When the active introduction of telemedicine services began in Russia a few years ago, many experts believed that this would increase the availability of medical care, and most importantly, make it cheaper. And how does it work in practice? Igor Shaderkin, Ph.D., head of the laboratory of e-health at the Institute of Digital Medicine of the First Moscow State Medical University named after Sechenov of the Ministry of Health of Russia (Sechenov University), talks about this .
Two years ago, at one of the meetings of the GlobalCIO|DigitalExperts community, I talked about the applied aspects of the use of telemedicine, in particular, remote monitoring, Internet medical things. There was a lot of enthusiasm, a desire to move forward.
We can recall the main arguments in support of the law on telemedicine (TM):
TM will make medical care available in remote regions.
TM and TM technologies will reduce the economic costs of medical care.
The state will become the main player in the TM-services market.
However, in our material world, much depends on the economic background. In order for a direction to develop, it is necessary that there are interested parties who financially support the development of technology. And now we have come up against economic issues that make it impossible to move on.
When the pandemic began, it was expected that this would give a good boost to the development of telemedicine services. From March to August 2020, many public health facilities were redesigned to provide care to patients with COVID-19. At the same time, private clinics were not closed, but the number of patients decreased significantly. During lockdown, private clinics began to offer remote TM consultations to their patients in various formats: WhatsApp, Viber, Telegram, phone calls, specialized TM platforms.
Unfortunately, the first experience of using TM in private practice has shown its economic inefficiency. There has also been no jump in the introduction of remote technologies in public health facilities, especially in the “patient-doctor” direction.
Why is this happening? This is due, first of all, to the financial model of the Russian healthcare system. Much of it was inherited from the socialist past.
In Russia, there are 5 economic models of healthcare financing at the same time.
Compulsory health insurance (CHI). It accounts for 56.8% of the turnover of the medical services market. In fact, compulsory medical insurance is a veiled budget system of health care financing inherited from the USSR, which is not a classic insurance model and has been repeatedly criticized.
Budget target financing. 15.8% of turnover (part of high-tech medical care, quotas, targeted subsidies, etc.). Practically perform the same tasks with OMS. In the first and second models, the beneficiary is the state, whose financial interests are rather vague, influenced by the opinions of specific decision-makers, and, by and large, should be aimed not at extracting profit from health care, but at maximizing cost savings while fulfilling their social obligations to the public.
Private health care system (including paid services based on health facilities with state ownership). It makes up 15.8% of the turnover of the medical services market, including commercial services in public health facilities, Pocket Pay. The beneficiary is the specific owner of the clinic or other organization providing medical services.
Voluntary medical insurance (VMI). This model accounts for 4.9% of turnover. VHI is a real insurance model, but in the Russian Federation it has not been finally formed due to the lack of a legislative framework and insufficient awareness of the population, as well as the stereotype of medical services consumption that has developed over the years of the USSR.
The shadow sector of the medical services market. It occupies 6.7% of the value of the country's medical market. The beneficiary is a doctor or other medical professional providing medical care. In this model, it is worth noting a very short, but illegal, path of financial resources with minimal costs: how much the patient spent on payment, the doctor received so much.
Depending on the specific financial model, the approach to the development of telemedicine services also differs. Thus, the economic beneficiary of the compulsory medical insurance system and the budgetary system is the state, which is interested in fulfilling its social obligations prescribed in the Constitution, with minimal expenditure of funds. Therefore, the state, represented by executive authorities - the Ministry of Health of the Russian Federation, the regional Ministry of Health and the Departments of Health - sees in the TM system a tool for saving these funds, which is reflected in decision-making on telemedicine. Within the framework of this model, telemedicine has been developed within the established National Medical Research Centers (NMRC) according to profiles, where separate funding is provided, tied to staff rates, and reporting on the number of doctor-doctor consultations has been introduced. At the same time, by and large, the doctor-doctor consultation is a bit of an artificial topic. There is no super-need for a doctor to sit and think, “I need to urgently consult another doctor,” no. The situation is also complicated by a lack of funding, a shortage of personnel, and a lack of tariffs and KPIs for telemedicine. Therefore, we can say that there is practically no telemedicine in CHI and the budgetary system.
In private medicine, the situation is different: clinics are interested in making the average bill as high as possible. At the same time, the consultation itself takes only 30-40% of the average bill. When a patient comes to the clinic, he can be sent for an examination, additional services can be provided, which increases the average bill. This cannot be done within the framework of telemedicine. When using telemedicine, the average bill is 2-3 times lower (up to 5 times), since the patient usually pays only for a doctor's consultation. At the same time, telemedicine reception takes no less time than usual, and sometimes even more. Quite often, patients have to explain the technical details, where to press which button, so that it can be heard or seen. The doctor's risk is higher, as there is often not enough medical data to make a clinical decision, and the diagnosis and prescribing of drugs,
All this leads to the fact that telemedicine is most often used by private clinics to attract patients to the clinic for face-to-face appointments (the so-called lead generation) or as a competitive advantage over other clinics.
The only promising and economically justified direction of telemedicine in private medicine can be remote monitoring of the condition of patients. It is possible to form long-term monitoring programs that the patient buys "immediately" and "in parts". This allows you to increase the average bill of the patient by selling additional services, keep the patient as a client of the clinic, and increase patient loyalty.
The situation with telemedicine in VHI is also very difficult. On the one hand, telemedicine for VHI can be cost-effective, since the task of the insurance system is to reduce the cost of medical care and at the same time maintain a pool of loyal insured audience. However, as mentioned above, the turnover of VHI in Russia is very small. In addition, VHI does not include care for chronically ill patients. This is a big minus of this system.
The only sector where telemedicine is developing very actively is shadow medicine. Legislative restrictions on the use of telemedicine technologies (consultation from an office where there is a license, a ban on making a diagnosis, the use of special services for TM-consultation, informed consent, an identification and authentication system, etc.) are only a formality for doctors, many of them are not aware of such nuances. know and don't care. In fact, such medical services have no prime cost or it is minimal due to the fact that these services are provided at the bases where the health facility, where the doctor or other medical employee works, has already “paid for everything”. The doctor at the same time believes that he is driven by the "noble" goals of helping the patient in all ways available for this.
Telemedicine technologies at the stage of formation, implementation, development and further functioning require funding.
It is not justified to expect a reduction in healthcare costs from the introduction of TM technologies.
In the private healthcare system, TM technologies in the format of TM consultations are not cost-effective. Representatives of private clinics use TM mainly as an element of lead generation. From the point of view of private clinics, remote monitoring technologies that are embedded in patient management programs are economically justified.
It seems economically feasible to use TM in all its variants, including TM-consulting, in the VMI system. However, due to the low prevalence of VMI in Russia, one should not expect a significant increase in TM due to this sector.
The shadow sector is still the leader in the use of telemedicine in Russia.
Material taken from EverCare.ru