Structure of medical insurance, The GP's activity in conditions of medical insurance

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Theme 2. The structure of medical insurance, the GP’s activity in conditions
of medical insurance.
1. What does the medical insurance mean? What are the subject and object
of medical insurance? List and briefly characterize the subjects of
insurance. What does the insurance policy mean?
Medical insurance is a kind of personal insurance, the form of people interests
social protection in the system of health care, providing the guarantee of gaining
the medical aid and compensation the expenses on buying medical supplies in a
case of contingency loss for amount of savings.
Contingency loss is an episode of health aggravation.
Insured risk is a case of giving the medical aid.
The object of insurance is an insured risk which is connected with the
expenses on giving the medical aid in a case of contingency.
The subject of insurance: insured (citizens, employees), insurants (employers,
authorities, insurer (medical insurance company), medical and preventive
establishments, in some countries-the state funds of obligatory medical insurance.
1. The insurants are people who pay for insurance service. For example in
Russia the insurant of an employee is an employer. He must pay a single
social tax, the part of this tax comes in obligatory medical insurance of
employees. So, the insurants are the enterprises, the establishments,
organizations, and, also, businessmen who use the hired labour. In the
system of obligatory medical insurance, the insurants are authorities (for
idles), enterprises, establishments and organizations (for working people),
and also businessmen and representatives of free jobs. In the system of
voluntary insurance, the insurants can be people who have legal ability.
2. The insurers are medical insurance organizations. These are companies which
organize the medical insurance and know everything about saving and spending
of insurance payment. The insurer must have the license. The insurance medical
organization exercises such functions: 1) settles with and covers expenses of
medical service in medical and preventative establishments; 2) executes the
direct control of volume and quality of medical service; 3) asserts its clients
rights and interests; 3) gives the employees insurance policy and registers them
3. The insured are the employees. They are the direct consumers of medical
service. The insured should be as the citizens as foreigners or stateless working
on a labour contract .
The employers should make all employees irrespectively of sex, age,
citizenship, registration of a passport or the right of permanent residence
have the insurance policy.
The citizen who works on contract terms or another contract in accordance
to the civic rights is insured if only this clause is provided for terms of the
treaty.
4. Medical establishments such as inpatient and outpatient hospitals or other
medical establishments which provide medical service or serve the employees.

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5. Funds of OMI are the state noncommercial financial and credit establishments
which save the means for obligatory medical insurance of employees. The
means of these funds are the state property. These organizations carry out the
financing in the system of OMI and control the volume and quality of medical
service.
The insurance policy is a treaty of medical insurance which represents the
agreement between the insurant and the insure (the medical insurance
organization). Тhe insurant obliges to pay the insurance payment. The insurer
obliges to organize and finance the allocation of medical aid of certain kind and
quality (or other services in response to the programs of obligatory or voluntary
medical insurance).
Each insured citizen gets insurance policy.
The volume of insurance payment is fixed
 for obligatory medical insurance as a rate of payment which covers the
expenses of performance of the obligatory medical insurance program and
provides a profitable activity of medical insurance organization (insurance
company).
 for voluntary medical insurance by mutual agreement.
Medical insurance allows to guarantee a citizen gratuitous volume of medical
services in a case of a contingency loss (health abnormalities) if there is a treaty
with the insurance company. The last one covers the expenses of medical aid since
the moment of the first payment which is made by a person into the corresponding
fund.
2. What is the difference between the obligatory and voluntary medical
insurance? List the volume and kinds of the medical aid which is given by
obligatory medical insurance.
The obligatory medical insurance is a special variety of the state social
insurance it guarantees the equal opportunities to give the unlimited circle of
people the minimum volume of medical aid, for example all employed people get
OMI policy by an employer and all idles get one by agency body.
The volume of OMI which is given free of charge:
• the emergency medical aid in cases which threaten the citizen’s or his
associates’ life or health , which are caused by sudden exacerbation of disease,
exacerbation of chronic disease, accidents, injury, poisoning, abnormal
pregnancy and childbirth delivery;
• all the volume of the first medical and sanitary aid which is given by the
doctors of primary link (GP, district therapeutists, pediatrists) including the
preventive measures, and treatment as at the outpatient hospitals (GP’s
outpatient medical room) as at home, and also at the day ward and inpatient
hospital;
• in patient aid:

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 in a case of acute disease and exacerbation of chronic disease , poisoning,
injury which requires around the clock intensive care , supervision and
isolation by epidemiological indications;
 in a case of abnormal pregnancy, childbirth delivery and abortion,
 in a case of planning hospitalization with a purpose of treatment and
rehabilitation which requires around the clock supervision ,including the
children’s and specialized sanatorium;
 in a case of planning hospitalization with the purpose of treatment and
rehabilitation which doesn’t need around the clock medical supervision at
inpatient hospitals(departments, room ) .
3. What are the peculiarities and kinds of voluntary medical insurance? What
volume of medical aid is stipulated by it?
The voluntary medical insurance is an auxiliary program of medical aid
which is established by OMI.VMI is carried out in amount of payments of citizens
or employers.Peculiarities:
 VMI doesn’t insure health it insures expenses incurred during the time of
treatment, the last ones are compensated at once in accordance to the time
stage of medical intervention (pharmacology, diagnostics, inpatient hospital)
or in accordance to the kinds of medical aid (stomatology, gynecology,
cosmetology, death case) or on compensation shares, on the compensation
which is limited by the definite sum.
 VMI can be divided into individual (taking into consideration the
complication of a certain disease of a certain person) and collective ( taking
into consideration the risk of occurrence of certain disease in a certain group
of people)
 As a rule , the VMI programs are out of standard ( if it is not the corporate
insurance of the staff) they are created individually and can flexible in
response to somebody’s demands and requirements
 The tariffs (insurance payment) of VMI depend the list of risks, the level
of program, the district of service, the state of health of insured are defined,
as a rule, after medical check-up.
 The treaty is considered as valid since the moment when the first payment
has been paid, if there isn’t another clause of treaty.
 The medical insurance of people who go abroad (travelers) is a voluntary
kind of insurance. However, having insurance policy is an obligatory for
getting a visa to some countries (for example, the countries of the Schengen
agreement). As a rule, it includes: medical service (the treatment of a sudden
acute disease or injury), medical and transport services (the delivery of
patients to the hospital, taking from the one hospital to another, and, when it
is necessary , the evacuation of the patients to the country of his residing
with accompaniment), the repatriation of remains.
The voluntary medical insurance (VMI) includes:

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 given in inpatient hospitals medical aid- consultations, examinations,
surgical and therapeutic treatment, the expanses incurred during the time in
the hospital.
 given in outpatient hospitals medical aid –consultation, calling for a doctor
to the place of dwelling, sick leaves, diagnostics.
 providing the delivery of medical supplies and covering the expenses of it.
 the emergency medical aid-departure of an ambulance, medical check-up,
the delivery of medical supplies, the transport delivery.
 stomatological aid –examination and consultation, therapeutic and surgical
treatment, x-ray, anesthesia.
4. What is the order of voluntary medical insurance?
On a VMI contract example:
• an insurance treaty is concluded for a period of time within one year.
• To conclude an insurance treaty the insurant puts in a written application for
insurer
• Insurance treaties are concluded with individual persons , after the last ones
give the written declaration of the state of their health
• The treaty is declared valid since the moment of making the first payment.
• The place where the insurance treaty is valid is a country where and on
which legislative basis it has been concluded.
• The insurance treaty is terminated by mutual agreement and also in a case;
of its termination; when all insurants duties have been discharged entirely;
the death of insured.
5. What is the economical essence of medical insurance? What are its source of
financing?
1. The medical insurance is a system of public health care which basis consists of
financing from the special insurance funds. Moreover, the health care is financed
upwards
2. The insurance funds are formed at the expense of different sources of financing:
the state budgetary means; the payments of enterprises, businessmen and
employees.
3. As for obligatory insurance it is fixed the status of territorial accumulation of
means and resources in the insurance funds, the conditions and order of financing
the disease –preventative service. The territorial funds of obligatory medical
insurance as independent non-commercial structure become the central financial
organization. They bear the juridical and financial relations to either the citizens
(individual persons) or the enterprises, institutions or organizations (juridical
persons, insurants), insurance companies and also the objects of health care.

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Moreover, the territorial funds control the volume and quality of the medical aid
delivery. The territorial funds transfer a part of means into the state or federal fund
of OMI.
4. All economic organs, which are located in the area take part, in forming of the
territorial fund and local authorities are the insurants of living in this area idle
people (so, the medical aid of the idle people is financed at the expense of a local
budget.
5. The medical insurance system provides the administrative and economical
independence of disease-preventative establishments, entailing no deficit of their
financing and providing social guarantees when it serves the socially unprotected
people.
6. The medical insurance encourages saving all necessary means and forming the
system of requiring payment medicine, so, it is the effective source of health care
financing. The principle of medical insurance is “A healthy person pays for a
sick one, a rich person pays for a poor one”.
So, the income of medical insurance consists of following sources:
1) The revenue returns of state or federal OMI and territorial funds of OMI,
means of voluntary medical insurance and budgetary allocations.
2) In addition, the revenue returns of state and federal funds of OMI consist of
insurance fee of economical subjects, payments of territorial funds of OMI for
realization the mutual programs of OMI, income of temporary free means ( at
the expenses of state securities, bank deposits, securities of joint stock
companies, currency values in response to exchange adjusted control in
conditions of profitability and repayment, and other receipts.
3) The territorial OMI funds income consists of parts of insurance fee of
economical subjects , budgetary allocations for OMI pf idle people , income of
temporary free money, amount recovered as a setback, and another sources
which aren’t forbidden by active legislation.
4) The VMI income consists of next receipts: insurance premium in accordance to
an insurance treaty, temporary free finances which are invested in securities and
other receipts.
5) The budgetary funds consist of local budgetary allocations for OMI of idle
people, federal or state budgetary allocations for republic (regional) programs
of OMI, and also they can include another expenses valid for one occasion.
6. What is the machinery of control the quality of medical aid delivery using
different kinds of insurance? What are the functions of medical insurance
companies in control of volume and quality of medical aid delivery?
Taking control of volume and quality of medical aid delivery which is given in
accordance to OMI is a duty of medical insurance companies and directed to
ensuring citizens’ rights to get medical aid (medical service) of proper volume and
quality in accordance to OMI programs and OMI treaty of medical aid delivery

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(disease-preventative service) and also guarantee efficiency and rationality of using
OMI finances.
Taking control of volume and quality of the medical aid delivery OMI is allowed
to fulfill:
1. organizing and taking control on volume, terms and making an examination as
to quality of medical and medicament aid which has been given the insured by
medical companies which have contractual relations with OMI.
2. control on personified invoices of medical companies which are liable to pay in
conformity with all clauses of treaties in force on the allocation of disease-
preventative service in accordance to the OMI (treaty), a treaty between MIC
and medical company ,tariff agreement between interested parties, ways and
terms of payment for medical aid.
3. organizing and making an examination as to quality of medical aid in
connection with complaints which have been made by insured, their legal
representatives or insurants about quality of medical aid.
4. the analysis of results of examination as to quality of medical aid which is
given by working in a system of OMI medical companies including the
indicators of their activities.
5. brining in an action against medical companies in a case of abuse of insured
people rights compensation for damages, a possibility of a partial or complete
non-payment for services in a case of the breach of a treaty ,sanctions.
6. study insured satisfaction with volume, availability and quality of medical aid.
7. general conclusion and the analysis of results of volume control and an
examination as to quality of medical aid, showing the Health Care authorities
results ,conclusions and suggestions for using them in a system of medical aid
quality management given by medical companies;
8. giving the information to the insured citizens about their rights to get the
medical aid of guaranteed volume and quality in a system of OMI;
9. representation of citizens’ interests in administrative and judicial bodies.
With a purpose to organize the control of volume and quality of medical aid
the treaty which is concluded between medical company and MIC must foresee
that during the examination medical company shows the expert all necessary
documents including the primary medical information (outpatient’s card,
medical in-patient card , prenatal card, the history of child’s development, a
book of requiring payment medical services etc) and results of examination
which is made by medical company and Health Care authority.
7. What methods are provided by control of volume and quality of medical aid
by putting OMI into effect?
Control of volume and quality of medical aid by putting OMI into effect
provides:
-medical and economical control;
-medical and economical examination as to contingency;

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-an examination as to quality of medical aid.
 Taking medical and economical control they study the cases of medical aid
delivery in accordance the registry of bills for medical service which has been
given the citizens insured by OMI with a purpose
1) to control how correct the bills are filled in accordance to the active order of
information exchange in a system of OMI;
2) to identify which MIC the insured people belong to;
3) to check correctness of the coding of medical services and their
corresponding to the license;
4) to control validity of applications of tariffs for services ,their settling with in
conformity with current tariff agreement between interest parties , ways
and terms of payment for medical aid and an active treaty fordisease-
preventative service.
8. What is the meaning of medical and economical examination?
 During the medical and economic examination it is carried out the analysis
of trustworthiness of volumes of medical aid which are declared to be paid:
1) They observe the cases of medical aid delivery with a purpose to prove
validity of volumes of medical services which are liable to pay , their
conformity with records in the primary medical documents (outpatient’s
medical card, in-patient’s medical , prenatal card’ the history of child’s
development) and other record and report medical documents.
2) Medical and economic examination is carried out by experts who are
organizers of MIC by analysis of primary medical and record and report
documents (statistical coupons, registers etc) of medical companies as for
contingency which has been chosen during medical and economic control.
The results of medical and economic control and medic and economic examination
are formed by statements and can be reasons for organizing and making an
examination as to quality of medical aid.
9.What is the meaning of examination as to quality of medical aid in
conditions of medical insurance? What kinds of quality examination exist?
When are they carried out?
 The examination of quality of medical aid is carried out:
1) With a purpose to clear up the defects and mistakes which has been made in the
process of medical aid delivery with description of their real and possible
consequences and clearing up the reasons of their occurrence by making resolution
of the experts about proper or improper quality of medical aid delivery;
2) On te staff or free lances experts of quality of medical aid;
3) It can be carried out as:

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- having a special purpose examination as to quality of individual cases of
medical aid delivery (it is carried out in a case of lodging written complaints
from an insured person, his legal representative or an insurant about quality of
medical aid by medical company; by the requirements of law-enforcement
agencies; the necessity of acknowledgement of the receipt of medical and
medicament aid of proper volume and quality in the cases which have been chosen
during medical and economic control, infections and exacerbations as a result of
treatment; in a case of lethal outcome during the process of treatment; the first
appliance of children and people of the able-bodied age to be registered as a
disable person; in a case of repeated hospitalization caused by the same disease
within the month( quarter); illnesses (or temporary disablement with prolonged or
shorten terms of treatment),
-planned (subject matter) examination of quality, which is carried out in a
volume in response to the clause of the treaty with a purpose to estimate the
volume and quality of medical aid which is given to the private groups of citizens
according to the kind of medical aid delivery, nosologic form, age, social status,
level of medical company etc. The subject matter examinations are recommended
to be made in a planned order as to the whole complex of cases , which have been
chosen in accordance to thematic subjects or methods of occasional extract in any
medical company, as a rule, no less often than once within a year.
- making a purposeful and subject matter expert examination with agreement
between medical company administration and expert of quality of medical aid they
can make doctors’ round of medical subdivisions with a purpose to examine the
patients and control of the conditions of medical aid delivery (prospective
control)
 it can be carried out a visual kind of medical examination as to quality of
medical aid during the process of treatment (when the insured is in the
hospital0, it can be initiated by an insured person.
 with the purpose to control objectivity of resolution of the expert there can be
carried out repeated examination, which is made in a same way but by
another specialist.
2. What defects of medical aid delivery can be cleared up by the control of its
quality?
 as a result of control of volume and quality of medical aid in response to OMI
there can be cleared up actions or inactions of medical staff (failures of
medical aid delivery) which are:
1. Non- compliance or improper compliance of regulations of a disease-preventive
service in accordance to OMI. So, inconformity with medical aid and requirements
of OMI:

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- non-compliance, tardy or improper compliance of necessary for the patient
diagnostics, treatment, preventative measures (examinations, consultations,
operation, procedures, manipulations, transfusions, prescription of medicine etc.);
- unproved (without reasons or in a case of contra-indication) diagnostic, treatment,
preventative measures, rehabilitation which have been lead to diagnostic mistake ,
mistaken treatment, worthiness of patient’s state, exacerbation of disease or
prolongation of treatment; irrational usage of sources which belong to the medical
establishment;
- inconformity of above mentioned actions of medical aid with its purposes that
resulted harm for insured patient’s health and life.
2. Making out a bill for a service which hasn’t been delivered (a case of medical
aid) or repeated including of the same service into the bill . Making out a bill for a
service which isn’t provided by OMI program or a license of medical company,
and also for actions aren’t due to pay in adopted order of payment .
3. Disturbance in work of medical establishment which has caused insured patient
harm such as injury, burns and exacerbation happened and caused more expenses
for medical service during the time of treatment in the medical establishment in
medical staff fault.
- the infection which is connected with wrong actions of medical staff and receivd
inside the hospital;
- exacerbation after medical manipulations, measures.
11. What is the structure of insurance policy of the primary medical and
sanitary aid ?
As a rule, the primary medical and sanitary aid is given in the frame of OMI.
Otherwise, the OMI treaty always includes a clause of the first medical and
sanitary aid delivery. In this case the structure of the policy is usual. It contains:
 the standard information for insured person about policy: who it has been
given by and how it should be used etc.
 there is a serial number, name and surname of the insured person, his
working place, the number of OMI certificate, place of residence;
 it is named the exact date of the validity of the insurance policy in
accordance to; OMI program;
 it is added the program of medical service (which includes first medical and
sanitary aid) and list of medical establishments where these services can be
provided;
 the policy is signed by insured , by the manager of the insurance company,
the representative of local authorities, assurance company.

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