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In pursuance of clause 2 of the Resolution of the Government of the Russian Federation of December 19, 2015 N 1382 "About the Program of State Guarantees of Free Medical Aid to Citizens for 2016" (hereinafter referred to as the Program) the Ministry of Health of the Russian Federation, together with the Federal Obligatory Medical Insurance Fund, sends for use in work "Methodical recommendations on how to pay for medical care at the expense of compulsory medical insurance"developed by the working group of the Ministry of Health of the Russian Federation on the preparation of guidelines for the implementation of methods of payment for medical care under the program of state guarantees of free medical care to citizens (approved by order of the Ministry of Health of the Russian Federation dated December 15, 2015 N 931) instead "Methodical recommendations on how to pay for medical care at the expense of compulsory medical insurance"sent to the constituent entities of the Russian Federation by letter of the Ministry of Health of the Russian Federation of December 15, 2014 N 11-9 / 10 / 2-9454.

Application: 79 l. in 1 copy.

Methodical recommendations on how to pay for medical care at the expense of compulsory medical insurance

Approved by the decision of the working group of the Ministry of Health of the Russian Federation on the preparation of guidelines for the implementation of methods of payment for medical care under the program of state guarantees of free medical care to citizens (meeting minutes dated December 18, 2015 N 1)

I. Methods of payment for medical care in inpatient and day hospital conditions based on groups of diseases, including clinical and statistical groups (CSG) and clinical profile groups (CNG)

1. Basic concepts and terms

For the purpose of implementing these recommendations, the following basic concepts and terms are established.

Case of hospitalization – a case of inpatient and (or) day hospital care, within which one hospital inpatient card is maintained, which is a unit of the volume of medical care as part of the territorial program of compulsory health insurance;

Clinical-statistical group of diseases (CSG) – a group of diseases related to the same medical care profile and similar in the methods used to diagnose and treat patients and the average resource intensity (cost, cost structure and set of resources used);

Clinical profile group (CNG) – a group of CAGs and (or) individual diseases united by one profile of medical care;

Payment for medical care under the CLL (CNG) – payment for medical care at a rate calculated on the basis of the established: base rate, cost-effectiveness ratio and correction factors;

The base rate is the average amount of financial support for medical care per patient treated, determined on the basis of the standards for the volume of medical care and the standards for financial costs per unit of medical care established by the territorial program of state guarantees, taking into account other parameters stipulated by these recommendations (average cost completed case of treatment);

Relative cost-effectiveness ratio – a cost-effectiveness ratio of a clinical-statistical group of diseases or a clinical profile group of diseases established by these recommendations, reflecting the ratio of its cost-effectiveness to the base rate;

Differentiation Coefficient – a coefficient established at the federal level, reflecting a higher level of wages and an index of budget expenditures for certain territories, used in calculations if several differentiation coefficients are established for the territory of a constituent entity of the Russian Federation;

Correction factors – established at the territorial level: managerial coefficient, coefficient of the level (sublevel) of medical care, coefficient of patient treatment;

The managerial coefficient is a coefficient established at the territorial level that allows adjusting the tariff of a clinical-statistical group in order to manage the hospitalization structure and (or) take into account regional specifics of providing medical care for a specific clinical-statistical group;

The coefficient of the level of medical care – a coefficient established at the territorial level, which allows to take into account the differences in the amount of expenses depending on the level of medical care provided in inpatient and day hospital conditions;

The ratio of the sub-level of medical care – a coefficient established at the territorial level, which allows to take into account differences in the size of expenses of medical organizations belonging to the same level of medical care, due to objective reasons and calculated in accordance with established rules;

Patient treatment complexity factor — a coefficient established at a territorial level, established in individual cases due to the complexity of patient treatment, and taking into account the higher level of costs for providing medical care;

A subgroup in the clinical and statistical group of diseases is a group of diseases that was selected as part of the clinical and statistical group of diseases, taking into account additional classification criteria, including those established in the subject of the Russian Federation, for which a relative expenditure rate is set that differs from the relative expenditure statistical group, taking into account the established rules for the allocation and use of subgroups;

Payment for medical care for a service is an integral component of payment, which is used in addition to payment for a CGC in the framework of one hospitalization case strictly in accordance with the list of services established by these recommendations.

2. Introduction

The development of the Russian model of clinical and statistical disease groups began in 2012, when an analysis of the costs of medical organizations for the provision of inpatient medical care was carried out in three regions of the Russian Federation with the involvement of World Bank specialists. To develop recommendations, a working group was created by Order No. 412 of the Ministry of Health of the Russian Federation dated October 12, 2012, which included representatives of the Ministry of Health of the Russian Federation, health authorities of the constituent entities of the Russian Federation, the Federal Fund for Mandatory Health Insurance, territorial funds for mandatory health insurance, federal and regional health care institutions, medical insurance organizations. The working group proposed a method for determining the cost of treatment in a hospital using clinical and statistical (hereinafter also referred to as CSG) and clinical profile groups (hereinafter also referred to as CNG), additional correction factors – the level of medical care, patient obstruction complexity and the management coefficient.

The result of this work was the first Russian classification of the CGR, developed with the participation of the expert community and sent to the constituent entities of the Russian Federation by an information letter of the Ministry of Health of the Russian Federation of December 20, 2012 N 14-6 / 10 / 2-5305. The treatment case was assigned to a specific HSC within the model based on two classification criteria: diagnosis code in accordance with the international classification of diseases of the tenth revision (hereinafter ICD 10) and surgical intervention code in accordance with the Nomenclature of Medical Services, approved by order of the Ministry of Health and Social Development Of the Russian Federation dated December 27, 2011 N 1664n (hereinafter – the Nomenclature). The main results of the implementation of this model of KSG in a number of constituent entities of the Russian Federation in 2013 were a reduction in the average patient’s stay on a bed, as well as improved accounting of statistical information, including coding of surgical operations in accordance with the Nomenclature.

The increase in 2013 of the number of regions that paid for inpatient medical care based on the CGC allowed centrally aggregating a large amount of information about the medical care provided, which became the basis for the refinement and improvement of the first Russian CGC model. An updated version of the CRC was sent to the constituent entities of the Russian Federation by an information letter from the Ministry of Health of the Russian Federation dated November 11, 2013 N 66-0 / 10 / 2-8405 as part of the Recommendations on how to pay for specialized medical care in inpatient conditions and in day hospitals based on groups of diseases , including KSG and KPG, at the expense of the compulsory health insurance system and approved by the order of the Federal Fund for Mandatory Medical Insurance dated November 14, 2013 N 229. Updated mod l DRG included new classification criteria for assigning cases to the treatment of specific DRGs, such as: age, sex, diagnoses and combination operations. The relative cost-intensity ratios and the structure of disease groups were also revised.

The number of constituent entities of the Russian Federation that introduced the method of payment for inpatient care based on the CGC in 2014 increased to 43. At that, 8 pilot regions were selected (one in each federal district), on the basis of which work was carried out to further improve the Russian CGC model, including by re-analyzing the costs of medical organizations for the provision of inpatient medical care. In the pilot regions, the mechanisms of subgroup formation were tested within the framework of the standard list of CAGs, the allocation of subgroups of hospitals in terms of the levels of medical care and the issues arising in the process of transition to the system of payment of medical care based on CGCs from other funding methods.

Preliminary results of applying the second CSG model to pay for inpatient medical care indicate its effectiveness, first of all, in terms of increasing the intensity of hospital work – reducing the average length of stay of the patient on the bed and the corresponding increase in the number of beds. Also, the differentiated payment of medical care contributes to the increase in the share of complex cases of treatment in the structure of medical care, including the share of surgical interventions. Finally, the statistical information generated in the framework of the CGC system can serve as a basis for making management decisions in the distribution of medical care, as well as evaluating the activities of relevant departments of medical organizations and organizations as a whole.

The third model of KSG was sent to the regions by the information letter of the Ministry of Health of the Russian Federation of December 15, 2014 N 11-9 / 10 / 2-9454 "On the methods of payment for medical care provided under the program of state guarantees of free medical care to citizens".

The model was developed using the classification criteria and economic parameters used in the previous model, but contained a number of methodological changes. Thus, the allowable ranges and rules for the application of correction factors were defined, the regulation for distinguishing subgroups in the structure of the standard list of CGS was introduced, the criteria for determining and financing the cases of ultra-short and extra-long stays were defined. Also, combinations of ICD-10 codes and Nomenclature codes were defined, in which case was assigned to the KSG according to the diagnosis code, even in the case of a higher cost ratio of the surgical group. The list of diagnostic studies and treatment methods (thrombolysis) affecting the attribution of a case of treatment to a specific CSG was expanded, and a wider selection of children’s groups of diseases was carried out. The total number of groups was 258.

The third model of CGC, including partially or in combination with payment for CNG, was applied in 63 subjects of the Russian Federation, which allows to conclude that the system of CGCs is widespread in the regions and can be implemented as a single payment system for inpatient medical care in all subjects of the Russian Federation .

In 2015, in the regions that introduced the CRG, positive changes continued in the main indicators of hospital activities achieved in previous years. It is particularly necessary to note a significant reduction in the differentiation of tariffs for payment for medical care in treating the same disease, performing the same surgical operations and / or other special treatment methods used and complex medical technologies within the level of care, which is evidence of increased equity of the financing system.

These recommendations on methods of payment for specialized medical care in inpatient and day hospital conditions based on groups of diseases, including clinical and statistical groups (CSG) and clinical profile groups (CNG), are developed with due account of the experience of the subjects of the Russian Federation using the third model of the CGC in 2015.

The main differences of the new CGC model from the previous version are the introduction of the CGC to pay for medical care on the profile "Medical rehabilitation", a significant increase in the number of clinico-statistical groups to pay for medical care provided to the child population, approval of a separate list of CGCs to finance medical care provided in day hospital conditions, optimization of approaches to the application of correction factors, taking into account ensuring further reduction in the differentiation of tariffs for paying medical care, improving the formation of a three-tier system of medical care, the development of hospital-substituting technologies, increasing The availability of hospital care, involving the use of sophisticated medical technologies.

3. The main approaches to the payment of medical care for clinical and statistical groups (CSG) and clinical profile groups (CNG) diseases

When paying for medical care rendered in inpatient and day hospital conditions, by decree of the Government of the Russian Federation of December 19, 2015 N 1382 "About the Program of State Guarantees of Free Medical Aid to Citizens for 2016" (hereinafter referred to as the Program) the method of payment for the completed case of treatment of the disease is included, which is included in the corresponding group of diseases (including clinical and statistical groups of diseases).

Payment for the expense of the compulsory medical insurance of medical care rendered in inpatient conditions and in the conditions of a day hospital, under the GSC (CNG), is carried out in all insurance cases, except for:

– diseases in the treatment of which the types and methods of medical care are applied according to the list of types of high-tech medical care included in the basic program of compulsory health insurance, for which the Program establishes standards for financial expenditures per unit of medical care;

– socially significant diseases (sexually transmitted diseases, tuberculosis, HIV infection and acquired immunodeficiency syndrome, mental disorders and behavioral disorders), if financed under the territorial program of compulsory health insurance;

– diseases for which treatment types and methods of medical care are applied according to the list of types of high-tech medical care that are not included in the basic compulsory health insurance program for which the Program has established the average cost of medical care in the case of their financing under the territorial compulsory health insurance program;

– dialysis procedures involving various methods (payment is for a service).

When planning funds intended for financial support of medical care rendered in inpatient conditions (including day care) and paid by the CGC, of ​​the total amount of funds calculated on the basis of the standards of the territorial program of state guarantees of free medical care to citizens aid, means are excluded:

– intended for interterritorial settlements;

– intended to pay for medical care outside the KSG or CNG system (in cases that are exceptions);

– directed to the formation of a rationed insurance reserve of the territorial compulsory health insurance fund in terms of exceeding the established amount of funds intended for paying for medical care due to an increase in tariffs for paying for medical care as a result of exceeding the average correction factor compared to the planned one.

The model of financial support for medical care rendered in inpatient and day hospital conditions is based on combining diseases into groups (CGC or CNG) and is built on uniform principles regardless of the conditions of medical care.

The subject of the Russian Federation independently determines the method of payment for specialized medical care in a hospital environment:

on the basis of CNG, combining diseases;

on the basis of KSG, combining the disease.

This does not exclude the possibility of combining the use of these methods of payment for various diseases. All CSGs are distributed among the profiles of medical care – with some of the diagnoses, surgeries and other medical technologies can be used in adjacent profiles, and some are universal for use in several profiles. When paying for medical care in such cases, the assignment of KSG to a specific CNG is not taken into account. For example, when providing medical care in therapeutic beds of the CRH to a patient with a diagnosis of "Bronchial asthma"which refers to the csg "Asthma", payment is made on the corresponding KSG, regardless of the fact that this KSG is included into KNG "Pulmonology". The specific method of payment for medical care for various diseases is established by the territorial program of compulsory medical insurance.

Formation of CNG is carried out on the basis of medical activity profiles in accordance with the order of the Ministry of Health and Social Development of the Russian Federation of May 17, 2012 N 555n "About the approval of the nomenclature of bed fund for medical care profiles".

The formation of the CAG is based on the combination of the following parameters that determine the relative cost of treatment of patients:

1. Main classification criteria:

a. Diagnosis (ICD code 10);

b. Surgery and / or other medical technology used (code in accordance with the Nomenclature), if available;

2. Additional classification criteria:

a. Age category of the patient;

b. Concomitant diagnosis or complications of the disease (ICD code 10);

d. The duration of treatment.

Interpretation of groups in accordance with ICD 10 and the Nomenclature, as well as instructions for grouping cases, including rules for taking additional classification criteria into account, are provided by the Federal Mandatory Medical Insurance Fund to territorial mandatory health insurance funds in electronic form.

In the presence of surgical operations and (or) other applied medical technologies, which are the classification criterion, the treatment case is assigned to a specific CGC in accordance with the Nomenclature code.

If there are several surgeries and / or medical technologies used, which are classification criteria, payment is made on the KSG, which has the highest ratio of relative costs. In a number of cases stipulated by the Instruction, the case can be assigned to a particular KSG taking into account the diagnosis code according to ICD 10.

In the absence of surgical operations and / or applied medical technologies, which are the classification criteria, the treatment case is assigned to a particular CAG in accordance with the diagnosis code for ICD 10. If the patient is undergoing surgical treatment, then the choice between using the CGC, determined in accordance with the diagnosis code according to ICD 10, and the CGC, determined on the basis of the Nomenclature code, is carried out in accordance with the rules given in the Instruction.

When paying for medical care rendered in inpatient conditions, for the CGC as part of the standard CGC, in the tariff agreement, subgroups can be distinguished, including taking into account additional criteria established in the subject of the Russian Federation. At the same time, an additional classification criterion must necessarily be included in the register of bills generated by medical organizations and transferred to the TFOMS. As additional classification criteria can be defined: long stay in intensive care or the use of expensive resuscitation technologies, expensive medicines (consumables), the level of medical care in the case of the current monotonous phasing of its provision for a particular HCV. Isolation of expensive medications (consumables) as additional classification criteria is possible if there are specific indications determined by clinical guidelines (treatment protocols) in a limited number of cases included in the baseline of the PCG, only for drugs included in the List of essential and essential drugs for medical use and consumables included in the list of medical devices implanted into the human body during the medical care under the program of state guarantees of free medical care to citizens. Differentiating signs in such subgroups can be services for the use of specific drugs. The level of costs is determined on the basis of the prevailing average level of purchase prices for these drugs in a constituent entity of the Russian Federation or in accordance with the registered maximum selling prices.

The weighted average weighting factor of the cost capacity (CPS) of the subgroups should be equal to the ratio of the relative cost capacity established in the recommendations (with the possibility of its correction by applying the management coefficient).

VHC is calculated by the formula:

– the weighting factor of the consumption of subgroup i;

– the number of cases treated in subgroup i;

– the number of cases in the whole group.

The number of cases for each subgroup is planned in accordance with the number of cases for the previous year, taking into account the priorities existing in the subject of the Russian Federation. Detailed rules for the allocation and use of subgroups are governed by the Instruction.

The amount of financial support of a medical organization for a KSG or KPG is calculated as the sum of the cost of all hospitalizations in the hospital:

– the amount of financial support of the medical organization, rubles;

– the cost of a completed hospitalization in inpatient conditions, rubles.

The application of the method of payment for inpatient medical care for a CSG or CNG is possible only after making calculations in the subject of the Russian Federation on forecasting the size of financial support for medical organizations when they switch to paying for medical care for these groups of diseases. If the level of financial support of individual medical organizations differs from the size of their financial support when using the previously existing method of financing by more than 10%, it is necessary to analyze the structure of hospitalizations and make management decisions to optimize the level and structure of hospitalizations, including approval on the territory of the subject The Russian Federation managerial ratio, the ratio of the level of inpatient medical care and the allocation of subgroups in the structure KSG.

The analysis of the hospitalization structure in the context of medical organizations is carried out using the average cost ratio of the hospital, which is calculated by the formula:

– the number of cases of hospitalization of patients for a particular HCG or CNG in a hospital;

– the ratio of relative costs for a certain KSG or CNG;

– the total number of completed cases of inpatient treatment per year.

With proper organization of patient routing in a constituent entity of the Russian Federation, the average cost ratio of a hospital for medical organizations with a higher level of equipment should be of greater importance than for medical organizations with a lower level of equipment.

To determine the effectiveness of the activity of hospitals of medical organizations, the constituent entity of the Russian Federation evaluates the indicators of rational and targeted use of bed capacity according to the methodology recommended by the Ministry of Health of the Russian Federation.

4. The main parameters of payment for medical care for a CSG or CNG, determining the cost of a completed case of treatment

The calculation of the cost of a completed case of treatment for a CSG or CNG is carried out on the basis of the following economic parameters (Fig. 1):

1. The size of the average cost of a completed case of treatment included in the CSG or CNG (base rate);

2. The ratio of relative costs;

3. Differentiation rate, if available;

4. Correction factors:

a. managerial ratio;

b. coefficient of the level of care;

c. the complexity of the treatment of the patient.

The cost of one case of hospitalization in a hospital for a CGC or CNG is determined by the following formula:

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BS – the size of the average cost of a completed case of treatment (base rate), rubles;

– the ratio of relative costs of the CG or CNG, to which this case of hospitalization is related (the main coefficient set at the federal level);

PC is the correction factor of payment of KSG or KNG (integrated coefficient established at the regional level);

KD – the coefficient of differentiation, calculated in accordance with the decree of the Government of the Russian Federation of May 5, 2012 N 462 "On the procedure for distribution, provision and expenditure of subventions from the budget of the Federal Mandatory Medical Insurance Fund to the budgets of territorial mandatory health insurance funds for exercising the powers of the Russian Federation in the field of mandatory medical insurance transferred to state authorities of the constituent entities of the Russian Federation". This coefficient is used in calculations if there are several differentiation coefficients established for the territory of a constituent entity of the Russian Federation. If the differentiation coefficient is the same for the entire territory of a constituent entity of the Russian Federation, then this coefficient is taken into account in the base rate.

The size of the average cost of a completed case of treatment included in the CSG or CNG (base rate) is determined on the basis of the following parameters:

– the amount of funds intended for the financial support of medical care provided in inpatient conditions (in the conditions of day hospital) and paid for by the CGC or CNG (OS)

– the total planned number of treatment cases payable by the CGC or CNG;

– average pay adjustment factor for KSG or KPG (SEC).

The size of the average cost of a completed treatment case (base rate) is established by the tariff agreement adopted on the territory of the constituent entity of the Russian Federation, and is calculated by the formula:

SEC is calculated by the formula:

The size of the base rate is set for a year. Adjustment of the base rate is possible in case of significant deviations of the actual values ​​from the calculated ones no more than once per quarter. The calculation of the base rate is carried out separately for medical care rendered in inpatient and day hospital conditions. At the same time, taking into account the peculiarities of providing medical care in a day hospital in different regions, the base rate for a day hospital is unacceptable by more than 30% percent of the standards established by the Program. If it is not possible to calculate the average correction factor due to the insufficient amount of statistical information, it is recommended to set the SEC at the level of 1.1-1.2 in order to take into account the predicted increase in the average complexity of the treated patients as a sign of improving the reasonableness of hospitalization (this recommendation is based on the pilot testing KSG).

The planned number of cases of treatment for each medical organization (each CGC or CNG) is determined according to statistical data within the framework of personified registration in the field of compulsory medical insurance, carried out in accordance with Chapter 10 of the Federal Law of November 29, 2010 N 326-ФЗ "On compulsory medical insurance in the Russian Federation" taking into account the planned changes in the structure of hospitalizations.

The ratio of relative costs of use is determined for each KSG and KNG at the federal level (Appendix 1 (in stationary conditions) and Appendix 2 (in day hospital conditions) to these recommendations) and cannot be changed when setting tariffs in the constituent entities of the Russian Federation.

The compensation ratio of a KSG or KNG payment for a specific case is calculated taking into account the payment coefficients established in a constituent entity of the Russian Federation using the following formula:

– managerial coefficient for the CGC or CNG, to which the given case of hospitalization is related (used in calculations, if the specified coefficient is determined in the subject of the Russian Federation for the CGC or CNG);

– the ratio of the level of medical care in the medical organization in which the patient was treated;

KSLP – coefficient of patient treatment complexity (used in calculations, if the specified coefficient is determined in the subject of the Russian Federation for this case).

The calculation and determination of the values ​​of the correction factors is carried out separately for medical care rendered in inpatient and day hospital conditions.

The managerial coefficient is established by the tariff agreement adopted on the territory of a constituent entity of the Russian Federation for a specific KSG or CNG.

The goal of establishing the managerial ratio is: to motivate medical organizations to regulate the level of hospitalization in case of diseases and conditions that are part of a certain KSG or CNG, or to encourage the introduction of specific modern treatment methods. In addition, the management coefficient can be applied in order to stimulate medical organizations, as well as medical workers (through the implementation of incentive payments) to the introduction of resource-saving medical and organizational technologies, including the development of day hospitals in hospitals. During the period of transition to payment of medical care for the KSG, the management coefficient can be used to correct the risks of a drastic change in the financing of cases related to individual KSGs treated mainly in mono-profile medical organizations.

The management coefficient applies to the CRC or CNG as a whole and is the same for all levels of care.

The management factor must be set in such a way that the weighted average ratio of total cost of use (taking into account the number of cases for each KSG) is equal to 1,

The condition of application of the management coefficient:

– the number of cases treated in the clinical and statistical group j;

– the number of cases treated;

– management coefficient applied to the clinical and statistical group j;

– the ratio of relative costs for the clinical and statistical group j.

Summation in the numerator and denominator of the formula is carried out for all clinical and statistical groups.

The number of cases treated for each KSG is determined on the basis of actual data on the number of cases of treatment in the context of the KSG for the past year or on the basis of the planned number of cases of treatment for each KSG.

The value of the management coefficient can not exceed 1.4.

In the case of the use of a management coefficient for the purpose of risk correction, its value should be calculated taking into account the actual costs of providing medical care within a specific MHC.

For the CGC, including the payment of medical care with the use of complex medical technologies, including for diseases that are the main causes of mortality (the list is presented in the Instructions), the use of reduction factors is not appropriate.

For a CSG that includes payment for medical care for diseases, the treatment of which should mainly be carried out on an outpatient basis and in day hospital conditions (the list is presented in the Instructions), the use of a step-up management factor is not appropriate.

When paying for medical care, stages (levels) of the provision of medical care are taken into account in accordance with the procedures for providing it. The ratio of the level of medical care is established by the tariff agreement adopted on the territory of the constituent entity of the Russian Federation, in the context of three levels of medical care (with the exception of cities of federal significance, where it is possible to establish two levels) differentially for medical organizations and (or) structural subdivisions of medical organizations in accordance with current legislation. At the same time, the structural subdivisions of a medical organization that provide medical care, respectively, in inpatient conditions and in day hospital conditions, on the basis of patient routing, can be attributed to different levels of medical care.

The ratio of the level of medical care reflects the difference in the cost of medical care, taking into account the severity of the patient’s condition, the presence of complications, and conducting in-depth studies at various levels of medical care.

Within the 3rd level, the medical care system allocates a sub-level, including federal medical organizations that provide medical care within several constituent entities of the Russian Federation.

The boundaries of the values ​​of the ratio of the level of medical care, recommended to establish in the tariff agreements of the constituent entities of the Russian Federation:

1) for medical organizations of the 1st level – up to 1.0;

2) for medical organizations of the 2nd level – from 0.9 to 1.2;

3) for medical organizations of the 3rd level (except for federal medical organizations) – from 1.1 to 1.5;

4) for federal medical organizations providing medical care within several constituent entities of the Russian Federation – from 1.4 to 1.7.

The values ​​of the ratio of the level of care provided for each subsequent level set by the tariff agreement must necessarily exceed the values ​​established for the previous levels.

Given the objective criteria (the difference in the energy used, the population density of the service area and

– weighted average level i;

– sublevel coefficient j;

– the number of cases treated in hospitals with sublevel j;

– the number of cases in the whole level.

The allocation of sublevels is possible strictly after performing the calculations in accordance with the above method.

In case of allocation of sublevels of medical care, the corresponding coefficients are used in the calculations instead of the coefficients of the level of medical care.

Considering that the differences in the costs of providing medical care are taken into account when calculating cost-effectiveness ratios, the use of the ratio of the level of medical care in paying for medical care for a number of KSGs for which medical care is provided mainly at the same level of care is considered impractical. The list of CSGs for which it is not recommended to apply the coefficient of the level of care provided is given in the Instruction.

The patient treatment complexity ratio (CSLP) is set by the tariff agreement adopted on the territory of the subject of the Russian Federation for individual cases of medical care.

KSLP takes into account the higher level of costs of providing medical care to patients in some cases.

KSLP is established on the basis of objective criteria, the list of which is provided in the tariff agreement and is necessarily reflected in the account registers.

KSLP is applied also at superlong terms of hospitalization caused by medical indications. For long-term hospitalizations, there are cases of treatment lasting more than 30 days with the exception of a number of CAGs (listed in the Instructions), for which treatment periods exceeding 45 days are superlong.

The total value of KSLP in the presence of several criteria can not exceed 1.8, except in cases of extremely long hospitalization. In the case of a combination of the fact of a superlong hospitalization with other criteria, the calculated value of CSLP, based on the duration of hospitalization, is added without limiting the total value.

Cases in which it is recommended to install the CSLP and the recommended ranges of its values ​​are set out in Appendix 3 to these recommendations. At the same time, it is possible to establish in the tariff agreement various values ​​from the recommended ranges depending on the performance of specific surgical interventions and diagnostic studies that have taken place.

5. Approaches to payment of individual cases of medical care for a CRC or CNG

The tariff agreement should define the procedure for payment of interrupted treatment cases, including ultra-short treatment cases, as well as cases involving the transfer of patients from one structural unit to another within the same medical organization or between medical organizations.

For ultrashort include cases in which the duration of hospitalization is less than 3 days inclusive. A list of groups that are exceptions is provided in the Instructions. Moreover, if the patient underwent a surgical operation, which is the main classification criterion for attributing this treatment case to a specific PSG, the case is paid in the amount of 80-100% of the cost determined by the tariff agreement for this PSG. The specific share of payment for these cases is set in the tariff agreement. If a surgical treatment or other intervention determining the assignment of a case to a KSG has not been carried out, the case is paid in the amount of not more than 50% of the cost determined by the tariff agreement for the KSG (the main classification criterion for referring to the KSG in these cases is the ICD 10 diagnosis). At the same time, a differentiated approach to the payment of these cases may be established in the region depending on the actual number of days of treatment.

When transferring a patient from one department of a medical organization to another within a round-the-clock hospital (in case of transfer from a 24-hour hospital to a day hospital, it is at the discretion of the subject of the Russian Federation), if this is due to the emergence (presence) of a new disease or condition belonging to another ICD class 10 and not a consequence of the natural progression of the underlying disease, nosocomial infection or complication of the underlying disease, as well as when transferring a patient from one medical organizations in the other, both cases of treatment of the disease are subject to 100% payment in the framework of the relevant KSG, with the exception of ultrashort cases, which are paid in accordance with established rules. Moreover, if the transfer is made within the same medical organization, and the diseases belong to the same ICD 10 class, the payment is made in the framework of one treatment case for the CMC with the highest amount of payment.

When sent to a medical organization, including federal, for the purpose of a comprehensive examination and (or) preoperative preparation of patients who subsequently need surgical treatment, including for the further provision of high-tech medical care, these cases are paid as part of specialized medical care by the CGC, formed by the ICD 10 code or by the Nomenclature code, which is the classification criterion in the case of performing a diagnostic study.

Medical care, including emergency care, as well as medical rehabilitation in accordance with the procedures and on the basis of medical care standards, can be provided to parents (legal representatives) hospitalized to care for children suffering from serious chronic disabling diseases requiring long-term treatment. , and is paid to medical organizations of pediatric profile, having the necessary licenses, according to the corresponding CGC (CNG).

After providing high-tech medical care to a medical organization, including a federal medical organization, if indicated, the patient can continue treatment in the same organization as part of specialized medical care. The specified cases of the provision of specialized medical care are paid on the KSG, formed according to the ICD code 10.

The distribution of the volume of medical care rendered inpatient and in day hospital conditions between medical organizations can be done with or without specification in the context of the GLC or CNG.

The assignment of a case of medical care to high-tech medical care is carried out in accordance with the ICD-10 codes, patient model, type of treatment and treatment method similar to the parameters established in the Program within the list of types of high-tech medical care, including treatment methods and sources of high-tech financial support. medical care (hereinafter – the List). Payment for the types of high-tech medical care included in the basic program of compulsory health insurance is carried out according to the standards of financial expenses per unit of medical care, approved by the Program. If at least one of the above parameters does not match the List, payment for the case of medical care is provided within the framework of specialized medical care for the relevant CSG based on the performed surgical operation and (or) other applied medical technologies. At the same time, the size of the tariff for medical care, calculated for the CSG, taking into account the application of correction factors (with the exception of the patient treatment complexity ratio), should not exceed the standard financial cost per unit of high-tech medical care provided by the appropriate method.

Treatment on the profile of medical rehabilitation is performed in the conditions of the round-the-clock, as well as day hospital (in

When evaluated on a Rankin scale of 3 or less, the patient receives rehabilitation assistance in day hospital conditions (in

Given the characteristics of the provision, as well as the lifelong nature of the treatment and, accordingly, payment for medical care during dialysis procedures, including various methods, the method of payment for medical care for the service is used to pay for these procedures provided in inpatient conditions and in day hospital conditions. At the same time, the cost of the service, taking into account the number of actually performed services, is an integral component of the payment for a case of treatment, which is applied in addition to the payment for the CGC in the framework of one treatment case. The list of recommended tariffs (excluding the differentiation coefficient) for payment of dialysis procedures, taking into account the application of various methods, is presented in Appendix 4. The differentiation coefficient (if any) is applied to the cost of the service, taking into account the share of salary expenditures as part of the medical care tariff. The application of correction factors to the cost of services is unacceptable. Taking into account the only statutory method of payment for medical care provided in day hospital conditions – a completed case of treating a disease, the lifelong nature of the treatment provided and the constant number of procedures per month for the vast majority of patients, in order to take into account the amount of medical care performed as part of the territorial program of compulsory Medical insurance per unit volume in day hospital conditions is taken one month of treatment. In stationary conditions, it is necessary to refer the treatment to the finished case during the entire period of the patient’s stay in the hospital. At the same time, during the treatment period, both in the round-the-clock and in the day hospital, the patient should be provided with all necessary medications, including for the prevention of complications. If the provision of medicines is carried out at the expense of other sources (except for OMS), medical care using dialysis is performed on an outpatient basis.

Ii. Methods of payment for primary health care provided on an outpatient basis, including on the basis of a per capita rate of funding for adhered persons

1. Basic approaches to pay for primary health care provided on an outpatient basis

When paying for medical care provided on an outpatient basis, the Program has established the following payment methods:

– according to the per capita standard of financing for adhered persons in combination with the payment per unit volume of medical care – for medical service, per visit, for treatment (completed case);

– per unit of medical care – for medical service, per visit, for treatment (completed case) (used when paying for medical care provided to insured persons outside the subject of the Russian Federation in whose territory the policy of compulsory medical insurance is issued, as well as in individual medical organizations without attached people);

– according to the per capita standard of financing for adhered persons, taking into account the performance indicators of the medical organization, including the inclusion of the costs of medical care provided in other medical organizations (per unit volume of medical care).

2. Basic payment parameters for primary health care

In accordance with sub-clause 1 clause

– the average amount of financial support for medical care provided on an outpatient basis by medical organizations participating in the implementation of the territorial program of compulsory health insurance in a given subject of the Russian Federation, per insured person, rubles;

– the average standard of the volume of medical care provided in the outpatient setting for preventive and other purposes (including visits to health centers, visits due to clinical examination, visits to nurses) established by the territorial program of state guarantees of free medical care to citizens in the basic program of compulsory health insurance visits;

– the average standard of the volume of medical care provided in the outpatient setting due to diseases, established by the territorial program of state guarantees of free medical care to citizens in terms of the basic program of compulsory health insurance, appeals;

– the average standard of the volume of medical care provided in the outpatient setting in an emergency form, established by the territorial program of state guarantees of free medical care to citizens in terms of the basic program of compulsory medical insurance, visits;

– the average standard of financial costs per unit of medical care provided in outpatient settings with preventive and other purposes (including visits to health centers, visits due to clinical examination, visits to nurses) established by the territorial program of state guarantees of free medical care to citizens in terms of basic compulsory health insurance programs, rubles;

– the average standard of financial costs per unit of medical care provided on an outpatient basis due to diseases, established by the territorial program of state guarantees of free medical care to citizens in terms of the basic compulsory health insurance program, rubles;

– the average standard of financial costs per unit of medical care provided in an outpatient setting in an emergency form, established by the territorial program of state guarantees of free medical care to citizens in terms of the basic program of compulsory medical insurance, rubles;

– the amount of funds allocated to pay for medical care provided on an outpatient basis per unit volume of medical care to insured persons outside the subject of the Russian Federation in whose territory the policy of compulsory health insurance was issued, rubles;

– the number of the insured population of the subject of the Russian Federation, people.

Based on the average amount of financial support for medical care provided in outpatient settings by medical organizations involved in the implementation of the territorial program of compulsory health insurance in a given subject of the Russian Federation, the basic (average) per capita rate of funding for outpatient medical care is determined per insured person , according to the following formula:

– basic (average) per capita financing standard, rubles;

– the amount of funds allocated to pay for medical care provided on an outpatient basis per unit volume of medical care to persons insured in this subject of the Russian Federation, rubles.

The per capita financing standard for adhered persons (hereinafter referred to as the per capita standard) does not include:

– expenses for financial support of measures for carrying out all types of clinical examination and preventive examinations of certain categories of citizens, the procedures for which are established by the regulatory legal acts;

– expenses for dialysis on an outpatient basis;

– Expenses for emergency medical care.

Also, the per capita financing standard for adhered persons does not include the cost of financial support for medical care for socially significant diseases (sexually transmitted diseases, tuberculosis, HIV infection and acquired immunodeficiency syndrome, mental disorders and behavioral disorders) if they are financed under territorial compulsory health insurance program.

At the same time, in the subject of the Russian Federation, certain types of expenses may not be included in the per capita standard (for dental medical care, medical care by profile "obstetrics and gynecology" and

When generating registers of invoices and invoices for payment of medical care provided on an outpatient basis, regardless of the method of payment used, all units of volume are indicated with an indication of the size of the established tariffs.

The Commission for the development of the territorial compulsory health insurance program, regardless of the method of payment used, establishes uniform basic rates for payment of medical care for each volume unit, including those used for intra-institutional, inter-agency (carried out by medical insurance organizations) and inter-territorial (made by territorial compulsory medical insurance funds) a) calculations, in accordance with sub-clause 3 of clause

Based on the basic (average) per capita rate of financing of medical care provided on an outpatient basis, taking into account the objective criteria for differentiating the cost of providing medical care set forth in Clause 4 of Requirements, a differentiated per capita rate for homogeneous groups (subgroups) of medical organizations is calculated in the subject of the Russian Federation according to the following formula:

– differentiated per capita rate for the i-th group (subgroup) of medical organizations, rubles;

– weighted average integrated coefficient of differentiation per capita standard, determined for the i-th group (subgroup) of medical organizations.

The unification of medical organizations into homogeneous groups (subgroups) is carried out on the basis of the values ​​of the integrated coefficient of differentiation per capita standard. The integrated coefficient of differentiation per capita standard is determined for each medical organization according to the following formula:

– integrated coefficient of differentiation per capita standard, specific to the medical organization;

– the sex-age differentiation coefficient of the per capita standard calculated for the relevant medical organization;

– coefficient of differentiation by the level of expenditure on the maintenance of individual structural units (obstetric centers, medical stations and

– coefficient of differentiation, taking into account the characteristics of the settlement and the density of the attached population of the subject of the Russian Federation (if necessary);

– coefficient of differentiation by the level of expenses for the maintenance of the property of medical organizations (if necessary);

– coefficient of differentiation, taking into account the achievement of the target indicators of the salary level of medical workers established "road maps" development of health care in the subject of the Russian Federation (if necessary);

– district wage ratio and percentage wage supplement for work experience in the Far North and equated localities, as well as for work in areas with special climatic conditions that are established for the territory of a constituent entity of the Russian Federation or the city of Baikonur by legislative and other regulatory legal acts of the Russian Federation and the USSR or the estimated level of the budget expenditure index established for the territory where the medical organization is located (in accordance with nktom Claims 6).

Thus, it is used in calculations if several differentiation coefficients are established for the territory of a constituent entity of the Russian Federation. If the coefficient of differentiation is the same for the entire territory of a constituent entity of the Russian Federation, then this coefficient is taken into account in the basic (average) per capita rate of financing.

In the case of the application, the use of differentiation coefficients that take into account similar features should be excluded.

The presented list of coefficients is exhaustive, the use of other coefficients not covered by these recommendations is unacceptable. In this case, in the subject of the Russian Federation, only those coefficients are used that reflect the characteristics of this subject.

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At the same time, when calculating each differentiation coefficient, a value equal to 1 corresponds to the weighted average level of the corresponding expenses that are taken into account for the calculation of this coefficient.

To calculate the age and sex differentiation rates of the per capita standard, the number of insured persons in a constituent entity of the Russian Federation is divided into age and gender groups (subgroups) in accordance with clauses 7, 8 of the Requirements. At the same time, in accordance with clause 7 of the Requirements, for each gender and age group (subgroup), single values ​​of the differentiation coefficient within the limits of the subject of the Russian Federation are calculated. These coefficients are established by the tariff agreement of the subject in accordance with sub-clause 4 of clause

The obtained values ​​of the integrated coefficient of differentiation per capita standard are ranged from the maximum to the minimum value and, in case of significant differences, are combined into homogeneous groups with the subsequent calculation of the weighted average of this coefficient for each group.

In order to align the amount of funds calculated by differentiated per capita standards to the total amount of funds for financing health care organizations, the correction factor (PC) is calculated using the formula:

– the number of insured persons attached to the i-th group (subgroup) of medical organizations, people;

The actual differentiated per capita standard for the i-th group (subgroup) of medical organizations (FDPN) is calculated by the formula:

– actual differentiated per capita financing norm for the i-th group (subgroup) of medical organizations, rubles;

The distribution of insured persons by medical organizations that have adhered persons is established at the beginning of the relevant year and may be adjusted based on data from the regional segment of the Unified Register of Insured Persons.

When paying for primary health care according to the per capita financing standard for adhered persons in combination with payment per unit volume of medical care, the maximum amount of financial support for a medical organization having adhered persons is determined based on the value of the differentiated per capita standard using the following formula:

– the maximum amount of financial support of a medical organization that has attached individuals, rubles;

– the number of insured persons attached to this medical organization, people.

The actual amount of financial support for a medical organization with adhered persons is based on the actually rendered volumes of medical care:

– the actual amount of financial support of a medical organization with adhered persons, rubles;

– the actual volume of primary health care provided on an outpatient basis, visits (appeals);

– per unit volume of medical primary health care provided on an outpatient basis for the i-th group (subgroup) of medical organizations, rubles.

The actual amount of financial support of a medical organization with adhered persons may not exceed the maximum amount of financial support. In the case of a justified excess of the amount of medical care distributed by the Commission for the development of the territorial program of compulsory medical insurance, the Commission may pay for medical care up to 10% above the limit of financial support for a medical organization with adhered persons. Financial provision of relevant expenses is carried out in the event of the underfulfilment of distributed volumes of medical care at the expense of savings of available funds or, in the case of fulfilling distributed volumes, at the expense of the rationed safety stock of the territorial compulsory health insurance fund of a constituent entity of the Russian Federation. At the same time, the fulfillment of volumes is taken into account on an accrual basis from the beginning of the year.

When a medical organization carries out annual volumes of medical care distributed by the Commission for the development of a territorial compulsory medical insurance program taking into account the needs of the attached population for this medical care, the maximum and actual amounts of financial support for a medical organization having adhered persons are equal.

Tariffs per unit volume of primary health care provided on an outpatient basis for the i-th group (subgroup) of medical organizations are determined on the basis of uniform for all medical organizations of the Russian Federation constituent set by the tariff agreement of the constituent entity of the Russian Federation , basic tariffs per unit volume of medical care, as well as the weighted average integrated coefficient of differentiation of the per capita rate determined for the i-th groups (subgroups) of medical organizations:

– base rate per unit volume of medical primary health care provided on an outpatient basis, rubles.

When paying for medical assistance in terms of per capita financing standards for adhered persons, taking into account the performance indicators of the medical organization, including including the costs of medical care provided in other medical organizations as part of funds allocated for financial support of a medical organization that has adhered persons, according to the per capita standard, the share of funds allocated to payments to medical organizations is determined in case of reaching the target values ​​of indicators tativnosti activities.

At the same time, the amount of financial support for a medical organization with adhered persons is determined by the per capita standard by the following formula:

– financial support of a medical organization with affiliated persons, per capita standard, rubles;

– the number of insured persons attached to this medical organization, people;

– the amount of funds allocated to payments to medical organizations in case of reaching the target values ​​of the performance indicators of activity, rubles.

Performance indicators, the order of their application and target values ​​are set by the Tariff Agreement in accordance with sub-clause 3 of clause

As part of the application of this method of payment in addition to the cost of financial support for primary health care provided in an outpatient setting by the relevant medical organization, the per capita standard may include the cost of financial support for medical care provided in other conditions (medical care provided in stationary , in the conditions of day hospital, emergency medical care), as well as other medical organizations.

When paying for medical care per unit volume of medical care in certain cases of the Program, the amount of financial support for a medical organization is formed on the basis of actually rendered volumes of medical care determined by the following formula

– the actual amount of financial support of the medical organization, rubles;

– the actual volume of primary health care provided on an outpatient basis, visits (appeals);

T – the rate per unit volume of medical primary health care provided on an outpatient basis, rubles.

At the same time, the tariff for a unit of the volume of primary health care provided on an outpatient basis is the same for all medical organizations of the subject of the Russian Federation included in one level of medical care.

Financial support for expenses of medical organizations that do not have stuck persons, as well as types of expenses that are not included in the per capita standard, is carried out per unit volume of medical care.

Recommended correction factors for the cost of treatment, taking into account the multiplicity of visits for diseases in the main specialties, are given in Appendix 6. For specialties that are not included in this application, calculations are performed in the constituent entities of the Russian Federation on their own in accordance with actual data. For federal medical organizations that provide medical care within several constituent entities of the Russian Federation, multiplying factors are established for the cost per unit of medical care from 1.4 to 1.7.

As features of payment for certain types of medical care provided on an outpatient basis, the following should be noted.

When conducting dialysis on an outpatient basis, payment is made for a medical service — one procedure of extracorporeal dialysis and one day of peritoneal dialysis. At the same time, in order to take into account the volume of medical care, it is advisable to consider treatment for one month as one treatment (on average 13 procedures of extracorporeal dialysis, 12-14 depending on the calendar month, or daily exchanges with effective dialysate volume during peritoneal dialysis during the month). When conducting dialysis on an outpatient basis, the provision of drugs for the prevention of complications is carried out at the expense of other sources. Tariffs for services are set differentially by dialysis methods (hemodialysis, hemodiafiltration, peritoneal dialysis). At the same time, given the same costs, the absolute cost of dialysis services is the same, regardless of the conditions of its provision. The list of recommended tariffs (excluding the differentiation coefficient) for payment of dialysis procedures, taking into account the application of various methods, is presented in Appendix 4. The differentiation coefficient (if any) is applied to the cost of the service, taking into account the share of salary expenditures as part of the medical care tariff.

Dispensary observation in the framework of the provision of primary health care to patients with chronic non-communicable diseases and patients at high risk of their development is included in the per capita ratio of funding for adhered persons. In this case, the unit of the volume of medical care provided is treatment, which includes the dispensary observation of the patient during the month. The setting of the tariff for the follow-up of the patient is carried out on the basis of the multiplicity of visits to doctors and diagnostic studies recommended for this pathology, including the use of remote technologies for obtaining information about the functional and biochemical indicators of the patients’ condition.

The recommended values ​​of tariffs for payment of medical care within the framework of medical examinations and preventive examinations of certain categories of citizens (without a differentiation factor) are presented in Appendix 7. These values ​​can be adjusted to reflect the coverage of the population with clinical examinations and preventive examinations, as well as the gender and age structure of the population.

When paying for outpatient dental care for visits and appeals, it is recommended to take into account conventional units of labor-intensiveness (EET), which for many years have been used in dentistry to plan the accounting for services provided, to report on the activities of specialists, and to pay them.

Payment for dental care on an outpatient basis should be based on the principle of maximum reorganization of the oral cavity and teeth (treatment of 2, 3 teeth) per visit, which is most effective, as it reduces the time to call the patient, preparation of a workplace, a transaction field, work with documents and

The recommended classifier of basic medical services for the provision of primary medical and sanitary specialized dental care, expressed in OET is presented in Appendix 8.

Iii. Methods of payment for emergency care, including on the basis of a per capita financing ratio

1. The main approaches to the payment of emergency medical care

In accordance with the Program, the payment of emergency medical care provided outside the medical organization (at the place where the ambulance brigade, including emergency specialized, medical care, and also in the vehicle during medical evacuation) is called, is paid according to the per capita standard of financing in conjunction with payment for calling ambulance.

2. The main parameters of payment for emergency medical care

In accordance with sub-clause 1 clause

– the average amount of financial support for emergency medical care provided outside the medical organization by medical organizations participating in the implementation of the territorial program of compulsory medical insurance of a given subject of the Russian Federation, per one insured person, rubles;

– the average standard of emergency medical care outside the medical organization, established by the territorial program of state guarantees of free medical care to citizens in terms of the basic program of compulsory medical insurance, calls;

– the average standard of financial costs per unit of emergency medical care outside the medical organization, established by the territorial program of state guarantees of free medical care to citizens in terms of the basic program of compulsory medical insurance, rubles;

– the amount of funds allocated for payment of emergency medical care outside the medical organization provided to insured persons outside the subject of the Russian Federation in whose territory the policy of compulsory medical insurance for a call is issued, rubles;

– the number of the insured population of the subject of the Russian Federation, people.

The basic (average) per capita standard of financing for emergency medical care provided outside the medical organization is calculated based on the average size of financial support for emergency medical care provided outside the medical organization by medical organizations participating in the territorial program of compulsory medical insurance of this subject of the Russian Federation, in calculation per one insured person according to the following formula:

– the basic (average) per capita rate of funding for emergency medical care outside the medical organization, rubles;

– the amount of funds allocated for the payment of emergency medical care outside the medical organization to the insured in this subject of the Russian Federation for a call, rubles.

Tariffs for calls to ambulance services are established by a tariff agreement, including payment for ambulance services in the event of a thrombolysis.

Additional types of emergency medical care may be established in the constituent entity of the Russian Federation, which are paid for calling an ambulance.

It is possible to use the payment option, in which the medical organization receives the share of funds set by the tariff agreement according to the per capita financing norm, and the rest – according to the tariffs for the call.

Registers of invoices for payment of medical care must include all units of the volume of emergency medical care provided at the established tariffs.

Based on the basic (average) per capita rate of funding for emergency medical care provided outside the medical organization, taking into account the objective criteria for differentiating the cost of providing medical care in a constituent entity of the Russian Federation, a differentiated per capita rate of financing emergency medical care for homogeneous groups (subgroups) of medical organizations is calculated using the following formula :

– differentiated per capita rate of ambulance financing for the i-th group (subgroup) of medical organizations, rubles;

– weighted average integrated coefficient of differentiation of the per capita rate of ambulance financing defined for the i-th group (subgroup) of medical organizations.

At the same time, medical organizations are united into homogeneous groups (subgroups) on the basis of the values ​​of the coefficient of differentiation of the per capita standard. The integrated coefficient of differentiation of the per capita rate of ambulance financing is determined for each medical organization according to the following formula:

– integrated coefficient of differentiation per capita standard, specific to the medical organization;

– the sex-age differentiation coefficient of the per capita standard calculated for the relevant medical organization;

– coefficient of differentiation average radius of the service area (if available);

– coefficient of differentiation, taking into account the features of settlement and population density of the subject of the Russian Federation (if any);

– coefficient of differentiation of the level of expenditure on the maintenance of the property of medical organizations (if any);

– coefficient of differentiation, taking into account the achievement of the target indicators of the salary level of medical workers established "road maps" health development in the subject of the Russian Federation (if available);

– district wage ratio and percentage wage supplement for work experience in the Far North and equated localities, as well as for work in areas with special climatic conditions that are established for the territory of a constituent entity of the Russian Federation or the city of Baikonur by legislative and other regulatory legal acts of the Russian Federation and the USSR or the estimated level of the budget expenditure index established for the territory where the medical organization is located (in accordance with nktom Claims 6).

It is used in calculations if several differentiation coefficients are established for the territory of a constituent entity of the Russian Federation. If the coefficient of differentiation is the same for the entire territory of a constituent entity of the Russian Federation, then this coefficient is taken into account in the basic per capita (average) per capita rate of funding for emergency medical care outside the medical organization.

In the case of the application, the use of differentiation coefficients that take into account similar features should be excluded.

The list of coefficients is exhaustive, and the use of other coefficients not provided for by these recommendations is unacceptable. In this case, in the subject of the Russian Federation, only those coefficients are used that reflect the characteristics of this subject.

At the same time, when calculating each differentiation coefficient, a value equal to 1 corresponds to the weighted average level of expenses taken into account for calculating the coefficient.

To calculate the gender and age coefficients of differentiation of the per capita rate of ambulance financing, the number of insured persons in a constituent entity of the Russian Federation is divided into gender and age groups (subgroups) in accordance with clauses 7 and 8 of the Requirements. At the same time, in accordance with clause 7 of the Requirements, for each gender and age group (subgroup), single values ​​of the differentiation coefficient within the limits of the subject of the Russian Federation are calculated. These coefficients are established by the tariff agreement of the subject in accordance with sub-clause 4 of clause

The obtained values ​​of the integrated coefficient of differentiation of the per capita rate of ambulance financing are ranged from the maximum to the minimum value and, in case of significant differences, are combined into homogeneous groups with the subsequent calculation of the weighted average value of this coefficient for each group.

In order to bring the volume of funds calculated according to the differentiated per capita standards for financing emergency medical care outside the medical organization, into line with the total amount of funds for the financing of medical organizations, the correction factor (PC) is calculated using the formula:

– the number of insured persons attached to the i-th group (subgroup) of medical organizations, people;

The actual differentiated per capita rate of funding for emergency medical care outside the medical organization for a group (subgroup) of medical organizations (FDPN) is calculated by the formula:

– actual differentiated per capita rate of emergency medical assistance financing for the i-th group (subgroup) of medical organizations, rubles;

The amount of financial support of a medical organization that provides emergency medical care outside the medical organization is determined based on the value of the differentiated per capita rate, the number of the population served, and the amount of medical care that is paid for calling the following formula:

– the amount of financial support of the medical organization providing emergency medical care outside the medical organization, rubles;

– the number of insured persons served by this medical organization, people.

In the event of a significant deviation of the volumes of emergency medical care actually fulfilled from the volumes allocated by the Commission for the development of the territorial compulsory health insurance program, the amount of financial support of the medical organization can be adjusted in accordance with the mechanism determined by the tariff agreement of the Russian Federation.

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