Neocate reimbursement – why doctors should not be intimidated.

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Piotr Kłodziński|
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For several months now, the medical community, and therefore the lawyers cooperating with them, have been witnessing the extremely scandalous practice of the National Health Fund, which shifts the costs of reimbursement of milk for the youngest patients onto doctors. We are talking about the Neocate milk replacer, which is available in a form for newborns (up to 12 months of age) and a variant for small children (over 12 months of age), which is difficult to obtain in Poland. Many of the youngest patients either do not have access to formula for small children or are unable to change their diet overnight and need to use formula for newborns for longer. How does the National Health Fund respond to this problem? He replies: Doctor! Then you pay! – over PLN 140 for each can you prescribed to sick children. Who would otherwise be malnourished… that is, simply hungry.

To make you realize the scale of the problem: the National Health Fund has already demanded a total of over PLN 5 million from prescribers, and at least 1,680 doctors have already been punished for nothing.

At the beginning of this article, it is necessary to outline the details of this shocking case in greater detail.

There are two hypoallergenic milk replacers on the market intended for consumption by the youngest children: Neocate LCP for children up to 12 months of age and Neocate Junior for children over 12 months of age. They differ only minimally in terms of composition and, unfortunately, very much in terms of reimbursement indications. The milk is intended for patients struggling with food allergies and hypersensitivities - cow's milk protein allergy, food protein intolerance or other similar diseases. Reimbursement assumptions created by the Ministry of Health provide that Neocate LCP will be used up to 12 months of age, and Neocate Junior in older children. It was therefore assumed quite optimistically that the body of a sick child or a child suffering from food allergies works like a well-oiled machine and will be able to accept new milk without any problems "day by day" after the age of 12 months. However, reality brutally verified this assumption and showed the imperfection of the reimbursement system, for which the National Health Fund decided to punish... doctors.

Neocate – why does the National Health Fund punish doctors?  

Recently, National Health Fund inspections have swept through medical offices like a tsunami, looking for various shortcomings. However, it seems that the inspectors paid special attention to one element... The way doctors prescribe Neocate. The scrupulous National Health Fund has diagnosed a problem in which Neocate LCP milk is prescribed to children who are older than the 12 months provided for in the reimbursement, while for them the reimbursement system provides for Neocate Junior.

This situation seems to be quite logical - after all, there are specific reimbursement criteria, as described below, the system is "not made of rubber" and the resources are not infinite, so if a doctor prescribes a given nutritional product outside the reimbursement system, someone should bear the cost - either a patient in a pharmacy or a doctor after a check-up, right? Well just no.

This way of looking at the described problem is a complete distortion of the idea and ratio legis of the reimbursement system operating in Poland, it violates the patient's constitutional and statutory right to health care and medicines, and is completely heartless from the "human" point of view. And therefore, it is inconsistent with the principles of social coexistence, and therefore usually proves ineffective in court anyway. But why threaten doctors with further penalties? To make people's lives more enjoyable? Is it to "earn" some more money for the National Health Fund budget?

How does the Neocate refund system work?

To understand the above problem, you need to familiarize yourself with how the refund system works. So let's use the example of Neocate. Neocate LCP milk itself costs about PLN 150 per can in a pharmacy (which translates into a cost of PLN 1,500/month to feed one sick patient). When a doctor prescribes this preparation, he or she may, of course, prescribe it outside the reimbursement system. In this case, the patient will pay the full PLN 150 for the can, for which he can pay PLN 3.20. The difference is therefore diametrical and the entire reimbursement system was created to support patients whose drug costs could simply be too high.

Therefore, in order to prescribe a drug under reimbursement, the reimbursement criteria set by law must be cumulatively met. In the case of Neocate, we have two: firstly, specific medical indications, and secondly, the age criterion.

And while the National Health Fund rarely questions the validity of the Neocate prescription based on a medical criterion, it very carefully questions the age criterion.

Therefore, when a doctor prescribes Neocate LCP to a child older than 12 months (or 18, because the National Health Fund arbitrarily decided - in favor of the patients - that he is willing not to question the validity of the Neocate LCP prescription up to this limit), the National Health Fund demands a refund of the refund amount. And this one is not small, because one can costs over PLN 140.

Why do doctors prescribe Neocate LCP for older children?

Unfortunately, contrary to the expectations of the National Health Fund, the body of a sick child does not work like a machine. Some of the youngest patients are not able to adapt from "day to day" to Neocate Junior milk, which should be prescribed to them after 12 (or 18, as described above) months of age. Some bodies take more months to change, and for some it is never possible.

This means that in some children, the reimbursement criteria regarding age are completely unsuited to the real medical need. In some cases, even after the age of 18 months, patients are unable to eat any other product than Neocate LCP.

The problem of availability of Neocate Junior milk on the market is also very important. In many pharmacies it is a scarce product, and for many years it has been included on the list of scarce drugs by the Minister of Health (not wanting to be inaccurate - Neocate LCP is also on this list), which means that this preparation is available in many pharmacies and for many less computerized and parents with cars - it is simply unavailable in their commune, poviat, and sometimes even voivodeship.

Doctors are therefore often faced with a choice: prescribe the only milk that a seriously ill child can consume or that his or her parent can buy at a pharmacy, or... well, condemn the smallest patient to starvation? As brutal as it sounds, this is the reality.

However, if you can lose faith in people many times by looking at the activities of the National Health Fund, you can rebuild it by looking at doctors who pass the test for humanity and remembering the text of the oath "primum non nocere", aware of the risk they incur, they prescribe reimbursed Neocate LCP milk to older patients. Otherwise, they would either condemn them to starvation or their parents to bear unbearable costs (PLN 1,500/month for one child!).

What does the National Health Fund say about this?

The National Health Fund, on the other hand, has found an endless source of financing in this practice... It demands reimbursements from doctors for prescriptions issued contrary to the age criterion. And although he has known this problem for many years, already in 2019, together with the Zielona Góra Agreement Federation (representing doctors) and the Ministry of Health, he established a specific practice in this area, at the end of 2021 and throughout 2022 he decided to change his mind and cynically use this systemic gap to be exploited nomen omen “funds” – from doctors. The Health Fund systematically imposes "penalties" on subsequent doctors who act in accordance with patients' rights, the idea of the reimbursement system and, above all, in the interest of children's health and life. The following table shows how much the National Health Fund "recovers":

No description.

Doctor, doctor, please don't give up so easily

This action is deeply scandalous and unacceptable in a civilized state of law. As part of the Law Firm's activities, we conduct several proceedings, defending doctors in cases with the National Health Fund regarding Neocate. Other law firms also handle such cases. And that's good, because the truth is that courts usually protect doctors. We already know from experience that in equally absurd cases regarding reimbursement, the justice system is not afraid to side with doctors. It is difficult for him to side with the National Health Fund, which is an institution that is once again blatantly violating the principles of social coexistence. Doctors really shouldn't be financing the healthcare system. You don't have to pay this fine, and this is the moment to fight.
About my own money and, above all, about principles. Although those doctors who have fines of PLN 100,000 may well lose their apartment.

There is only one long-term solution to this problem - the reimbursement act needs to be changed. Otherwise the same problem will come back again. Perhaps under a different name.
And the solution is simple - a doctor who did not participate in any criminal activity should not be obliged to return the refund.

And if the National Health Fund wants to block the prescription of a certain drug for a certain age group, it should IT-block the possibility of issuing such reimbursed prescriptions. After all, it is only a few hours of work for an averagely talented IT specialist using the E-Prescription system. Otherwise, we will be able to continue saying that the National Health Fund contributes to its own imaginary damages. Imaginary - because no one else claims that feeding children can be called harm. And this contributes one hundred percent, because he could have prevented it himself. But he is probably afraid of protests by parents of hungry children in front of his headquarters.

3.5/5 - (6 votes)

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