From this article you will learn how a knee joint replacement is carried out under a quota, where to start the process, and what documents you need to collect. How to get a quota, for what indications it is given for prosthetics (knee and hip joints). Do I need to pay for an operation or a prosthesis, general information about quotas. How much does knee replacement cost without a quota?
Author of the article: Victoria Stoyanova, category 2 doctor, head of the laboratory at the diagnostic and treatment center (2015–2016).
Article publication date: 05/05/2019
Article updated date: 01/19/2020
Knee replacement is an expensive procedure (the price can be, for example, several hundred thousand rubles), which is beyond the means of most of the population. However, there is a solution to the problem: the state provides the opportunity to perform an operation under the High-Tech Medical Care Program (under quota), which is financed from the budget.
Knee replacement. Click on photo to enlarge
What is the program:
- This is money allocated from the state budget for free joint replacement (knee, hip).
- Anyone can collect documents and obtain the right to undergo surgery if they have grounds for this (indications specified in the Program).
- Endoprosthetics under a quota are performed in any government institution (clinic) where there is special equipment and qualified specialists.
- A quota is an opportunity to undergo surgery, get a new prosthesis and spend 4-5 days in the hospital at the expense of budget funds.
In 2021, amendments were made to the Program, reducing the indications for which a quota can be obtained. People currently falling into this category are:
- with deforming gonarthrosis of the knee (at a stage when other treatment methods are ineffective);
- with dysplasia against the background of arthrosis;
- with postoperative deforming arthrosis.
Click on the photo to enlarge
Other citizens can undergo free surgery and receive a fixed compensation (from 160 thousand rubles) only under an individual rehabilitation program (abbreviated IPR), which is drawn up:
- disabled people with deforming diseases of the knee joints (gonarthrosis);
- who received a quota in 2014 or earlier.
To complete the paperwork, contact a traumatologist.
Getting a quota: where to start
The first step to free endoprosthetics is to contact a traumatologist or orthopedist at the clinic. He will help prepare documents for submission to the quota committee (they are created in health care institutions at the place of residence). The period for reviewing documents is 3 working days, after which a decision is made on the need for endoprosthetics. What documents are needed:
- An extract from the medical history with information about diagnosis and health, certified by the attending physician and the head of the organization (chief physician) who refers the patient to endoprosthetics.
- Results of diagnostic, clinical laboratory examinations, doctors’ conclusions indicating the need for surgery.
- Radiographs of the joint in different projections.
X-ray of the knee joint
If the committee makes a positive decision, the patient is given a protocol with which he applies to the Department or Ministry of Health of the region.
Having received the protocol (in the original), you need to collect:
- original referral for hospitalization from the attending specialist (traumatologist) with an extract from the medical history;
- original written application from the patient (consent to data processing).
Copies are also needed:
- identification document;
- pension insurance certificate (if available);
- health insurance policy;
- disability documents (if available).
Sample referral for hospitalization
The Department (Ministry) of Health reviews received documents within 10 working days. If the decision is positive, the patient’s data is transferred to the nearest clinic, where prosthetics are performed according to the quota. The hospitalization period is determined there. The patient is notified of the timing of the procedure (usually by telephone or email).
Indications for surgery, reasons for refusal of quota
In order for a patient to receive permission for free prosthetics, all specialists taking part in the registration procedure (starting with the attending physician and ending with the quota commission at the Department of Health) must come to the conclusion that it is vital for him to replace the joint.
Indications for surgery are:
- Primary deforming gonarthrosis (impaired leg mobility, unbearable pain).
- Deforming postoperative arthrosis.
- Bone dysplasia in combination with gonarthrosis (defects in the formation and development of bones and cartilage, leading to joint destruction).
- Other conditions (life threatening).
Prosthetics under a quota can be obtained by anyone who has a reason for it (indications included in the approved list). Difficulties often arise when preparing the necessary documents.
They can refuse:
- if the patient has not undergone a preliminary diagnostic examination;
- did not provide the necessary documents (health insurance policy, extract from the medical history, expert opinion, etc.);
- the papers do not contain the necessary information, are filled out incorrectly, are not endorsed, there are no seals or signatures of specialists;
- the results of diagnostic tests (blood tests, x-rays) are out of date.
Therefore, before sending documents to the Department of Health, you should review them again with your attending physician.
When surgery is inevitable
Main indications
- gonarthrosis, accompanied by pronounced functional disorders, persistent painful symptoms, valgus or varus deformity of the legs;
- aseptic necrosis of the femoral condyles;
- autoimmune diseases that result in degeneration of joint tissues - ankylosing spondylitis, systemic lupus erythematosus, gout, rheumatoid arthritis;
- an incorrectly healed fracture that cannot be corrected by other methods;
- congenital abnormalities of the joint structure;
- local neoplasms in the osteochondral structures of the knee, which require mandatory resection.
What and how will you need to pay for under a quota?
Question: “Do I need to pay and for what?” – occurs regularly among people interested in free knee replacement.
Endoprosthetics carried out according to quota:
- produced free of charge, no need to transfer money for the operation or buy a prosthesis;
- postoperative stay in a medical institution and rehabilitation (massage, exercise therapy exercises under the guidance of a specialist, etc.) are paid for from the compulsory medical insurance policy.
The only limitation within the framework of free endoprosthetics is that the patient cannot independently choose a prosthesis; the manufacture of an individual one is also excluded. Replacement is made with models that were purchased specifically for these purposes.
Why do questions about payment arise? They may be caused by the existence of other government programs:
- According to the IRP, prosthetics are available free of charge to people with disabilities due to a specialized disease (gonarthrosis with impaired joint mobility).
- For people who received permission for prosthetics under the IRP program in 2014 or earlier, the state will compensate the costs (a fixed amount, from 160 thousand rubles) after the operation.
- The IPR is approved on the basis of the conclusion of a medical and social examination.
Thus, before the operation, you need to find money to pay for the procedure and purchase a prosthesis, but some of it will come back in fixed state assistance.
Individual rehabilitation program form
This was the case until 2015, then changes were made to the IPR:
- for patients who received paperwork for joint replacement for a core disease after December 31, 2014, all costs are reimbursed from compulsory health insurance (CHI);
- endoprostheses were excluded from the list of means for rehabilitation, and now people pay their cost at their own expense.
The procedure for compensation with funds from the compulsory medical insurance policy has not yet been regulated, so it is impossible to say with certainty how much you are required to return after the operation.
About the individual rehabilitation program
Often patients are not satisfied with the length of the waiting period.
There is another legal method to obtain government support for prosthetics. But to implement it, a serious amount of money is needed.
The essence of an individual rehabilitation program
- The point of the event is that the citizen pays the clinic for the costs of manipulation and treatment from his own savings.
- After completing all the necessary activities, the money spent is paid to him by the budget.
The benefits in this case are received by all parties to the process, they are as follows:
- There is no need to wait for the government agency to pay for the purchase of a prosthesis.
- The clinic has the necessary funds to purchase all materials and medicines.
- Prostheses are purchased only from the most trusted suppliers and are of high quality.
- The budget pays only for the assistance provided, so to speak, based on the actual services performed.
There is only one drawback of the program: a significant amount is required, which will be returned to the citizen after a certain time. The cost of a hip joint prosthesis varies from 120 to 190 thousand rubles. It depends on the design and material of manufacture.
Charitable organizations can finance the purchase of a hip replacement.
Payment for a prosthesis from the budget is made in the following cases:
- if the person is disabled due to the disease in question;
- the right to receive a prosthesis was documented before 01/01/2015.
- others (individually).
Citizens who received the right to a quota before 01/01/2015 are allocated a fixed amount. It amounts to 160 thousand rubles. Additional expenses must be paid from your own funds.
Dear readers!
We describe typical ways to resolve legal issues, but each case is unique and requires individual legal assistance.
To quickly resolve your problem, we recommend contacting qualified lawyers on our website.
There is another method through which you can get a high-quality prosthesis for free. We are talking about an individual rehabilitation program. Such operations, even in leading clinics in the capital, are carried out at the expense of the state budget. To do this, a citizen must consult a doctor, after which it is necessary to draw up the relevant documents.
After the operation, during discharge, another document is drawn up for the return of funds. That is, this system involves the initial payment of the cost of the endoprosthesis. However, after the operation is completed, the funds will be returned to the citizen. At the same time, the waiting period for the operation takes much shorter periods of time than in the case of applying to the Ministry of Health to obtain a quota.
The average time from a person's visit to the hospital to surgery is three weeks. The money will be returned to the citizen within the same period after discharge. Moreover, this program uses only high-quality replacement prostheses. All artificial joints used come only from leading manufacturers.
General information about quota
Knee replacement surgeries have become commonplace. Now they are performed not only in megacities, but also in large regional centers of Russia, where there are departments or specialized clinics equipped with the necessary equipment for the operation.
The procedure for registering and providing a quota does not have regional specifics, however, you can apply for free help only to government agencies that have received a license for such types of activities and approved by the Ministry of Health.
The waiting period depends on the number of quotas allocated by the Ministry of Health. This means that a hospital can operate on a limited number of patients per year (for example, 20 or 50). Therefore, you can wait in line from 3 to 12 months (sometimes more, but not much, the matter does not drag on for several years).
Where can I read it?
To find out the current legal standards regarding the issue under consideration, you should study the order issued in 2013 by the Ministry of Health, issued under number 565n. It indicates all the features of the provision of quotas, as well as a list of persons eligible to participate in the program. Additional official information is also contained in the government decree issued a year later. This document was published under number 1273. It also discusses the features of inclusion in the waiting list, possible diagnoses with which you can get to the clinic for free (or partially free).
How much does a knee replacement cost without a quote?
The knee replacement procedure is quite expensive (only a similar operation on the hip joint is more expensive).
Surgery prices vary:
- From the venue. In private clinics, you also have to pay for a diagnostic examination, surgery, anesthesia, the cost of a prosthetic joint, and hospital stay; on average, this will cost from 100 thousand rubles. In a public institution, the operation will be cheaper - the patient will only need to buy a prosthesis.
- From the type of prosthesis. Their price depends on the manufacturer (imported - from 200 thousand rubles, domestic - from 130 to 170), the material of manufacture (metal or ceramics - from 170 thousand, combined materials - from 130), the method of prosthetics (cement-based - cheaper, from 120 thousand).
- Depending on the type of operation. Partial replacement of the joint surface (femur or tibia) is 2 times cheaper than total replacement.
The cost of the operation may be increased by individual production of the prosthesis, additional diagnostic tests, or visiting a foreign clinic.
Friction pair
This parameter of the prosthesis directly determines the length of its service life and the effect on the patient’s organic tissues. In fact, a joint is a joint whose components rub against each other. If in technology the process is smoothed out by the presence of lubricant, then in the human body there is none, so the components wear out significantly over time. The degree of wear is directly related to the survival of the joint. It is determined by the materials used and the number of movements made by a person.
In order for the joint to live longer, it is necessary to install systems with the most effective friction parameters, as well as reduce the number of motion cycles. The longest wear periods are typical for systems that use ceramics, but the price for such prostheses is the highest.