Why do we need custom chemotherapy?

Proven content

The recent confusion related to the reimbursement of non-standard treatment in oncology by the National Health Fund is only a weak echo of the everyday problems of oncological treatment in Poland. Taking up the matter by the media brought to light, on the one hand, the fear of cancer patients about the limitations of therapy, and on the other – the efforts of doctors and nurses, trying by all means – contrary to the suggestions of the President of the National Health Fund – to conduct this therapy.

I have been treating people with cancer for several years. Therefore, acting in a constant crisis is nothing new to me. A handful of the following comments are an attempt to comment on the current situation in the financing of oncological chemotherapy in Poland.

What is custom chemotherapy?

Non-standard chemotherapy is a term used in settlements between the Hospital and the National Health Fund. It is a technical concept – suffice to mention that it is not always chemotherapy (and – for example – biological targeted therapy) and sometimes it is the most standard. So what is it?

The current model of accounting for oncological treatment is as follows: the doctor has a list of drugs that can be administered as part of standard treatment. In addition – usually in the case of more expensive procedures – the so-called therapeutic programs in which the National Health Fund reserves the criteria of eligibility and disqualification from treatment, and introduces an arbitrary form of assessment of the effects of treatment. Finally, there is a third method of accounting for oncological therapy – precisely as part of non-standard chemotherapy: if a treatment method is not included in the list of – let’s say simply – generally available, or in the therapeutic program, the attending physician may apply to the National Health Fund for its financing. Each application for non-standard treatment must be approved by the regional clinical oncology consultant.

The case might seem simple, but:

– each application requires the completion of documentation (electronic and printed) according to strictly established and changing rules. A formal defect usually causes delays in considering the application (example from own practice: another regulation of the National Health Fund changed the layout of a certain page of an annex from vertical to horizontal, filling the annex vertically was the reason for not considering the application);

– the decisions of the National Health Fund regarding the classification of specific treatment methods into one of the three reimbursement methods change several times a year – usually with a retrospective date. Something that was a standard yesterday, today is non-standard, or reimbursed under the therapeutic program (everything is settled differently) etc .;

– the list of generally available drugs is supplemented with the maximum daily dose of the drug that can be used – it is known that no one has mastered the dosage of oncological drugs as perfectly as an official of the National Health Fund. The original list of doses contained a significant number of errors – it underestimated the maximum reimbursed daily doses of several drugs below the threshold of their action – then the doctor faced a choice: to administer the acting dose and not obtain a refund, or to use a non-effective dose, but reimbursed;

– consent for non-standard treatment covers not only the type of drug, but also the mode in which it is to be administered (a fact from own practice: the patient underwent non-standard treatment with tablets as part of outpatient admissions, during the next cycle there were medical indications for hospitalization and continuation of treatment in the Ward. The payer refused the reimbursement – because the consent concerned outpatient treatment. It was necessary to fill in a new application, another opinion of the consultant, etc. All only to give the same pills – only in the Ward!)

– non-standard treatment can be (from the medical point of view) as standard as possible: I remember that about a year or two ago one of the drugs included in the old and cheap, but very effective breast cancer treatment regimen (according to Ansfield) was not included in the list of generally available drugs for breast cancer, nor in the therapeutic program. The solution was to write applications for non-standard treatment using a XNUMX-year-old program, or to provide this drug to patients by the hospital;

– and finally, the essence of the problem – a significant number of requests for non-standard treatment are rejected. I can understand this situation: we live in a poor country, and non-standard therapies are often not fully proven effective – usually at a high price. However, I cannot understand the mechanism in which the Regional Departments of the National Health Fund differ when it comes to granting consent for non-standard treatment with the same drug in analogous clinical situations. Whether or not a patient receives treatment may depend on where they are registered!

– all this takes a huge amount of time and energy. Oncologists are starting to lack a little energy. The patients never had time.

Is it bad?

Contrary to appearances, I do not think it is that bad. Each bureaucracy is looking for its raison d’être – and so the NHF bureaucracy will inevitably create piles of orders, procedures, mix, cancel what it ordered every month ago, etc. This makes the functioning of doctors who were burdened with de facto duties outside of their activities extremely difficult. Most of the patients are unaware of the tremendous amount of nonsensical reporting work required to administer one simple cycle of chemotherapy. Of course, time is limited and you either comfort the sick person or fill out the receipts (and the queue goes up). However, it is important that sensible oncological treatment is reimbursed. In my opinion, taking into account the economic misery of our country, it is not too bad, although a lot still needs to be done. The only unacceptable practice seems to me to differentiate the reimbursement of expensive oncological therapies by various Regional Departments of the National Health Fund.

What should it look like?

The key to the problem is the principle of competence – the optimal method of treatment is decided by me, about the level of its reimbursement – the insurance institution, and about the method of its execution – the clerk employed by the hospital. I know that I will not live to see such times. So what to do within the current system? First of all – follow the rules of art: some therapies are worth fighting for, and some not – this is the awareness of every reliable specialist in oncology. Since the text does not concern the effectiveness of treating individual cancers, but the turmoil around its reimbursement, I do not develop this idea.

Secondly – you must not take the patient’s emotions on yourself, because this will help the first two in the queue, and the next twenty will not be able to accept. It is not the doctor, but the payer, who restricts access to treatment (and this is probably his role in the system). Third, if high-cost treatment is optimal, it must be persistently applied for. I personally wrote dozens of applications for non-standard treatment. Most were rejected. Most of the sick are already dead. In my opinion (which is the result of experience and knowledge), the therapy I applied for could bring clinical benefit to the patients. There was nothing else I could do. Fourthly – you should not listen to politicians, because they are distorted people and they will say everything in front of the camera, and the patient and the doctor who owe him will get their butt. Fifth – not to have too much hope for any real improvement of the situation, because it is not rational.

Final note.

In all of the above text, I have said nothing about the real problems of oncology – that is, cancer, suffering, hopes and lost hopes, fear and dying, but only the problems that some of us have created for another of us.

Text: lek. med. Grzegorz Świątoniowski – specialist oncology

See I fight cancer and I can do it!