Direct and Indirect Costs Associated with AMD in Poland
Dr n. med. Jakub Gierczyński, MBA, Doradztwo i ekspertyzy
The report "Direct and Indirect Costs of AMD in Poland" was drafted in November 2015 in the frames of the project "Social Audit of AMD Treatment in Poland". Its aim is to present the most important aspects and key data on the direct and indirect costs of the disease known asage-related macular degeneration (AMD)in Poland. Direct costs are primarily spend by public payer - the National Health Fund (NFZ). Indirect costs are the expenses of the Social Insurance Institution (ZUS). The data presented in the report are derived from the public domain.
System conditions of ophthalmology in Poland
Number of institutions providing services in the field of ophthalmology
According to the Central Statistical Office (GUS) in 2013 there were 182 hospital ophthalmological branches in Poland (an increase of 12 branches compared to 2012). They had a total number of 3 329 beds (an increase of 26 beds). 251.4 thousand patients were treated there in 2013 (an increase of 16.4 thousand patients).
The number of eye diseases specialists
According to the Polish Chamber of Physicians in 2015 the profession of ophthalmologist carried 4 498 specialists, 25% of whom were over 60 years of age. Nearly half of the ophthalmologists work in five voivodships only: mazowieckie,śląskie, małopolskie, łódzkieand dolnośląskie. This affects of course the availability of services for the other Polish citizens. The highest residents-per-ophthalmologist ratiowas noted in podkarpackie, lubuskie and warmińsko-mazurskie, and the lowest – in mazowieckie, łódzkie and dolnośląskie.
Financing of ophthalmology by the public payer
Financing of health care services in the field of ophthalmology is implemented within the framework of agreements concluded by the providers of the National Health Fund (NFZ) in the types of infirmary care (AOS) and hospital treatment (LSZ). NFZ data for the first time show the declined value of contracts in the field of ophthalmology in total in 2014 compared to 2013. In addition, the fulfilment of these agreements in 2013 and 2014 was lower than the contracted value. Analyzing the share of directory B - Eye diseases in relation to the number of patients and to the costs of procedures settled within Catalogue 1a System of the Uniform NFZ Patient Groups in total in 2012-2014, points at an increase of the number of people treated in the framework of ophthalmic services and at a decrease in NFZ expenditures for them at the same time. This is also confirmed by conclusions from prof. Grabska-Liberek publication: "Over the last four years expenditures for ophthalmology have decreased considerably, as well as the number of service providers fulfilling the agreements. The share of ophthalmic contracts in total cost of health care has decreased too, even though the number of procedures performed grows”.
Limits of access to services in the field of ophthalmology in the public system
Since January 2015 in Poland a referral to an eye diseases specialist from the GP is obligatory. This is a big hurdle for patientsand it leads to delays in the diagnosis and treatment of AMD. Additional restriction of the access to medical services for AMD patients are the limits of NFZ contracts to perform medical services in outposts. They cause queues of patients waiting for treatment.
Indirect costs of eye diseases
Statistics published on the website of the Social Insurance Institution (ZUS) show the total expenditures on benefits related to disability incurred in the group: Eye and appendages of eye diseases (H00-H59). These diseases caused work inability for the persons insured. Expenses amounted to PLN 768 128 500 in 2012 and PLN 804 694700 in 2013. There was thus an increase of PLN 36 566200, i.e. 4.76%. Total expenditures on benefits related to disability incurred in this group in 2013 accounted for 2.5% of total expenditures on benefits related to disability incurred this year by disease groups that caused the inability to work. The number of sick leave days due to self-illness of persons insured in ZUS in the group: Eye and eye appendages diseases (H00-H59) amounted to 1 494 253 days in 2013 and 1 637 517 days in 2014. There was therefore an increase of 143 264 days,that is of 9.6%.
Direct costs of AMD treatment in Poland
Financing the AMD treatment in Poland according to the National Health Fund data
Direct costs of AMD treatment in Poland are primarily public payer - the National Health Fund (NFZ) -expenditures. The costs of medical care incurred privately will be analyzed in a separate project, due to the lack of such data in the public domain at the moment.
The DRG NFZ System
The benefits for patients hospitalized for eye diseases are reported by the service providers of the type of hospital treatment. Aggregated data are compiled by the National Health Fund Head Office and presented in the System of Uniform Patient Groups (DRG). Statistics related to the hospitalizations of patients with the disease can be found in catalogue B - Eye diseases. NFZ finances AMD treatment in the framework of hospital treatment, settling procedures in the following groups:
• B01 - wet form of AMD verteporfin treatment with photodynamic therapy;
• B02 - wet form of AMD treatment with intravitreal injection of monoclonal antibody anti-VEGF.
Noteworthy is the growth of 22.24% of the treated patients number from 6 620 in 2013 to 8 092 in 2014 in the group B02 - Treatment of the wet form of AMD using intravitreal injection of monoclonal antibody anti-VEGF.
Catalogue B – Eye diseases / Number of patientsGroup / 2013 / 2014 / Dynamics
2014 vs 2013
B01 – wet form of AMD verteporfin treatment with photodynamic therapy / 158 / 105 / -33,54%
B02 – wet form of AMD treatment with intravitreal injection of monoclonal antibody anti-VEGF / 6 620 / 8 092 / 22,24%
Table 1. Number of patients treated in groups B01 and B02 in 2013 and 2014
This corresponded to an increase of 8.23% NFZ expenses in this area from PLN 48 709 729.80 in 2013 to PLN 52 718 877.26 in 2014.
Value of procedures settled (PLN)Group / 2013 / 2014 / Dynamics
2014 vs 2013
B01 – wet form of AMD verteporfin treatment with photodynamic therapy / 1 399 320,00 / 846 768,00 / -39,49%
B02 – wet form of AMD treatment with intravitreal injection
of monoclonal antibody anti-VEGF / 48 709 729,80 / 52 718 877,26 / 8,23%
Table 2. Value of procedures settled by NFZ in groups B01 and B02 in 2013 and 2014
The value of treatments in B02 group - treatment of the wet form of AMD using intravitreal monoclonal antibody anti-VEGF injection - settled in different provinces is shown in the table and chart below. NFZ settled the greatest value of procedures in 2014 in mazowieckie – PLN 11 801 400 (an increase of 6.43% up to 2013), kujawsko-pomorskie - PLN 5 394 325 (21.92% up), śląskie – PLN 4 702 980 (13.83% down) and małopolskie – PLN 4 241 627 (7.91% up). The highest growth of procedures settled in 2014 compared to 2013 was recorded in the provinces lubelskie (188.25%) and opolskie (63.22%).
Province / 2013 / 2014 / Dynamics2014 vs 2013
mazowieckie / 11 088 324 / 11 801 400 / 6,43%
kujawsko-pomorskie / 4 424 426 / 5 394 325 / 21,92%
śląskie / 5 458 103 / 4 702 980 / -13,83%
małopolskie / 3 930 771 / 4 241 627 / 7,91%
pomorskie / 2 422 611 / 3 046 821 / 25,77%
podlaskie / 3 428 217 / 3 028 608 / -11,66%
dolnośląskie / 2 077 633 / 2 473 260 / 19,04%
podkarpackie / 2 178 540 / 2 223 000 / 12,04%
łódzkie / 2 360 701 / 2 194 360 / 7,05%
lubelskie / 732 701 / 2 111 980 / 188,25%
świętokrzyskie / 1 606 876 / 2 031 587 / 26,43%
warmińsko-mazurskie / 1 974 651 / 1 932 300 / -2,14%
lubuskie / 1 536 680 / 1 849 306 / 20,34%
zachodniopomorskie / 1 870 284 / 1 679 600 / -10,2%
wielkopolskie / 876 455 / 984 358 / 12,31%
opolskie / 468 312 / 764 400 / 63,22%
Table 3. PLN value of treatments in B02 group - Treatment of the wet form of AMD using intravitreal monoclonal antibody anti-VEGF injection - settled in different provinces in 2013 and2014
The greatest number of treatments in B02 group - Wet AMD treatment using intravitreal injection of monoclonal antibody anti-VEGF - was settled in 2014 in mazowieckie - 4 539 (19.20% up), kujawsko-pomorskie - 2 100 (an increase of 40.37%), śląskie - 1835 (3.27% down) and małopolskie - 1 656 (an increase of 23.58%). The highest increase in the number of procedures settled in 2014 in comparison with 2013 was recorded in the provinces lubelskie (226.29%) and opolskie (86.08%).
Chart1. PLN value of treatments in B02 group - Treatment of the wet form of AMD using intravitreal monoclonal antibody anti-VEGF injection settled in different provinces in 2013 and 2014
Province / 2013 / 2014 / Dynamics2014 vs 2013
mazowieckie / 3 808 / 4 539 / 19,20%
kujawsko-pomorskie / 1 496 / 2 100 / 40,37%
śląskie / 1 897 / 1 835 / -3,27%
małopolskie / 1 340 / 1 656 / 23,58%
podlaskie / 1 235 / 1 227 / -0,65%
pomorskie / 819 / 1 173 / 43,22%
dolnośląskie / 712 / 968 / 35,96%
łódzkie / 921 / 879 / -4,56%
podkarpackie / 735 / 855 / 16,33%
lubelskie / 251 / 819 / 226,29%
świętokrzyskie / 544 / 785 / 44,30%
warmińsko-mazurskie / 749 / 754 / 0,67%
lubuskie / 526 / 724 / 37,64%
zachodniopomorskie / 631 / 646 / 2,38%
wielkopolskie / 302 / 380 / 25,83%
opolskie / 158 / 294 / 86,08%
Table 4.Number of treatments in B02 group - treatment of the wet form of AMD using intravitreal monoclonal antibody anti-VEGF injection settled in different provinces in 2013 and 2014
Chart2.Number of treatments in B02 group - treatment of the wet form of AMD using intravitreal monoclonal antibody anti-VEGF injection settled in different provinces in 2013 and 2014 Attention: ordinates (vertical) axis is wrong described. There should be amounts: PLN 0, 500, 1000,…,4500 on it.
Medication Program "The treatment of neovascular (wet) form of age-related macular degeneration (AMD) (ICD-10 H35.3)"
Proclamation of the Minister of Health of 23 April 2015 on the list of reimbursable medicines, foodstuffs intended for particular nutrition and medical devices introduced to the public refund from1 May 2015 a new medication program "The treatment of neovascular (wet) form of age-related macular degeneration (AMD) (ICD-10 H35.3)" (Annex B.70.). Since 1 November 2015 there were modifications to the program description.
Under the program the drugs: Aflibercept (Eylea) and Ranibizumab (Lucentis) are due to reimbursement from 1 May 2015. See Table 5.
Active substance / Name, formand dose
/ Package contents / Prices (PLN)
Official price / Wholesale gross price / Financing limit
Aflibercept / Eylea, solution for injection, 40 mg/ml / 1 phial
or 0,1 ml / 3 456,00 / 3 628,80 / 3 628,80
Ranibizumab / Lucentis, solution for injection, 10 mg/ml / 1 phial / 3 562,92 / 3 741,07 / 3 741,07
Table 5. Drug prices in the medicationprogram "The treatment of neovascular (wet) form of age-related macular degeneration (AMD) (ICD-10 H35.3)"
In November 2015 the process of contracting agreements between service providers and the public payer (NHF)was completed. Since then 124 eye centres in Poland perform the above medication program, most of them located in the province
mazowieckie - 19, dolnośląskie – 16 and śląskie – 14.
Chart 3.Number of outposts performing the AMD medication program in 2015
The highest value of contracts undersigned by the National Health Fund with healthcare providers for the treatment of neovascular (wet) form of AMD in 2015 was recorded in thevoivodships: małopolskie– PLN 2 809405, (of which PLN 1 957 279 for drugs and PLN 852 126 for medical services), śląskie – PLN 2 389 704 (of whichPLN 1 468 720 for drugs and PLN 920 984 for medical services) and mazowieckie –PLN 2 229 308 (of which PLN 1 439 666 for drugs and PLN 789 642 for medical services).
Province / Contract value (PLN)Total / in that:
Drugs / Medical services
dolnośląskie / 1 195 189 / 709 350 / 485 839
kujawsko-pomorskie / 467 548 / 359 700 / 107 848
lubelskie / 586 500 / 394 100 / 192 400
lubuskie / 117 280 / 78 800 / 38 480
łódzkie / 929 225 / 598 360 / 330 865
małopolskie / 2 809 405 / 1 957 279 / 852 126
mazowieckie / 2 229 308 / 1 439 666 / 789 642
opolskie / 168 237 / 94 890 / 73 347
podkarpackie / 1 580 600 / 945 732 / 634 868
podlaskie / 247 079 / 142 269 / 104 810
pomorskie / 94 006 / 53 238 / 40 768
śląskie / 2 389 704 / 1 468 720 / 920 984
świętokrzyskie / 16 480 / 11 436 / 5 044
warmińsko-mazurskie / 800 600 / 525 000 / 275 600
wielkopolskie / 481 252 / 287 500 / 193 752
zachodniopomorskie / 932 487 / 669 211 / 263 276
Poland / 15 044 900 / 9 735 251 / 5 309 649
Table 6. Value of contracts undersigned by the National Health Fund for the treatment of neovascular (wet) form of AMD in 2015 in different provinces
Chart 4. Value ranking of contracts undersigned by the National Health Fund for the treatment of neovascular (wet) form of AMD in 2015 in different provinces
The assessment of the availability of services is significantly affected by the value of the benefits for one citizen of the region financed by the provincial branch ofthe National Health Fund (ie. regional per capita rate). According to this index the highest level of services availability under contracts to medication program "The treatment of neovascular (wet) form of age-related macular degeneration (AMD)" in 2015 appeared in the małopolskie (PLN 0.83), podkarpackie (PLN 0.74) and warmińsko-mazurskie(PLN 0.55), and the lowest in świętokrzyskie (PLN 0.01), pomorskie (PLN 0.04) and lubuskie (PLN 0.11). Average Polish rate was PLN 0.39 per capita.
Province / Contracts (PLN) / Number of citizens / Per capita ratio (PLN))
małopolskie / 2 809 405 / 3 368 336 / 0,83
podkarpackie / 1 580 600 / 2 129 187 / 0,74
warmińsko-mazurskie / 800 600 / 1 443 967 / 0,55
zachodniopomorskie / 932 487 / 1 715 431 / 0,54
śląskie / 2 389 704 / 4 585 924 / 0,52
mazowieckie / 2 229 308 / 5 334 511 / 0,42
dolnośląskie / 1 195 189 / 2 908 457 / 0,41
Polska / 15 044 900 / 38 478 602 / 0,39
łódzkie / 929 225 / 2 504 136 / 0,37
lubelskie / 586 500 / 2 147 746 / 0,27
kujawsko-pomorskie / 467 548 / 2 089 992 / 0,22
podlaskie / 247 079 / 1 191 918 / 0,21
opolskie / 168 237 / 1 000 858 / 0,17
wielkopolskie / 481 252 / 3 472 579 / 0,14
lubuskie / 117 280 / 1 020 307 / 0,11
pomorskie / 94 006 / 2 302 077 / 0,04
świętokrzyskie / 16 480 / 1 263 176 / 0,01
Table 7.Per capita ratio in frames of NFZ contracts undersigned by the National Health Fund for the treatment of neovascular (wet) form of AMD in 2015 in different provinces
Chart 5. Per capita ratio in frames of the NFZ contacts for the medicationprogram "The treatment of neovascular (wet) form of age-related macular degeneration (AMD)” in 2015 in different provinces (PLN)
The highest value of ten contracts in the country of every 124 ophthalmologic centres in Poland with a contract under the medication program "The treatment of neovascular (wet) form of age-related macular degeneration (AMD)" valid for 2015 received medicinal subjects listed in Table 8.
Province / Service provider / Contractvalue (PLN)Name / Addres / Total / in that:
Drugs / Services
małopolskie / Szpital Specjalistyczny
im. H. Klimontowicza w Gorlicach / 38–300 Gorlice,
ul. Węgierska 21 / 569 988 / 400 000 / 169 988
małopolskie / Mw-Med Ambulatorium / 31–416 Kraków- Śródmieście, ul. Dobrego Pasterza 207A / 544 999 / 380 003 / 164 996
małopolskie / WojewódzkiSzpitalOkulistyczny / 31–723 Kraków- Nowa Huta, Os. na wzgórzach 17B / 536 899 / 368 003 / 168 896
małopolskie / Szpital Wojewódzki im. św. Łukasza SP ZOZ
w Tarnowie / 33–100 Tarnów, ul. Lwowska 178A / 492 016 / 372 000 / 120 016
podkarpackie / Kliniczny Szpital Wojewódzki nr1 im. F.Chopina
w Rzeszowie / 35–055 Rzeszów,
ul. Szopena 2 / 418 416 / 253 524 / 164 892
śląskie / ScanmedMultimedis SA / 41–503 Chorzów,
ul. Wiejska 4 / 373 911 / 229 911 / 144 000
śląskie / Uniwersyteckie CentrumOkulistyki I Onkologii Samodzielny Publiczny Szpital Kliniczny Śląskiego UM wKatowicach / 40–514 Katowice,
ul. Ceglana 35 / 355 500 / 215 100 / 140 400
podkarpackie / Wojewódzki Szpital Podkarpacki Im.
Jana Pawła Ii w Krośnie / 38–400 Krosno,
ul. Korczyńska 57 / 345 191 / 209 159 / 136 032
zachodnio- pomorskie / SzpitalWojewódzki im. M. Kopernika wKoszalinie / 75–581 Koszalin,
ul. Chałubińskiego7 / 344 045 / 256 165 / 87 880
małopolskie / Centrum Okulistyki NZOZ
Centre de la Vision / 30–033 Kraków- Krowodrza,
ul. Sienkiewicza34 / 283 099 / 200 003 / 83 096
Table 8. The highest value of ten contracts in the country of ophthalmologic centres in Poland with a contract under the medication program "The treatment of neovascular (wet) form of age-related macular degeneration (AMD)" valid for 2015 (PLN)
Indirect costs of AMD in Poland
According to prof. Stankiewicz’s report indirect costs of retinal diseases arise, among others, from the reduction of production potential of the society, due to absence of the patient and his guardians. This value significantly exceeds the total direct costs, i.e. medical expenses. The cost of lost productivity due to retinal diseases is increasing from year to year. This justifies the assertion that faster diagnosis (by increasing the availability of consultation) and the immediate initiation of intravitreal injections, would significantly reduce the indirect costs incurred by the Social Insurance Institution and the society as a whole.
The sick leave days number and the number of medical certificates for self-sickness of persons insured in ZUS in group: Diseases of the retina (H30-H36) in 2013-2014
The sick leave days number due to self-sickness of persons insured in ZUS in group: Diseases of the retina (H30-H36) reached 233 246 days in 2013 and 253 179 daysin 2014. There was thus an increase of 8.55% (19 933 days).In terms of the number of medical certificates of incapacity for work in a group: Diseases of the retina (H30-H36) 14 787 job leaves were reportedin 2014. In comparison to 2013 (13 793 leaves) it is an increase of 7.21% (994 leaves). See the table and the graph below.
H30–H36 Retina diseases / 2013 / 2014 / 2014 vs 2013Sick leave days number / 233 246 / 253 179 / 19 933 (8,55%)
Number of medical certificates / 13 793 / 14 787 / 994 (7,21%)
Table 9.Sick leave days number and number of medical certificates due to self-sickness of persons insured in ZUS in group: Diseases of the retina (H30-H36) in 2013 and 2014
Sick leave days number Number of medical certificates
Graph 6.Sick leave days number and number of medical certificates due to self-sickness of persons insured in ZUS in group: Diseases of the retina (H30-H36) in 2013 and 2014
Against the background of sickness absence days number due to self-illness of the persons insured in ZUS group: A00-Z99 All diseases, group: Eye and appendages of the eye diseases (H00-H59) accounted for 0.70% in 2013 and 0.77% in 2014. Group H30-H36 Retinal diseases accounted for 0.11% in 2013 and 0.12% in 2014 of all days of sick absences recorded by the Social Insurance Institution.
Days number / Share / Days number / Share
H30–H36
Deseases of retina / 233 246 / 0,11% / 253 179 / 0,12%
H00–H59 Eye and appendages of the eye diseases / 1 494 253 / 0,70% / 1 637 517 / 0,77%
A00–Z99
All diseases / 213 392 670 / 100% / 212 616 713 / 100%
Table 10.Sickness absence days number due to self-illness of the persons insured in the ZUS group: Eye and appendages of the eye diseases (H00-H59) and in group: H30-H36 Retinal diseases, as a part of all days of sick absence (A00–Z99) in 2013-2014
Against the background of all medical certificates number registered by the Social Insurance Institution due to self-illness of the persons insured in ZUS group: A00-Z99 All diseases, group: Eye and appendages of the eye diseases (H00-H59) accounted for 0.74% in 2013 and 0.81% in 2014. Group H30-H36 Retinal diseases accounted for 0.08% in 2013 and 0.09% in 2014 of all medical certificates registered by the Social Insurance Institution. See Table 11.
Diseases / 2013 / 2014Number of certificates / Share / Number of certificates / Share
H30–H36
Deseases of retina / 13 793 / 0,08% / 14 787 / 0,09%
H00–H59 Eye and appendages of the eye diseases / 128 093 / 0,74% / 137 145 / 0,81%
A00–Z99
All diseases / 17 333 946 / 100% / 16 965 652 / 100%
Table 11.Medical certificates number due to self-illness of the persons insured in the ZUS group: Eye and appendages of the eye diseases (H00-H59) and in group: H30-H36 Retinal diseases, as a part of all days of sick absence (A00–Z99) in 2013-2014
Sickness absence days number due to self-illness of persons insured in ZUS group: H30-H36 Diseases of the retina, according to individual diagnoses of retinal diseases in 2013-2014, shows the table below. For the diagnosis H35 Other disorders of the retina 69 507 days of sickness absence in 2013 were reported and 76 149 days of sickness absence in 2014. So an increase of 9.56% has been reported.
Diseases / Sickness absence days number2013 / 2014 / Dynamics 2014vs2013
H30 / Choroiditis and retinitis
/ 18 189 / 16 426 / -9,69%
H31 / Other disorders of choroid / 3 761 / 4 291 / 14,09%
H32 / Disordersof choroid and retina diseases classified elsewhere / 3 277 / 3 031 / -7,51%
H33 / Detachment and tear of retina
/ 110 994 / 124 083 / 11,79%
H34 / Retinal vascular occlusion / 14 378 / 16 008 / 11,34%
H35 / Other disorders of retina / 69 507 / 76 149 / 9,56%
H36 / Retinal disorders
in diseases classified elsewhere / 13 140 / 13 191 / 0,39%
H30–H36 Diseases of retina / 233 246 / 253 179 / 8,55%
Table 12. Sickness absence days number due to self-illness of persons insured in ZUS group: H30-H36 Diseases of the retina, according to individual diagnoses of retinal diseases in 2013-2014
The number of medical certificates for self-illness of persons insured in ZUS group: H30-H36 Diseases of the retina, according to individual diagnoses of retinal diseases in 2013-2014, are shown in the table below. For the diagnosis of H35 Other disorders of the retina 4 980 medical certificates in 2013 were recorded and 5 436 in 2014. Therefore an increase of 9.16% has been reported.
Diseases / Number of medical certificates2013 / 2014 / Dynamic
2014 vs2013
H30 / Choroiditis and retinitis
/ 1 518 / 1 359 / -10,47%
H31 / Other disorders of choroid / 283 / 308 / 8,83%
H32 / Disorders of choroid and retina diseases classified elsewhere / 225 / 211 / -6,22%
H33 / Detachment and tear of retina
/ 5 099 / 5 644 / 10,69%
H34 / Retinal vascular occlusion / 824 / 914 / 10,92%
H35 / Other disorders of retina / 4 980 / 5 436 / 9,16%
H36 / Retinal disorders
in diseases classified elsewhere / 864 / 915 / 5,90%
H30–H36 Diseases of retina / 13 793 / 14 787 / 7,21%
Table 13. Number of medical certificates for self-illness of persons insured in ZUS group: H30-H36 Diseases of the retina, according to individual diagnoses of retinal diseases in 2013-2014
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