Models of organization and methods of payment for medical care for patients with malignant neoplasms and anemia at the expense of compulsory medical insurance

The availability of medication is directly determined by the ability to reimburse its costs, which determines the appropriateness of anemia therapy and the prognosis for cancer patients. Aim of the work was to assess the potential for financing medical care for patients with malignant neoplasms and anemia using compulsory medical insurance.

A review of payment methods for medical care for patients with malignant neoplasms and anemia using compulsory medical insurance funds in accordance with Russian legislation was conducted. Models of medical care organization are identified depending on the suspected etiology of anemia. Suitable payment methods for each model are substantiated.

For patients who develop anemia after starting anticancer therapy, there are several options for paying for medical care using compulsory medical insurance: 1) a single clinical statistical group with antitumor therapy [ds19.157–ds19.180; st19.182–st19.202], as well as a patient treatment complexity coefficient sl005 for a concomitant disease – unspecified anemia (International Classification of Diseases, 10^th revision code D64.9) (i.e. without an established etiology); 2) 1^st clinical statistical group (1^st insurance event) with antitumor therapy [ds19.157–ds19.180; st19.182–st19.202]; 2^nd clinical statistical group (2^nd insurance event) with treatment for anemia of specified etiology (except International Classification of Diseases, 10^th revision code D64.9) [ds05.001–ds05.002; st05.001–st05.002]. A decision-making algorithm has been developed to ensure a legal mechanism for the use of treatment complexity coefficient, within the framework of which erythropoiesis-stimulating drugs for unspecified anemia are prescribed before the diagnosis of anemia in malignant neoplasm is established.

Compliance with the proposed decision-making algorithm before submitting an insurance claim for payment with treatment complexity coefficient s1005 for unspecified anemia opens up opportunities for insurance coverage of erythropoiesis-stimulating drugs in oncology medical organizations, which increases the availability of drug treatment for patients insured under compulsory medical insurance.