The Social Health Insurance Fund has raised one of the most pressing problems for our citizens – a long wait for consulting and diagnostic services. The branch of the Foundation told what to do in such cases and how to protect their rights to timely medical care.
Solving the problem of long-term waiting for patients to receive consulting and diagnostic services (CDU) is a universal task. In the regions, health departments monitor the availability of CDU. To improve the situation, the list of FSMS providers for in-demand services is expanding.
–Are there any requirements for medical organizations regarding providing the patient with the service?
– According to the Rules for monitoring the fulfillment of the terms of the contract between the medical organization and the FSMS, if the waiting time for the CDU exceeds 10 calendar days, then this is a violation of the terms of the contract. For this, the medical organization will be fined in the form of withdrawing money when paying for this service by the Fund. Therefore, clinics should be interested in providing patients with the necessary medical services in a timely manner. However, in fact, sometimes citizens cannot get to a narrow specialist for a long time or sign up for a CT scan, ultrasound, X-ray, if this is a routine examination.
- Let's consider such an example. The patient received a referral to a neurologist's appointment, but at the registry office he learns that the record for the current month is complete. At the beginning of next month, there are also no more places. As it turned out, in this clinic, the entry for the next month opens on the 20th and is quickly filled in. What should a patient do to get an appointment with a neurologist?
- The polyclinic should provide its patients with the necessary medical services. If she cannot provide the necessary service at home in a timely manner, then the patient has the right to receive it in another clinic under a co-fulfillment agreement. In such a situation, it is necessary to make an appointment with the district doctor again (since this is an appeal for a planned case) and ask the doctor for a new referral to another medical organization with which the polyclinic has a co-execution agreement. If the case is urgent, then you can apply on a first-come, first-served basis and explain the situation. The direction is issued in the information system. At the request of the patient, it can be issued in paper form.
– If the district doctor says that they do not have a contract with other clinics for the consultation of a neurologist, or he does not know about the co-executors of his polyclinic, what should the patient do?
- The patient has the right to independently find a medical organization that has the necessary medical service. Then check whether it is a supplier of the Fund – to do this, go to the official website of the fms Fund.kz and in the section "Purchase of medical services"check the availability of a medical organization in the list" Database of healthcare entities "or in the list " Providers of medical services".If the desired medical organization is among the Fund's suppliers, then ask for a referral from the local doctor to this particular clinic.
As a rule, local doctors do not know which clinics can provide this or that service, because there are many of them and the list can be updated daily. Patients can request such information from the responsible employee of their medical organization. But in order to simplify and speed up the process, it is better for the patient to inform himself of the place where he would like to receive this service.
However, it should be noted that the queue in the selected clinic can also be filled. Therefore, it is better to initially specify there the possibility of recording for the desired period.
– The same problem with the appointment to the gynecologist for a month or two, although the patient has a referral in the system.
- There should be no problems with an appointment with a gynecologist at all, since there is a minimum set of specialists in primary health care centers (PHC), including gynecologists at the site, whose staff is designed for a normalized number of attached women of fertile age. Therefore, if the minimum services of a gynecologist are required, the patient can register at the registry.
- Also, patients often ask themselves: why is it noted in the polyclinic that, for example, the ultrasound record is filled in for two months, but at the same time the same patient can be taken immediately for a fee? Is there any rate of records for the day?
– We need to explain how this system works as a whole, this is a global practice. A medical organization enters into a contract with a financial operator (in Kazakhstan, this is the Social Health Insurance Fund) for a year for certain services under the GOBMP and in the OSMSna for a certain amount, that is, for a specified number of services for the entire period. At the same time, contracts with clinics are reviewed throughout the year, the volumes are increased if necessary.
Accordingly, based on the total volume in the contract, each medical organization plans the number of services per day, for which it then registers its patients. If the appointment for the day is filled out, patients can optionally undergo the service for a fee. That is, the reception is conducted both within the framework of fulfilling obligations under the contract (when paying for the patient's service by an authorized financial operator), and on a commercial basis, when the patient himself acts as the source of payment.
This is just a question of underfunding the health care system, which we all know about. We still do not have enough funds to fully cover the needs of the population for medical care. That is why the OSMS system was introduced, which has already significantly increased the amount of funding for domestic healthcare and increased the availability of consulting and diagnostic services.
- Thank you for the detailed explanations. And what should a patient do if it is not possible to get a referral to receive services in another clinic for co-execution?
– If the district doctor refuses to give a referral to a narrow specialist or for diagnostic tests to a clinic that the patient has chosen among the Fund's suppliers, then you need to contact the Patient Support Service in this clinic and explain the situation there, insist on your rights. The service was specially created to solve issues immediately on the ground.
If the Patient Support Service does not manage to reach an understanding, then you can contact the deputy head of the polyclinic for the medical part or the head himself.
If it is impossible to resolve the issue, you can contact the number 1406-this is the hotline of the Foundation, which accepts appeals from the population. There are also other communication channels – this is the Qoldau 24/7 mobile app, @Saqtandyrybotin Telegram and the official website fms.kz The main thing is to know about your rights and not be afraid to defend them!