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5IMPROVING THE MODEL OF PROVIDING HIGH-TECH
MEDICAL CARE ON THE PROFILE«DERMATOVENEREOLOGY» FOR PATIENTS WITH SEVERE DERMATOSES
M.D. Rudih N. M.1 2M.D. Alekseeva N. U.2
Russia, Irkutsk 1Clinic of Irkutsk State Medical University 2Irkutsk State Medical University
Abstract. In article the analysis of change of approaches and volumes by rendering high-tech medical care on the profile «Dermatovenereology» in territories of the Russian Federation is presented. For the purpose of increase in availability of high-tech medical careto patients with severe dermatoses, the option of improvement of the organization of this type of medical care is offered.
In accordance with the Presidential Decree 26.09.1992 №1137 «On measures to promote health in the Russian Federation" thefinancing of high-tech medical care (HTMC) was carried out from the federal budget. Real, tangible for the population of the introduction of this type of medical care began only in 2002. Prior to 2005 inclusive HTMCprovided 67 federal medical institutions that received this additional targeted funding.
In 2006 it was decided to include measures to develop HTMC in the national project "Health". One of the priority tasks of the project was to ensure the free and fairness HTMC who need it, regardless of the place of residence in the Russian Federation. The number of federal health care institutions providing HTMChas been increased to 93for successful implementation of this task.
During the period 2002-2013 the security of Russian citizens with high-tech medical care increased by more than 8 times and it was by 2013 352,3 per 100 000 population (in 2002 - 43,0). Including four-timegrowth of HTMC observed on a profile «Dermatovenereology»: in 2002 - 0,4; in 2013- 1,7 per 100 000 population. The highest performance of high-tech medical care on the profile «Dermatovenereology»were in 2007 and 2008 (respectively 2.0 and 1.9 per 100 000 population).
75%of the 24 000 patients with severe forms of the skin disease(received treatment in 2002-2013on the profile «Dermatovenereology»)consisted patients with psoriasis. The overwhelming majority of patients with severe dermatoses (20 000, or 83% of the total number of patients in this group) were provided with high-tech medical care. The result of the treatment of patients with HTMCwas a significant improvement and clinical recovery (92% of treated patients).95% of them received physiotherapy and multicomponent treatment, 5% received treatment with genetically engineered biological drugs.
The limit number of participants is the beneficiaries of the quota for high-tech medical care. So, two federal health medical institutioninvolved only in the realization of the state task on the profile and type of carein 2002. In 2004, nine institutions of different levels were already participants in this type of medical care, in 2006 - 13; 2008 - 18; 2013 - 16. Research centers, research institutes clinics of higher educational institutions, federal specialized hospitals have been involved inassistance of high-tech medical care on the profile «Dermatovenereology». This type of care was partially closer to the residents of the Siberian, Ural and Far Eastern Federal Districts. However, the problem of the availability of high-tech medical care has not been resolved for patients in these regions.
Until 2014, the financing of high-tech medical care provided only from the federal budget. "Federalization" of high-tech medical care limited the possibility of obtaining the quota by medical institutions in the regions. The most problematic for patients issue was the cost of travel to the place of treatment.
In 2014, the HTMC was included in the basic program of compulsory medical insurance and containeda total of 459 treatments for diseases for 21 profile. The reason for this was the fact that began to operate a federal law on the division of powers between the federal authorities and the authorities of subjects of the Russian Federation subjects (Federal Law 06.10.1999 №184-FZ was in the red. 03.07.2016 "On General principles of organization of legislative (representative) and executive bodies of state power of subjects of the Russian Federation", p. 21). Thus, the regions have
received considerable independence in the provision of specialized, including high-tech medical care. Since 2014 the provision of this type of medical care is only possible at the expense.
One model of the patient was regulatedonly by the list of high-tech medical care on the profile «Dermatovenereology»from means of compulsory health insurance. This model was severe common forms of psoriasis without joint damage in the absence of prior methods of systematic and physiotherapeutic treatment. At the same time, the basic program of state guarantees of free medical care provision to citizens for 2014 in the section of high-tech medical care at the means of compulsory health insuranceis not provided for the treatment of severe psoriasis and psoriatic arthritis with the use of genetically engineered biological drugs, dermatitis (severe forms of atopic dermatitis, localized scleroderma , pemphigus, psoriatic arthritis).
For example, the Irkutsk region can be stated that the division of powers between federal framework and frameworkof the federation subject in the compulsory health insurance contributed to the real approximation to the patient of high-tech medical care. So, in 2014 for the first time in the region it has been allocated funding from the compulsory health insurance for the provision of hightech medical care on the profile «Dermatovenereology»in the amount of 170 completed cases.150 of from themhave been received by Clinicof Irkutsk State Medical University (Clinic).
List of types of high-tech medical care for 2015, included in the basic benefits package (Resolution of the President of the Russian Federation 28.11.2014 №1273 with supplement to the program of state guarantees of free medical care for citizens on 2015), also funded by subventions from the budget Federal Fund of the compulsory health insurance territorial.
In 2015, the list has included all 8 models on the profile «Dermatovenereology». there was now an opportunity to receive an effective high-tech therapy for patients with severe atopic dermatitis, localized scleroderma, pemphigus. The ratio of financial costs per unit of volume for this type of medical care and the profile was 91 052 rubles.
During 2014-2015 treatment with application of high-tech medical care with financing from sources of compulsory health insurance was received by 300 patients severe forms of vulgar psoriasisin dermatological department of Clinic.The duration of hospitalization in hospitals averaged 25 bed-days (instead of the recommended 12,2for specialized medical care). Patients have received treatment with application of general and local narrowband phototherapy with emission 311nm, photochemotherapy (PUVA therapy), plasmapheresis in combination with cytostatic(methotrexate), immunosuppressive (cyclosporine A) drugs, synthetic derivatives of vitamin A (acitretin). More long duration of hospitalization (25 bed-days) has allowed to conduct to patients full examination, treatment, to make optimum recommendations.
In 2016, treatment with high-tech planned 170 patients with severe forms of psoriasis, atopic dermatitis, a localized sclerodermaon the basis of dermatological department of Clinic. The amount of financing on one completed treatment case within HTMC on the profile«Dermatovenereology»in 2016 was 96 874.43 rubles, which is 24,4% higher than in 2014 (77 850 rubles) and 6,4% higher than in 2015 (91 052 rubles).
Despite increase in financial security of one finished case of rendering HTMC on the profile «Dermatovenereology» in 2015 and 2016, there was no opportunity to receive treatment by means of genetically engineered biological therapy for patients with the most severe forms of psoriasis, resistant to other types of system therapy. The amount of financing existing today on one completed case of treatment doesn't allow even to cover expenses on acquisition only of genetically engineered medicines for patients with psoriasis which cost makes from 150 to 230 thousand rubles.
Thus, financing HTMC of at the expense of means of compulsory health insurance by a subvention from the budget of the compulsory health insurance Federal fund to budgets of the compulsory health insurances territorial funds, has allowed regions to show successfully independence in rendering this type of medical care; promoted increase in availability of HTMC to the population both in respect of expansion of its volumes, and by eliminating the need to transport costs.
The introduction of the regions of this type of care has opened the possibility to receive effective therapy for patients with severe psoriasis and psoriatic arthritis, atopic dermatitis, localized scleroderma, pemphigus. At the same time, approved (according to the Program of the state guarantees) the HTMC methods - physiotherapeutic in combination with cytostatic, immunosupressivny and other groups of medicines of system therapy - received today widespread.However, for the patients with the most severe cases of psoriasis and psoriatic arthritis, resistant to the listed types of therapy, and in need of genetic engineering of biological therapy the impossibility of her receiving within HTMC at the expense of means of compulsory health insurance remains so far because of the insufficient amount of financing at the rate on unit of volume of medical care.
32 № 9(13), Vol.2, September 2016
WORLD SCIENCE
Considering existence in the territory of subjects of the Russian Federation of the medical organizations both federal level, and the regional submission having the certain tasks rendering forspecialized medical care to the population there is urgent a question of division of the HTMC methods and tasks on their performance depending on the level of subordination of the medical organizations.The first group includes methodsHTMC, became widespread, which may be included in the compulsory health insurance basic program and provided to regional institutions. The HTMC more difficult methods demanding big financial expenses, which will mainly appear in the institutions of federal submission located in regions, can be carried to the second group.Similar division will promote improvement of quality to the rendered both specialized, and high-tech medical care, and also increase in regions of availability of HTMCon the «Dermatovenereology» profile to patients with the most severe dermatoses.
REFERENCES
1. Federal Law 21.11.2011 №323-FZ "On the basis of protection of citizens in the Russian Federation".
2. Federal Law 29.11.2010 №326-FZ "On compulsory medicalinsurance in the Russian Federation".
3. Territorial program of state guarantees to citizens of the Russian Federation free medical care in the Irkutsk region on 2014.
4. Territorial program of state guarantees to citizens of the Russian Federation free medical care in the Irkutsk regionon 2015.
5. Territorial program of state guarantees to citizens of the Russian Federation free medical care in the Irkutsk regionon 2016.
6. Federal Law 06.10.1999 №184-FZ «On General principles of organization of legislative (representative) and executive bodies of state power of subjects of the Russian Federation» (in the red. 03.07.2016).
7. Resolution of the President of the Russian Federation 28.11.2014 №1273 «On the Program of the state guarantees of free rendering medical care to citizens for 2015 and for planning period on 2016 and 2017».
