Úhrady z verejného zdravotného poistenia a hľadanie „nadštandardu" | Medicínske právo
              

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Úhrady z verejného zdravotného poistenia a hľadanie „nadštandardu"


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Keď prispievame do poistného „fondu“, tak následne očakávame, že za nás bude zdravotná starostlivosť zaplatená. Pri štúdiu Ústavy SR narazíme na jej čl. 40, ktorý občanom Slovenskej republiky výslovne priznáva právo na bezplatnú zdravotnú starostlivosť a na zdravotnícke pomôcky na základe zdravotného poistenia za podmienok, ktoré ustanoví zákon. Toto právo garantuje pre občanov väčší rozsah práv, keďže najvšeobecnejší subjekt každý (1) má ex constititione právo (len) na ochranu zdravia.

Obrazok

 

Dlhodobo otázny a polemický je pojem „bezplatná“, ktorý vysvetľuje Drgonec (cit.): „S pojmom „bezplatná" sa spája zdravotná starostlivosť, aj poskytovanie zdravotníckych pomôcok. Obe sa poskytujú za podmienok ustanovených zákonom na základe zdravotného poistenia, a teda z tohto pohľadu „bezplatne"" (2) . Tejto otázke sa už venovalo aj plénum Ústavného súdu SR v konaní vedenom pod sp. zn. PL. ÚS 38/03, ktorého výsledkom bol nález sprevádzaný zaujímavým dissentom sudkyne Gajdošíkovej a sudcu Baránya. Uvádza sa v ňom napríklad (cit.): „Výraz „bezplatná“ použitý v Čl. 40 Ústavy totižto svojou podstatou nepripúšťa mieru alebo odstupňovanie bezplatnosti, lebo sám je presným vyjadrením miery."

 

1. Úvodné poznámky

Je potrebné si uvedomiť, že zdravotná poisťovňa je pri vykonávaní povinného verejného zdravotného poistenia špecializovanou finančnou inštitúciou sui generis. Pokiaľ ide o vykonávanie verejného zdravotného poistenia, nemôžeme zdravotnú poisťovňu považovať za „klasickú komerčnú akciovú spoločnosť" (3). Zdravotnú starostlivosť z verejného zdravotného poistenia prepláca zdravotná poisťovňa na základe zákona č. 577/2004 Z. z. o rozsahu zdravotnej starostlivosti uhrádzanej na základe verejného zdravotného poistenia a o úhradách za služby súvisiace s poskytovaním zdravotnej starostlivosti v z. n. p. (ďalej len „zákon o rozsahu zdravotnej starostlivosti uhrádzanej na základe verejného zdravotného poistenia) a lieky, zdravotnícke pomôcky a dietetické potraviny na základe zákona č. 363/2011 Z. z. o rozsahu a podmienkach úhrady liekov, zdravotníckych pomôcok a dietetických potravín na základe verejného zdravotného poistenia a o zmene a doplnení niektorých zákonov v znení zákona č. 460/2012 Z. z. (ďalej len „zákon č. 363/2011 Z. z.“). Existujú teda zákonné limity, čo má byť z verejného zdravotného poistenia preplatené , a tak isto je stanovený istý dispozičný priestor, v ktorom je možné riešiť špecifické prípady hodné osobitného zreteľa.

Bežný pacient sa na preplácanie zdravotnej starostlivosti pozerá optikou „sedliackeho rozumu“, t.j. keď roky nič nepotreboval a poslušne platí zdravotné odvody, v čase nutnej intervencie do jeho zdravia očakáva adekvátnu zdravotnú pomoc – bez čakania a bez doplatkov.
Keď teda nastane situácia, v ktorej je vyhľadanie zdravotnej starostlivosti nutnosťou, pacient prirodzene očakáva:

  1. adekvátnu zdravotnú starostlivosť;
  2. že potrebnú liečbu a starostlivosť už má „predplatenú";
  3. že všetko, čo bude po zdravotnej stránke potrebovať, bude za neho aj následne zaplatené bez jeho dodatočnej finančnej spoluúčasti.

Vzhľadom na rokmi vžité „pravidlá fungovania“ zdravotného poistného systému, tieto očakávania považujeme za pochopiteľné. Je však na mieste položiť si otázku, aká „miera bezplatnosti" zdravotnej starostlivosti je tá proporcionálne správna.

 

2. Zdravotná starostlivosť a „nadštandard“

Základný princíp platiaci pri uhrádzaní zdravotnej starostlivosti znie: zdravotná poisťovňa platí štandardnú liečbu a „nadštandard“ (všetko nad rámec štandardnej liečby) uvedený v cenníku poskytovateľa zdravotnej starostlivosti platí pacient. Samotný pojem „štandard“ je značne problematický nielen z dôvodu mnohovýznamovosti tohto slova, ale aj preto, že zákon 577/2004 Z. z. ho používa len na jednom mieste. Ide o §44 ods. 4, podľa ktorého môže poskytovateľ požadovať úhradu za nadštandardný pobyt v zdravotníckom zariadení ústavnej starostlivosti. V ďalšom texte budeme termín „štandard" používať ako synonymum pre slovné spojenie úhrady z verejného zdravotného poistenia v zákonom stanovenom rozsahu a následne pod pojmom „nadštandard" budeme rozumieť úhrady z verejného zdravotného poistenia nad rámec zákonom stanoveného rozsahu.

Zákony účinné v Slovenskej republike však umožňujú v osobitných prípadoch žiadať aj čosi navyše. Konkrétne § 42 zákona o rozsahu zdravotnej starostlivosti uhrádzanej na základe verejného zdravotného poistenia rieši postup v prípade „nadštandardnej“ zdravotnej starostlivosti u nezmluvného poskytovateľa zdravotnej starostlivosti.

Zákonnými podmienkami príspevku na úhradu zdravotnej starostlivosti zdravotnou poisťovňou sú:

a)poskytnutie zdravotnej starostlivosti u nezmluvného poskytovateľa zdravotnej starostlivosti,
b)žiadosť spĺňa kritériá poisťovne pacienta,
c)podmienky úhrady boli vopred určené a zverejnené zdravotnou poisťovňou,
d)súhlas zdravotnej poisťovne ex ante (vopred),
e)predloženie dokladov pacientom,
f)cena zákroku nesmie byť vyššia, než obvyklá.

V prípade, že ide o zdravotný výkon, ktorý nie je uvedený v Zozname zdravotných výkonov indikovaných pri jednotlivých chorobách (4), sa k týmto podmienkam priraďuje ďalšia – účasť ďalšieho subjektu, a síce revízneho lekára zdravotnej poisťovne (5). Takýto zdravotný výkon možno plne alebo čiastočne uhradiť poistencovi len s predchádzajúcim súhlasom tohto revízneho lekára.
Na základe uvedeného je teda možné formulovať záver, že zdravotnú starostlivosť nad rámec štandardu uhrádza zdravotná poisťovňa, ak na ňu dal predchádzajúci súhlas jej revízny lekár.

AD vopred

Žiadosť o úhradu z verejného zdravotného poistenia nad rámec zákonom stanoveného rozsahu sa má obligatórne podať vopred na predpísanom tlačive. Túto podmienku možno vzhľadom na vyššie uvedenú časovú tieseň vnímať ako brzdu rýchleho konania v prípade vážneho ohrozenia zdravia. Z opačného pohľadu je možné konštatovať, že je to práve táto conditio sine qua non, ktorá eliminuje ľubovôľu pacienta a determinuje poskytovateľa zdravotnej starostlivosti na takého, s ktorým má zdravotná poisťovňa pacienta uzatvorenú zmluvu. V prípade odôvodnených okolností to samozrejme ad hoc umožňuje povoliť liečbu aj u iného poskytovateľa. Podľa nášho názoru by zákonodarca (a subsidiárne aj zdravotné poisťovne) mal ustúpiť od tejto podmienky, resp. konkrétnejšie vymedziť kedy a ako je možné schváliť, resp. uhradiť zdravotnú starostlivosť v prípade podania žiadosti až po vykonaní zákroku. Vzhľadom na čím ďalej tým väčšiu komplikovanosť zdravotníckych zákrokov a na značný pokrok vedy v medicíne, považujeme takúto novelizáciu právnej úpravy za nevyhnutnú.

AD verejne

Povinnosť zverejnenia podmienok úhrady zdravotnej starostlivosti zdravotnou poisťovňou považujeme zásadne za správnu. Podľa nášho názoru by tieto podmienky mali byť prerokované s poistencami a nemali by byť jednostranným diktátom poisťovateľa. Je otázne, akou formou by sa takáto diskusia mala uskutočniť, no vieme si predstaviť napríklad zavedenie interného pripomienkového konania, prostredníctvom ktorého by poistenci mohli navrhnúť zmeny alebo doplnky navrhovaných podmienok nadštandardného preplácania.

AD obvykle

Ako sme už uviedli vyššie, cena zákroku nesmie byť vyššia než obvyklá. Uvedený aspekt je vo svojej podstate nedopovedaným výrokom. Podľa nášho názoru posudzovanie len ceny samotného zákroku nie je úplne relevantným ekonomickým ukazovateľom finančnej náročnosti liečby pacienta. Zdravotná poisťovňa by mala brať ohľad nielen na konkrétny zákrok, ale aj na ekonomické náklady celkovej liečby pacientovho ochorenia. Ak hoci „drahší“ zákrok vyrieši pacientov zdravotný problém, resp. zredukuje náklady ďalšej liečby, je ekonomicky výhodnejší ako hoci lacnejší zákrok, ktorý však pacientov problém nerieši efektívne.

Je mnoho prípadov, kedy je ťažké posúdiť, či konkrétne vyšetrenie bolo naozaj potrebné, či nebolo nadbytočné, resp. metóda nebola zbytočne predražená. Zámer zákonodarcu zabrániť svojvôli pacienta, resp. nezmluvného poskytovateľa zdravotnej starostlivosti je čitateľný a legitímny. Súčasný právny stav však na druhej strane umožňuje, aby sa použitím determinantu „obvyklej ceny“ zdravotná poisťovňa vyhla uhradeniu odôvodnenej nadštandardnej starostlivosti. Preto by pri jej rozhodovaní mali zohrať úlohu aj iné ukazovatele a konkrétne špecifiká na strane pacienta (jeho zdravotný stav a podobne).

 

3. Lieky, zdravotnícke pomôcky, dietetické potraviny a „nadštandard“

Analogicky je upravená úhrada aj pri liekoch, zdravotníckych pomôckach a dietetických potravinách. § 88 zákona 363/2011 Z. z. stanovuje, že zdravotná poisťovňa poskytne poistencovi príspevok na úhradu nezmluvným poskytovateľom, ak sú splnené kritériá, ktoré určuje zdravotná poisťovňa a zverejňuje ich na svojom webovom sídle. Súčasne zákon explicitne vyžaduje podanie žiadosti v písomnej forme spolu s dokladmi o úhrade.

Zákon v tomto prípade taxatívne vymedzuje prípady, akú zdravotnú starostlivosť môže poisťovňa prostredníctvom vopred udeleného súhlasu poistencovi plne alebo čiastočne uhradiť.

 

4. Dôvody voľby nezmluvného poskytovateľa

V závere tohto článku by sme sa ešte radi pristavili pri pojme nezmluvný poskytovateľ zdravotnej starostlivosti, konkrétne pri dôvodoch, ktoré by mohli viesť pacienta k tomu, aby navštívil nezmluvného poskytovateľa.

Dôvody je možné roztriediť nasledovne:

1.Nedôvera v zmluvných poskytovateľov zdravotnej starostlivosti

Tento dôvod možno vnímať značne polemicky, vzhľadom na fakt, že nedôvera môže byť len subjektívnym aspektom založeným na predsudku alebo klebete. Ak žijeme v právnom štáte, tak zdravotná poisťovňa, ktorá uzatvára zmluvu s poskytovateľmi zdravotnej starostlivosti by mala zohľadňovať odbornosť poskytovateľa a subjektívny faktor by sa mal eliminovať v prospech dobra pacienta.

2. Strach

Strach môže implikovať to, že pacient v snahe o čo najkvalitnejšiu liečbu, požaduje tú najmodernejšiu starostlivosť v najmodernejšom zdravotníckom zariadení, ktoré síce poskytuje väčšiu istotu, no pri jednoduchších zákrokoch možno nie je nevyhnutne potrebné. Príkladom by mohla byť napríklad operácia na hypermodernej operačnej sále. Do konfliktu sa v tom prípade dostávajú právo na poskytovanie zdravotnej starostlivosti v tej najvyššej kvalite s obmedzenosťou zdrojov a hospodárnosťou vynakladania verejných zdrojov. Riešenie tohto konfliktu môže podľa nášho názoru priniesť uplatnenie zásady proporcionality zohľadňujúce konkrétne okolnosti prípadu.

3. Časová tieseň

Aj v prípadoch, keď nejde o neodkladnú zdravotnú starostlivosť (6), ľudia prirodzene chcú konať rýchlo, lebo sa boja hoci aj minimálneho zhoršenia zdravotného stavu. V tom prípade zohráva hlavnú rolu blízkosť zdravotníckeho zariadenia a zmluva s poisťovňou je radená medzi sekundárne aspekty.

 

Záver

Zatiaľ čo lekári hľadajú odborný medicínsky priestor na poskytovanie “nadštandardnej“ zdravotnej starostlivosti, autori upozornili na priestor, ktorý už súčasné právne úpravy týkajúce sa poskytovania zdravotnej starostlivosti poznajú a jeho využívanie umožňujú.  Štandardná zdravotná starostlivosť sa teda dá poskytnúť „nadštandardným“ spôsobom, ak sa vykoná v nezmluvnom zdravotníckom zariadení.

 

Autori: JUDr. Tomáš HUSOVSKÝ, JUDr. Vladimír VOLČKO – Advokátska kancelária h&h Partners

Článok bol publikovaný v časopise Slovenský lekár, ročník 23 (37), číslo 1 – 2/2013, s. 32 nasl. ISSN 1335-0234.

 

Obrázok: freedigitalphotos.net

 


 

Zoznam odkazov

  1. Napríklad ide o občana štátu mimo EÚ alebo azylanta.
  2. DRGONEC, J. Ústava Slovenskej republiky – Komentár. Šamorín : Heuréka, 2007, 1 197 s. ISBN 80-89122-38-8. str. 420.
  3. Viac v náleze Ústavného súdu SR sp. zn. PL. ÚS 3/09.
  4. Pozri Nariadenie vlády 776/2004 Z. z., ktorým sa vydáva Katalóg zdravotných výkonov.
  5. Pozri §9 zákona 581/2004 Z. z.
  6. Neodkladnú starostlivosť definuje §2 zákona 576/2004 Z. z.



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