Insured persons may apply for orthopedic supplies depending on the severity of the disease. What medical devices are financed and to what extent is explained by the doctor Artur Fałek, who is an expert at the Rafał Piotr Janiszewski Advisory Office.
Anna Tłustochowicz: What does the slogan of orthopedic supplies mean?
Artur Fałek:Today there are exactly 137 products that are medical devices.
137 orthopedic products?!
Let me put it this way: orthopedic equipment is not only orthopedic equipment.
(Laughter)
(Laughter)This may sound funny, but the thing is, it's a very broad category. The regulation of the Minister of He alth on medical devices available on request is more and more precise, and there are more and more items in it. The conditions for reimbursing products by the National He alth Fund are also changing.
If these are not strictly orthopedic products, what else?
The medical device is both a urological catheter and a computed tomograph. Some of these products are purchased by patients in open pharmacies, e.g. blood glucose test strips or dressings, while others may require adjustment to a specific person, they can be manufactured in series or made to measure for a single patient. Among other things, there are orthopedic items, i.e. orthoses, prostheses, things that help you move around.
We intuitively recognize them as orthopedic equipment.
Yes, but today we are talking more about products that are available to patients on request. They are also i.a. catheters, ostomy bags, diaper pants, aids and optical devices (eyeglass lenses, magnifiers, telescopes), as well as hearing aids and equipment for insulin pumps.
Staying with orthopedic injuries, you mentioned the doctor about orthoses. If the patient sprains his leg, he may demand that he should not be put on a heavy plaster, but a modern, light orthosis?
Maybe, if it is clinically possible. Of course, if we are talking about an insured patient! An orthosis is an apparatus that stabilizes a joint orpart of the body and instead of putting a plaster cast on the patient, sometimes an orthosis can be used. It is used, inter alia, in sprains, sprains or injuries of the ligamentous apparatus.
The orthosis is comfortable and you can take it off, for example, for bathing.
Yes, that's true. Of course, if absolute immobilization is required, then rigid dressings are put on, but not necessarily plaster dressings. The rigid dressing can, for example, be made of plastic. You ask if the patient can demand that an orthosis or a lighter type of dressing be applied. This type of orthopedic equipment, as stated in the regulation, is due to the patient. So: yes.
We are en titled to orthopedic care just as we are en titled to reimbursed drugs.
I think that most of the sick people know the provisions of the Regulation of the Minister of He alth, which we are talking about today, and if not, it is worth getting to know them, because it may turn out that a medical device that is used by the patient on a permanent basis may be it will be issued with a refund.
Free?
Or with partial payment. It depends. Generally, if we are talking about children, then orthopedic equipment is most often available with a zero surcharge. The regulation of the Minister of He alth, which is the key document in our conversation today, specifies several things. First, of course, what the patient may be commissioned to receive. And here we have 137 products listed. Later, it was determined who could order them for the patient.
Doctor of course?
Of course, but not only. In the case of orthopedic items, they can be physiotherapists, and in the case of products such as catheters, diaper pants, stoma bags - also nurses who can issue orders on their own if they have an undergraduate degree, or simply extend orders previously issued by a doctor. Going further, the regulation sets a limit on public funding. With each product, we can see the upper price level of the product, which is reimbursed. We also have information about the amount of the recipient's own share in the limit of financing from public funds.
Simply put: how much will the patient have to pay extra to him?
Exactly. It sometimes happens that the amount of the deductible is zero percent. The regulation also defines the criteria for granting the product, its period of use and the limit of repair prices. Well, because some of these products, let's imagine a wheelchair, do not need to be replaced just because something broke. If it isthe axis of one wheel is defective, then there is no need to give the patient another wheelchair, only the National He alth Fund finances its repair.
Would you like to discuss how this regulation works with specific examples?
Here you go. Let's take the prosthetic shoe insert that complements the amputee foot. It is used for ordinary footwear. The limit of public funding is PLN 200, and the recipient's share is 0 percent.
So the patient gets it for free.
Yes, but on condition that its cost does not exceed PLN 200. Above the limit, for adults, there is an additional payment of the difference between the price and the amount of the financing limit. So, at the cost of PLN 220, the patient will pay an additional PLN 20.
It may turn out that it is impossible to buy an insole for PLN 200!
It can't turn out that way. The regulation and contracts with service providers who supply patients are structured in such a way that the service provider must always offer at least one such prosthesis for PLN 200.
Sure. Are the wheelchair and prosthesis up to a certain price limit for free?
Dentures are generally free. Also orthoses for children. There is a 10% fee for adults and orthoses.
Short.
They can cost a bit! If, for example, the orthosis covers the hip girdle, thigh, shin and foot, the limit of public funding is PLN 2,500. So an adult patient will pay an additional PLN 250. Let's take a corrective near vision lens: depending on the severity of the visual defect, the prices of these lenses vary, but generally children have 0 percent. surcharges, and adults - 30 percent. In the case of hearing aids, the financing limit is PLN 2,000, and again - children get them for free, and adults - after the age of 26 - in this case - pay extra depending on the depth of the hearing damage. The advanced hearing aid has a financing limit of PLN 5,500, and a person over 26 pays 50 percent. cost.
This is actually a large amount.
In the case of breast prosthesis, the financing limit is PLN 280 and the patient does not pay extra. You can get such a prosthesis once every two years. In the case of wheelchairs that you asked about, if they are manual, i.e. powered by the hands of a disabled person, the financing limit is PLN 600 and it is available to the patient for free. Pointing to the permanent limitation of the possibility of independent walking, such a stroller can be obtained once every 5 years. And if the wheelchair needs to be repaired during this time, the repair cost limit is PLN 180.
What about a better stroller?
Made fromlight alloys and foldable: the financing limit is PLN 1700 and it can be fully refunded for the patient once in four years. Of course, if someone finds a trolley that costs, for example, 5,000. PLN, it will have to cover the price difference out of his own pocket.
The limit of public funding is always emotional and up for discussion. The patient will always find more modern products that will be more expensive. I always say it's the same as with cars: you can have a Fiat and a Mercedes.
Can the patient also get the electric wheelchair for free?
Maybe, but up to the limit of 3,000 zloty. The regulation refers to an electric wheelchair that stabilizes the back and head. Once every four years, patients with paresis and those after paralysis can receive such a wheelchair for free.
You told the doctor that dentures are available for free, and I see an amputee doing a fundraiser every now and then. I understand that the one that is free is such a very simple, basic version?
Not only. Let's take a look at the regulation: there is a modular shin prosthesis with a limit of PLN 4,500, available to the patient with a 0% surcharge once every 3 years. There is a shell prosthesis with a hip basket, the limit of which is 6,000. zloty.
So I understand that these are not "wooden legs", like those from pirate movies, but I also guess that the patient will not be able to run.
No. More advanced dentures offer such a possibility. Electronic, which can cost both 30 and 70 thousand. zloty. The insurance system does not offer such things.
And should the doctor say?
You could definitely discuss it. Why is this not the case today? The answer, of course, lies in the prosperity, or rather the impoverishment of our system. If we pay a low he alth insurance premium on low wages and, in addition, not all of them pay this premium, we have as much money as we have and then there is a painful matter of choice. What to spend? Or at POZ? Are you on drugs? Is it for hospital treatment? Is it to provide patients with medical devices? After all, patients need all this!
Today we still spend too little on medical devices. I have no doubts about it.
Let's look at our disproportion: we spend over PLN 15 billion on drugs, and here - around a billion. When I was working in the Ministry of He alth, I compared it with other he alth care systems in Europe. If we would like to have the same proportions as in Western Europe, then we should spend 2-3 times more on orthopedic equipment. And then we would have the option to expand the listproducts available to patients and the introduction of more favorable principles of their financing.
Do people with a degree of disability have more privileges in the case of orthopedic care?
No. People without disabilities, as a rule, do not receive orders for these devices, so all the patients we are talking about today, if they are not disabled, have impaired motor functions or are chronically ill.
Mothers of disabled children, when they protested in the Sejm, raised the topic of diaper pants. Two diapers per day were required!
Wearable medical devices, such as diaper pants or urological catheters, have been a big problem for years. Previously, it was en titled to 90 items per month, and the financing limit was PLN 77. Oncological patients did not pay extra, while people with neurological diseases - 30 percent. prices.
Today is better?
Since September last year, the quantitative limit for diaper pants, anatomical diapers or absorbent panties is also 90 items, while instead of the limit for 90 items of PLN 77, a price limit was introduced for one item, currently it is PLN 1.70. So the price cap per item has almost doubled. Of course, three a day in some diseases is not a lot.
The sick person often needs much more!
However, we have at least approached the market price of a diaper pants. Unfortunately, there is also a change that is unfavorable for cancer patients. Now they also have to pay 30% of the price.
Is it still the case that patients have to renew the order for the products every month?
No, no! In this regard, a lot has changed for the better.
Now an assignment valid for six months can be obtained and it can be renewed by a nurse. Moreover, it is done electronically. It is therefore much simpler than when the patient actually had to come to the NHF ward every month to certify the order.
Are wigs for people with cancer still free, or do you also have to pay 30% ?
You don't have to. Up to PLN 250, wigs are fully refunded.
And for men and for women, or only for women?
And that's an interesting question! I will be happy to see if it has been found that the man is also en titled to the wig. Let's take a look at the regulation … Up to PLN 250, the patient's share is 0%. There is no question of gender. The wig can be ordered once a year in the event of cancer, permanent head injuries and diseases that cause permanent hair loss.
You said the doctor that every person with a disability, movement impairment, chronically ill - should read the Regulation of the Minister of He alth on medical devices available on request. This will be the summary of our conversation?
That's a good punch line. It is definitely worth getting to know our system in order to know your rights. Of course, medical professionals should be proficient in the provisions of this regulation and know what is owed to the patient, which does not change the fact that in many cases the old rule is true that no one will watch over our rights and take care of us as much as we do.
Expert
Dr. Artur Fałek, doctor
He is an expert of the Rafał Piotr Janiszewski Consulting Office in the field of the organization and operation of the he alth care system, the operation of state administration, legislation in the field of he alth care, and an expert in the field of reimbursement and drug management. He worked in the Ministry of He alth as the Director of the Department of Drug Policy and Pharmacy (2007-2015), previously as the Deputy Director (2007), in the National He alth Fund Headquarters as the Director of the Drug Management Department.
From 2005 he was a member and from November 2007 the Chairman of the Drug Management Team. He is the author, co-author of many organizational solutions and legislation in the field of pharmacy and drugs, he was a Deputy Member of the Management Board at the European Medicines Agency; Senior Project Officer in the "Transparency of the National He alth System Drug Reimbursement Decisions" project (2007-2008); was a representative of Poland in the work of working groups at the European level.
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