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.
To begin this article, the details of this scandalous case must be outlined more broadly. There are two hypoallergenic milk substitute preparations available on the market for very young children: Neocate LCP for children up to 12 months of age and Neocate Junior for children over 12 months of age. They differ only slightly in their composition, but unfortunately significantly - in their reimbursement indications. The milk is intended for patients struggling with food allergies and intolerances – cow's milk protein allergy, food protein intolerance, or similar conditions. The reimbursement assumptions established by the Ministry of Health provide that Neocate LCP will be used up to 12 months of age, and Neocate Junior for older children. It was therefore quite optimistically assumed that the body of a child suffering from food allergies or intolerances would function like a well-oiled machine and would be able to tolerate the new milk without any problems "from one day to the next" after reaching 12 months of age. However, reality has brutally verified this assumption and exposed the flaws of the reimbursement system, for which the National Health Fund (NFZ) has decided to punish... doctors.
Neocate – why does the National Health Fund punish doctors?
Recently, NFZ (National Health Fund) inspections have swept through doctors' surgeries like a tsunami, searching for various deficiencies. However, it appears that the inspectors paid particular attention to one aspect… We are talking about the way doctors prescribe Neocate. Meticulous NFZ officials have diagnosed a problem involving the practice of prescribing Neocate LCP milk to children over 12 months of age, which is beyond the refund period. For these children, the refund system provides for Neocate Junior. This situation seems relatively logical at first glance – after all, there are specific refund criteria, as discussed below; the system "isn't made of rubber," and funds are not infinite, so if a doctor prescribes a given nutritional product outside the refund system, someone should bear the cost – either the patient at the pharmacy, or the doctor after an inspection, shouldn't they? Well, not quite. This view of the described problem represents a complete distortion of the idea and the very *ratio legis* of the refund system operating in Poland, it infringes upon the patient's constitutional and statutory right to healthcare and medicines, and is also completely soulless from a "human" perspective. And thus, it is also contrary to the principles of social coexistence, making it usually ineffective in court anyway. So why threaten doctors with further penalties? To make people's lives more pleasant? Or to "earn" a little more money for the NFZ budget?
How does the Neocate refund system work?
To understand the above issue, it is necessary to familiarise yourself with the workings of the refund system. Let us therefore use the example of Neocate. Neocate LCP milk itself costs around PLN 150 per can at the pharmacy (which translates to a cost of around PLN 1500/month for feeding one sick patient). When a doctor prescribes this preparation on a prescription, they can, of course, prescribe it outside the refund system. In such a case, the patient will pay the full PLN 150 for a can, for which they might pay PLN 3.20. The difference is therefore diametrically opposed, and the entire refund system was created precisely to support the sick, whose medication costs could simply become insurmountable. To prescribe medication under the refund system, legally defined refund criteria must be cumulatively met. In the case of Neocate, there are two: firstly, specific medical indications, and secondly, the age criterion. And while the NFZ (National Health Fund) rarely questions the validity of prescribing Neocate based on the medical criterion, it very meticulously challenges the age criterion. Therefore, when a doctor prescribes Neocate LCP to a child older than 12 months (or 18, because the NFZ has arbitrarily decided – albeit to the benefit of patients – that up to this limit it is willing not to question the validity of prescribing Neocate LCP), the NFZ demands the refund amount back. And this is not a small amount, as on 1 can it is over PLN 140.
Why do doctors prescribe Neocate LCP for older children?
Unfortunately, contrary to the NFZ's expectations, a sick child's body does not function like a machine. A certain proportion of the youngest patients cannot adapt "overnight" to Neocate Junior milk, which should be prescribed to them after 12 (or 18, as described above) months of age. Some bodies need more months to change, and for some, it is never possible. This means that for a certain proportion of children, the age-related reimbursement criteria are completely unsuited to the real medical needs. In some cases, patients, even after reaching 18 months of age, are unable to eat anything other than Neocate LCP. The problem with the availability of Neocate Junior milk on the market is also very significant. In many pharmacies, it is a scarce commodity, moreover, it has been on the list of scarce medicines by the Minister of Health for many years (not to be inaccurate – Neocate LCP is also on this list), which means that this preparation is simply unavailable in many pharmacies and for many less informed and mobile parents in their municipality, district, or even sometimes region. Doctors are therefore often faced with a choice: prescribe the only milk that a severely ill child can consume or that their parent can buy in a pharmacy, or... well – condemn such a smallest patient to starvation? However brutal it sounds, this is the reality. However, while one can lose faith in people many times when looking at the NFZ's actions, one can regain it when looking at doctors who pass the test of humanity and remember the oath of "primum non nocere," aware of the risks they are taking, prescribing the reimbursed Neocate LCP milk to older patients. Otherwise, they would condemn them either to starvation or the parents to unaffordable costs (PLN 1500/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": 
Doctor, doctor, please don't give up so easily
This action is deeply scandalous and unacceptable in a civilised, law-abiding state. As part of the work of our law firm, we are conducting several proceedings, defending doctors in cases against the National Health Fund (NFZ) concerning Neocate. Other law firms are also handling such cases. And rightly so, because truth be told, courts usually protect doctors. We already know from experience that in equally absurd cases of refund repayment – the justice system is not afraid to side with doctors. It is difficult for it to side with the NFZ, which is an institution that once again flagrantly violates the principles of social coexistence. It is really not doctors who should be financing the healthcare system. This penalty does not need to be paid, and this is the moment when one must fight. For one’s own money, and above all, for principles. Although those doctors who face penalties of 100,000 zlotys may just as well lose their homes. There is only one long-term solution to this problem – the refund law must be changed. Otherwise, the same problem will return again. Perhaps under a different name. And the solution is simple – a doctor who has not participated in any criminal proceeding should not be obliged to repay the refund. And if the NFZ wants to block the prescribing of a certain medicine for a certain age group – it should block the possibility of issuing such refunded prescriptions through IT. After all, this would at most take a few hours of work for an average IT professional, with the E-Prescription system. Otherwise, we will continue to say that the NFZ contributes to the creation of its own imaginary damages. Imaginary – because no one else but them claims that feeding children can be called damage. And it contributes to this one hundred percent, because it could have prevented it itself. But it is probably afraid of protests from parents of starving children, outside its own headquarters.