The Conference: "Ambulance Service in the Mandatory Medical Insurance System: Problems, Risks and Solutions"

On June 28, 2012, a scientific and practical conference dedicated to the forthcoming inclusion of ambulance service in the mandatory medical insurance system (MMI) was held at the Gaidar Institute. The conference was attended by employees of the Gaidar Institute and RANEPA, representatives of the Ministry of Health of the Russian Federation, the Federal Fund of MMI, Territorial Funds of MMI and head doctors of ambulance service stations of a number of Russian regions.


In his opening address, Vladimir Mau, Rector of the RANEPA outlined the main challenges the Russian healthcare system would face at the current stage: a switchover to individual methods of treatment, handling of information asymmetry, raising of the role of information technologies, development of international contacts and raising of the share of private funds in financing. Also, the Rector of RANEPA reminded about advantages of “a catching-up modernization” and an opportunity of being the first to switch over to a new stage of development.

Svetlana Karchevskaya, Acting Chairman of the Federal Fund of Mandatory Medical Insurance reminded about the main changes in connection with the Federal Law on Mandatory Medical Insurance in the Russian Federation coming into effect. Svetlana Karchevskaya paid a particular attention to the fact that it would be necessary to solve practical issues which arise with inclusion of ambulance service in the system of mandatory medical insurance: payment of events which are not included in the territorial MMI program, "unproductive" calls and “stand-by duty” of ambulance crews at sport and cultural events.

Within the frameworks of the conference, the following reports were heard:
  • Payment of  Ambulance Service in the Healthcare Financing System (V.S. Nazarov, Head of the Budget Federalism Department of the Gaidar Institute);
  • The Results of Work of Ambulance Service in the Kaliningrad Region (V.D. Anokhin, Executive Director of the Territorial MMI Fund of the Kaliningrad Region)
  • Ambulance Service in the MMI System (S.F. Bagnenko, Rector of the Academician  I.P. Pavlov St. Petersburg  State Medical University)
  • Ambulance Service in the MMI System (М.М. Ziganshin, Head Doctor of the Ambulance Service Station in the city of Ufa)
  • Raising of Efficiency of Expenses in Ambulance Service (Y.V. Kamkin, Head Doctor of the Ambulance Service Station in the city of Perm).
 Vladimir Nazarov referred to the ultimate goal of the reforms – a response to challenges of the changing environment. Among the key lines of development of healthcare, the following was listed: handling of information asymmetry (including by means of introduction of patients’ electronic cards), development of competition in the MMI system (creating equal conditions both for government and non-government participants, including raising of tariffs, autonomization of  state-financed healthcare institutions and abandonment of  state-financing of capital expenses; development of competition between medical insurance institutions, development of competition between the out-patient and in-patient components). As the main  scheme for inclusion of ambulance service in the mandatory medical insurance, the fund-holding mechanism was proposed. With that mechanism employed, payment of services rendered by ambulance service is carried out on the basis of the per capita quota of financial provision for outpatient care. With utilization of the above mechanism, the risk of overstating of the number of calls can be adjusted by means of the global budget method and payment in accordance with the service standard, while motivation of out-patient hospitals towards reduction of the number of calls can be ensured by distribution of payment of services rendered by ambulance service pro rata the number of calls to people assigned to them.

Viktor Anokhin and Lyudmila Siglayeva presented the experience of their region as regards inclusion of ambulance service in the per capita tariff in conditions of complete fund-holding. For the purpose of a switchover to a new system of financing, a training which included optimization of the number of the personnel and work schedule, calculation of tariffs,   development of the updated medical cards and expert cards of ambulance service was initially carried out. Utilization of fund-holding was stopped in 2012 due to requirements of the modernization program, but the outputs received pointed to a considerable saving of resources and upgrading of the quality of work of ambulance service.

Sergei Bagnenko drew the attention of those present to the fact that inclusion of ambulance service in the system of mandatory medical insurance meant a change of the source of financing, but not of the mechanism of work, and for that reason it was important to develop the new logistics of emergency medical service. Such a change is feasible under the Russian legislation which draws a distinction between pre-hospital and hospital ambulance services. Also, Sergei Bagnenko stressed the importance of development of the hospital component of ambulance service in future.

In his speech, Marat Ziganshin touched upon the most topical issues which required to be resolved before a switchover to a new system of financing, including upgrading of the expert review of the quality of ambulance service, development of the system of emergency medical service, identification of patients, lead-up of different levels of the system of ambulance service to a switchover, accounting of standards in calculation of the updated tariffs and payment of “excess” calls.
Yevgeni Kamkin dedicated his report to outsourcing experience in ambulance service in the city of Perm. Such experience permitted both to reduce transportation costs and renew largely the car fleet. In the follow-up discussion, possible risks of a switchover to outsourcing and the ways of overcoming such risks were specified.  
At the end of the conference, a number of representatives of territorial funds presented a brief account of their experience related to a softer switchover to fund-holding and difficulties associated with it.

The results of the conference were summed up by Andrei Yurin, Deputy Minister of Health. He stressed the importance of establishment of an integrated system of healthcare organization where a key component should be a link between the out-patient segment, in-patient segment and ambulance service. Andrei Yurin noted that regional experience in reforms and innovations in healthcare, including outsourcing were important for development of the healthcare system in general. As regards inclusion of ambulance service in the system of mandatory medical insurance, A. Yurin pointed out that at present authorities of constituent entities of the Russian Federation had all the resources to study the main parameters of a change in the scheme of financing, and regions should handle actively that issue using the experience of their colleagues fr om other regions wh ere ambulance service had already been included in the system of mandatory medical insurance. To begin that work, no regulatory documents on the part of the federal center were required.

Presentation to speeches: