills its obligations to finance medical services, as the speakers noted, various obstacles arise in the patient's path — the lack of conditions, lack of equipment, shortage of specialized specialists, long queues, refusal to provide certain services.

Systemic problems in the healthcare sector need to be solved jointly through raising the level of management in medical organizations, additional financing of infrastructure, and creating favorable working conditions for medical workers.

“As the main participant in the healthcare system, the Foundation will continue to work to jointly address these issues in 2021, the main goal is to protect the rights of patients. The main figure in health care is the patient, his interests and health,” said Tokezhanov.

According to the chair of the board of the CSHI, the goal of the Fund is a competitive and transparent market for medical service providers, which becomes a catalyst for improving the quality of medical care in the healthcare system.

Over the years, the dynamics of the private supplier market has been more than 50%. This is a huge result that has been achieved literally over the past 3 years.

“We will be faithful to our principle — fair competition, this is the only way to quality medicine,” said Tokezhanov.

Answering the question of journalists about how much money was spent from the CSHI on the fight against coronavirus, starting from the moment the state of emergency was introduced in the country until today, the chairman of the CSHI Bolat Tokezhanov noted that about 187 were spent on the fight against coronavirus infection during this period. billion tenge. Specifically, in the areas: 110 billion were allocated to allowances for workers of healthcare entities (those healthcare workers who are fighting coronavirus infection), 54 billion for medical care and services to prevent coronavirus infection, and about 20 billion tenge were allocated for PCR diagnostics services (more than 1.9 million PCR tests) and for the departure of mobile teams — 3.2 billion.

As for the information disseminated in social networks about whether recipients of social benefits in the amount of 42,500 tenge during an emergency are debtors to the Medical Insurance Fund, director of the department for work with by legal entities and individuals of NJSC Social Health Insurance Fund Zabira Orazaliyeva explained that all citizens who consider themselves to be payers of a single aggregate payment must make permanent contributions to the fund, however, as for those who paid the CAP to receive a one-time social payment of 42,500 tenge, then by the decision of the interdepartmental commission, this category of persons is exempted from paying contributions for the months in which rykh received a social payment.

“In order to obtain the right to medical assistance in the system of compulsory social health insurance, payers of the CAP must pay contributions to the fund for at least three consecutive months preceding the date of receiving medical assistance. If a citizen has identified himself as a payer of a single aggregate payment, then you should have constant payments without interruptions. If there are interruptions in payments, the person will not be recognized by the payers of the CAP in any one month,” she said.

Thus, the legislation does not allow payment of the CAP for the past period, and in order to acquire the right to medical assistance in the compulsory social health insurance system, persons for whom the payment of contributions and contributions to the fund has not been made are required to pay contributions to the fund for the unpaid period, but no more twelve months preceding the date of payment, in the amount of 5% of the minimum wage established for the current financial year by the Law on the Republican Budget, which today is 2,125 tenge per month.

According to Zabira Orazalieva, the cost of treating one patient with coronavirus infection in the case of inpatient therapy depends on the severity of the disease. Treatment of a patient with moderate severity is reimbursed in the amount of about 400 thousand tenge, with a severe degree of severity - in the amount of more than 800 thousand tenge. These amounts include the costs of laboratory, diagnostic services, receiving inpatient and rehabilitation therapy.

Regarding the amount of monthly compulsory contributions to the fund for individual entrepreneurs who do not have employees and pay the OSHI exclusively for themselves, it is important to know that the rates for them and for individuals in private practice in general are set regardless of the forms of tax reporting. These are flat rates. Today their size is 2,975 tenge, it is noteworthy that it has not changed in 2020. This applies to those individual entrepreneurs that have not been liquidated, are not on the list of those who have suspended their activities, i.e. did not submit relevant applications to the tax authorities to suspend their activities, and are also not on the list of inactive individual entrepreneurs. As for the suspended and inactive individual entrepreneurs, these categories of individual entrepreneurs pay contributions as independent payers in the amount of 5% of one minimum wage.

In general, funds in the FSMS began to accumulate from July 1, 2017. For the entire period, including Dec. 31, 2020, 798 billion tenge was received on the account of the fund, which is located in the National Bank. These funds are used to pay for medical services that are provided within the framework of the compulsory health insurance.

Speaking about self-employed citizens, who, like others, are required to make contributions to the fund, it should be noted that there are 2 definitions for them. First, the self-employed is the one who pays the CAP on his own, which in turn is divided in 4 directions in the following proportions:

  • contributions to the UAPF;
  • deductions to the State Social Insurance Fund;
  • compulsory medical insurance;
  • individual income tax.

And there is the concept of a self-payer. In the case of a UCP payer, it is important that there is payment for at least 3 consecutive months in order for him to be eligible for medical assistance in the health insurance system. As for the self-payer, regardless of whether he contributed in 2020 or not, he will not receive insurance status if the obligation to pay contributions for the last 12 months is not fulfilled.

Also, if a person is an individual entrepreneur applying the simplified taxation system, but works for another company where his employer pays for the CSHI, he is also obliged to make contributions to the Fund as an individual entrepreneur. Thus, contributions to the fund are paid from both his employer and himself as an individual entrepreneur (if the individual entrepreneur is not registered as inactive or suspended activity).


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