Cancer patients in Russia may be deprived of the opportunity to independently choose a medical institution and a treating doctor. The new procedure for providing assistance in oncological diseases effectively gives regional officials the right to decide where to send the patient – to federal medical centers or local hospitals. Opponents of the changes believe that if these norms come into force, hundreds of thousands of people will become hostages of the new system.
The order of the Ministry of Health on the new procedure for providing assistance to adult cancer patients will come into force on January 1, 2022. In April, the document was registered by the Ministry of Justice, despite the campaign of patients against its adoption on social media and attempts by representatives of the medical industry to make their own changes. The Russian service of the BBC investigated how the cancer treatment system will be organized and why it raises so many questions in the medical community.
With the introduction of new rules, the routing of cancer patients in the region will be determined by the government body – the local Ministry of Health. The decree stipulates that regional authorities will now develop a list of medical organizations that provide assistance to cancer patients, a scheme of territorial attachment of primary and specialized oncological institutions, as well as a list of diseases for which telemedicine consultations are conducted with federal medical centers.
In the document, there remains a clause regarding the possibility for a primary care oncologist to refer a patient to a federal medical center for further diagnostic clarification and determination of treatment strategy. However, patients and some members of the medical community believe that the routing order specified in the regulation violates the patient’s right to choose the place of treatment, which is guaranteed to them by the Law on Basic Health Protection.
We explain quickly, simply, and clearly what happened, why it matters, and what will happen next. эпизоды means “episodes” in English. End of story. Podcast Advertising. “Oh, excuse me, how is it possible – routing and “has the right”? This is a violation of the basic principle of functioning of the health system, as described in the federal law,” wonders Dr. Mikhail Laskov, the founder of Dr. Laskov Clinic and an oncologist and hematologist.
Currently – and until 2022 – the routing through the compulsory health insurance (OMS) works by issuing referrals to the attending physician. In addition, Laskov adds, until now any specialist could issue a referral for a cancer patient to be examined at a federal oncology center. The new regulation limits these possibilities: now oncologists from the Center for Oncologic Outpatient Care (CAOP) or the primary oncology office will refer patients to centers under the federal authorities.
“So we have already taken away and limited the basic right of a doctor to refer his patient wherever he deems necessary, because now only an oncologist from the Centralized Oncology Assistance Program or office can do it,” emphasizes Laskov.
According to the current procedure, the attending physician still has the right to refuse a patient’s request for referral from a regional medical institution to a federal center if he or she does not consider the request justified. “Referral is always the agreement of the doctor that it is necessary, and the patient’s agreement to go there, it is a matter of agreement,” Laskov reminds. But now, according to the oncologist, the regional doctor in this matter is completely dependent on officials.
“Even if he secretly makes a referral to a clinic that is not on the list approved by the local authorities, the problem is this: it cannot be used,” says the founder of Dr. Laskov’s clinic. “The patient will present this referral to an organization that is not included in the routing. And that organization will not accept it because they will not get paid.”
Until a new order was issued, the doctor could disregard the recommendations of the regional Ministry of Health: the routing existed in the form of a “local order: “If they didn’t follow it, so what, nowhere in the law does it say that this is not a reason not to pay according to OMC rates,” explains the oncologist. Now, exceeding the established list of health care facilities by regional officials is considered a violation of the procedure and a reason for not paying for the services provided.
In other words, now when a medical organization sends a bill to the [OMS] fund or insurance company, the insurance company will legitimately say, “This is where it says you have to follow the routing, and you did not follow it. So, sorry, it’s on you,” Laskov concludes.
The treatment strategy for cancer patients is determined by a committee of specialists. According to the new regulations, it should include oncologists, radiotherapists and neurosurgeons in the case of tumors of the nervous system, and can only be carried out under certain conditions. The document defines it as follows: “Treatment tactics are determined by the medical board… of the medical organization, which includes departments of surgical methods for treatment of malignant neoplasms, anti-tumor drug therapy and radiotherapy”.
Thus, it turns out that a part of non-state oncology clinics operating in Moscow and other major Russian cities is excluded from the treatment process, emphasizes the head of the Russian Society of Head and Neck Cancer Specialists, Ali Mudunov. Mudunov is a participant in the “Onkonavigator” project, which develops roadmaps for cancer patients, and is the head of the specialized department of the Lapino Clinical Hospital “Mother and Child”. This center participates in the compulsory health insurance program and, according to the doctor, provides assistance to several hundred cancer patients from the Moscow region and other regions of Russia every month.
In these regions it is rare to receive high-tech medical assistance and the necessary treatment tactics. The new regulation on holding the council will not affect institutions like Lapino, but small private clinics that formally do not meet the requirements stated in the regulation, says Mudunov.
“We need to understand that when making a decision about the treatment or diagnosis of an oncological disease, the primary role is played not by machines, instruments or equipment, but by the doctor,” Mudunov says. “In this coordinate system, it is only necessary to analyze the information brought by the patient. The patient can bring the results of examinations and go to any private clinic where there are specialists of the required level. In order to make a diagnosis and prescribe a treatment, it is not necessary for that clinic to have a radiotherapy department, as stated in the new regulations”.
In the end, according to Mudunov, a significant number of healthcare organizations that provide care for cancer patients within the framework of compulsory health insurance will be eliminated. In addition to everything else, this will further increase the burden on already overburdened government institutions, both federal and regional. And in fact, this will lead to an even greater decrease in the efficiency of assistance: an increase in the workload of already overburdened institutions, an increase in queues, and an increase in decision-making time, despite the fact that the time intervals for diagnosis and assistance are clearly regulated,” Mudunov is convinced.
Telemedicine, through which the order proposes to conduct consiliences, according to the doctor, does not solve the problem in the format in which this service currently exists: in practice, the organization of remote consultations can take not a few days, as expected, but a week or more. Colleague Mikhail Laskov believes that there may be another negative consequence of the provision on consultations: according to the oncologist, in the regulation this provision is worded in such a way that it undermines “the basic principle of medical autonomy”.
The summoning of a council takes place on the initiative of the attending physician, but according to Laskov’s order, such consultations are his duty even in cases where they can be avoided. So it turns out that there is an oncologist in the clinic. A person comes to him and says, “I have a suspicious mole, it looks like a melanoma. This is the most routine thing that any oncologist in any clinic would check. But what does he do next? Well, he can’t do anything. There should be a surgical oncologist and a radiation oncologist in his organization. He can’t even get a panel of experts together because they don’t exist in the clinic,” says Laskov.
“All Russian and international education assumes that a doctor, having obtained a diploma, has completed a specialization, has undergone clinical training, which means that his role is to receive patients and prescribe treatment or examination for them. Otherwise, what is the point of their existence? – wonders the doctor. – What am I needed for now as an oncologist? For what purpose? To issue a certificate? To take money?”
It is unclear what specific tools the patient will have at his disposal to obtain a referral to Moscow after the new procedure comes into effect. Now, if a cancer patient is dissatisfied with the quality of care in his region and for some reason cannot get a referral to Moscow or St. Petersburg from his treating doctor, he still has options.
“For example, there is the possibility of writing a request to the chief physician to issue an official denial. You can complain to the insurance company, the local Ministry of Health or the Department of Health, the Federal Ministry of Health, or even the Prosecutor’s Office, in order to achieve the goal of being able to receive treatment in the clinic of your choice,” says Anastasia Kaflanova, Director of the Leukemia Fighting Foundation.
The Foundation, which helps people with hematology-oncology diseases, cooperates with federal centers and a number of regional clinics. The main flow of patients in need of expensive treatment, which is not always fully covered by the mandatory health insurance (OMS), comes from these institutions and certain doctors.
Kaflanova is afraid that the new order will increase the number of patients who will not be able to receive the necessary help in federal clinics in a timely manner, and therefore will not come to the attention of the organization. “It is no secret to anyone that the level of equipment and staffing across the country is very uneven and varies greatly. There is also a practice where doctors are simply afraid to ask for help. Because it is believed that everything we need is already available in the region, in our hospital,” says the director of the Leukemia Fight Fund.
“There is also an additional psycho-emotional burden on the doctor. In the end, the patient suffers again. For us as a foundation, they will simply be invisible. For the patient, this can be vital, critically important. Supporters of the new order, however, believe that it will, on the contrary, organize the system of providing aid. “Uniform requirements have been introduced for medical organizations providing assistance to cancer patients, including their capacity and structure. It is important that now any medical institution, regardless of ownership, including private ones, providing assistance in the field of oncology, can participate in the provision of medical care to patients on an equal basis. The procedure does not establish any prohibitions and does not restrict the rights of citizens to choose a medical organization and a doctor,” “Medvestnik” quotes the chief external specialist oncologist of the Ministry of Health, the Director General of the NMRRC of the Russian Academy of Sciences, Andrei Kaprin.
The BBC sent a request to the Russian Ministry of Health asking for clarification on how the norms specified in the document, which caused the greatest concern among medical professionals, will be implemented. However, at the time of publication, one week after the request, there was no response.
