They decided not to save on cancer – Newspaper Kommersant No. 167 (7368) of 09/12/2022

In 2023, the Federal Compulsory Medical Insurance Fund intends to test a payment system for each targeted therapy regimen for cancer, and not for clinical statistical groups (CSG). This should affect the availability of modern high-quality treatment, since, according to Olga Tsareva, FFOMS deputy chairman, DRG payments allowed clinics in some regions to choose the cheapest schemes, thus reducing therapy costs. Experts note that for the first time in a long time, the fund has expressed a position that is different from the position of the Center for Expertise and Quality Control of Medical Care of the Ministry of Health of Russia, which is developing the CSG.

The Federal Compulsory Medical Insurance Fund (FFOMS) plans in 2023 to temporarily stop paying for targeted therapy (treatment with drugs that block the growth and spread of cancer cells) for oncological diseases by clinical and statistical groups (they indicate the cost, cost structure and set of resources used to treat the disease ) and to test the payment system for each treatment regimen, Vademecum said, citing Olga Tsareva, deputy chairman of the FFOMS. According to the publication, speaking at the Innovative Oncology forum, Ms. Tsareva stressed that if the rejection of CSG turns out to be unjustified and the cost of therapy rises critically, the fund will return to the previous model.

The FFOMS explained to Vademecum that the idea to withdraw payment for targeted therapy from the CSG system is part of the process of preparing a program of state guarantees for 2023. The offer applies to both federal and regional clinics. The fund’s specialists hope that if the new system is nevertheless introduced, the availability of targeted therapy will increase: its use will not be limited by the cost of DRG, which means that it will be compensated “more fully” for clinics that most actively use innovative therapy.

The main claim of the professional and patient communities to the current system is its opacity. The CSC is developing the Center for Expertise and Quality Control of Medical Care of the Ministry of Health of Russia (TsEKKMP). “Features of billing in CHI imply different margins, that is, different income of a medical institution from providing assistance in each case,” Alexei Bereznikov, head of the working group on organizing compulsory medical insurance of the All-Russian Union of Insurers, told Kommersant. As a result, Polina Gabay, vice-president of the Together Against Cancer foundation of anti-cancer organizations, explains that some schemes can be scarce by 200 rubles, while others by 200 thousand rubles.

It should be noted that the Compulsory Medical Insurance Fund and the CECCM differ in their understanding of which method of payment for chemotherapy is optimal. The CECCMP supports the DRG system, as it averages the cost of paying for drug therapy for oncological diseases. Due to this, according to the experts of the center, it is possible to maintain a balance between more and less profitable drug regimens and prevent overspending of the annual budget of the FFOMS.

Olga Tsareva has repeatedly said that when using expensive CCG for targeted therapy, oncology dispensaries use the most inexpensive drug regimens. The CECKMP, at the site of which the CSG model for 2023 is being discussed, said that they are considering differentiating the payment scheme for the highest-cost group for solid tumors. But in 2022, this group includes schemes with immuno-cancer drugs – ipilimumab, pembrolizumab, and a combination of nivolumab and ipilimumab, follows from the materials of the Compulsory Health Insurance Fund. They are not targeted.

In the CHI system, there have already been cases of payment differentiation for individual drugs. For example, this happened in oncohematology. Since 2021, a list of 22 specific drugs has appeared in the CSG (a year later it expanded to 24), the therapy for which was paid for taking into account individual coefficients. The same thing happened in 2022 with genetically engineered drugs for the treatment of rheumatic diseases.

According to Polina Gabay, the intention of the FFOMS to test the new payment system is “extremely inspiring”. “For a long time, the fund for the first time expressed a position that is different from the position of the Ministry of Health of Russia and the CECKMP of the Ministry of Health of Russia. Apparently, this is due to the arrival of a new progressive leader to the fund, whose task is to eliminate the shortcomings in the system of financing medical care,” Ms. Gabay believes. She notes that the pilot will most likely not even affect all targeted drugs, but there is hope that in the future the practice will spread to other cancer treatment regimens.

In general, according to Ms. Gabay, the problem with paying for treatment under CHI is large-scale: now, in most cases, tariffs for medical organizations are unprofitable. “Medical institutions are forced to minimize their losses, therefore, of course, they prefer “tasty” schemes. This imperatively pushes the clinic to use certain drugs from certain manufacturers and, accordingly, not to use others,” says Ms. Gabay. Together Against Cancer President Bakhodur Kamolov adds that while this practice is “illegal and distorts approaches to medical practice,” the institution’s desire not to treat at a loss is “more than adequate.” He notes that many clinics are actually bankrupt, they have colossal accounts payable, solid and large institutions cover their losses with charitable funds. Mr. Kamolov hopes that the change in the system of payment for treatment under compulsory medical insurance will also affect the general situation.

“Kommersant” sent a request to the Center for Expertise and Quality Control of Medical Care, but at the time of publication did not receive a response.

Natalia Kostarnova, Polina Gritsenko