Order of the Ministry of Labor 1024 n main issues. Experts: what changes the new order on disability criteria? Citizens by federal government agencies
After monitoring the application of the classifications and criteria used in the implementation medical and social expertise citizens by federal state institutions of medical and social expertise, approved. Order of the Ministry of Labor and social protection Russian Federation dated September 29, 2014 No. 664n, in fact, after a year of application, the Order of the Ministry of Labor and Social Protection of the Russian Federation No. 1024n dated December 17, 2015 approved new classifications and criteria used in the implementation of medical and social examination of citizens by federal state institutions of medical and social examination .
On February 2, the Order of the Ministry of Labor and Social Protection of the Russian Federation dated December 17, 2015 No. 1024n “On the classifications and criteria used in the implementation of medical and social examination of citizens by federal state institutions of medical and social examination” (Order No. 1024n) came into force.
A change in the approach to determining disability led to the fact that during the re-examination, not all citizens with disabilities remained in this status. At the same time, the subjective factor was not excluded during the medical and social examination and the establishment of disability. It turned out that many seriously ill citizens, most of whom were children, were not recognized as disabled and did not receive appropriate treatment and rehabilitation opportunities.
The main purpose of issuing Order No. 1024n was to specify approaches to assessing the severity of impaired body functions and criteria for establishing disability, including for children, to clarify the wording of impaired functions, which should have excluded their unequal interpretation in different regions and further objectified approaches to medical treatment. social expertise.
Order No. 1024n included such diseases and defects that occur in children as insulin-dependent diabetes flowing into childhood, cleft lip and palate (cleft lip and palate), phenylketonuria, bronchial asthma occurring in childhood.
The new Order No. 1024n defines the main types of persistent disorders of the functions of the human body caused by diseases, the consequences of injuries or defects, and the degree of their severity, as well as the main categories of human life and the severity of the limitations of these categories.
As in Order No. 664n, six main groups of types of persistent disorders of the functions of the human body have been identified: violations of mental functions; violations of language and speech functions; violations of sensory functions; disorders of neuromuscular, skeletal and movement-related functions; disorders of the cardiovascular, respiratory, digestive, endocrine systems and metabolism, blood system and immune system, urinary function, function of the skin and related systems; violations caused by physical external deformity.
The algorithm for estimating the severity of persistent dysfunctions of the human body, caused by diseases, the consequences of injuries or defects, has also been saved - in percentages in the range from 10 to 100, with a step of 10%. There are still four degrees of severity of persistent violations of the functions of the human body - I degree - violations in the range from 10 to 30%, II degree - violations in the range from 40 to 60%, III degree - violations in the range from 70 to 80%, IV degree - violations in the range from 90 to 100%.
There is no fundamental difference in the establishment of disability groups. But, in Order No. 1024n there is no clear statement of the wording of the criteria that would be understandable not only to an ITU specialist, but also to an ordinary citizen or doctor medical organization who referred the patient to ITU.
Suppose, according to paragraph 8 of Order No. 1024n, the criterion for establishing disability is a health disorder with II or more pronounced degree of persistent impairment of the functions of the human body (in the range from 40 to 100 percent), due to diseases, the consequences of injuries or defects, leading to restriction 2 or 3 degrees of severity of one of the main categories of human life activity or 1 degree of severity of two or more categories of human life activity in their various combinations that determine the need for his social protection.
According to paragraph 9, the criteria for establishing disability groups are applied after the disability has been established for a citizen in accordance with the criterion for establishing disability, provided for in paragraph 8 of this. And then, specifically for disability groups, the categories of life activity corresponding to a particular disability group are not indicated.
Thus, paragraph 10 states: the criterion for establishing the first group of disability is a violation of human health with IV degree of severity of persistent violations of the functions of the human body (in the range from 90 to 100 percent), due to diseases, consequences of injuries or defects.
Clause 11 states: the criterion for establishing the second group of disability is a violation of human health with the III degree of severity of persistent violations of body functions (in the range from 70 to 80 percent), due to diseases, the consequences of injuries or defects.
Paragraph 12 states: the criterion for establishing the third group of disability is a violation of human health with II degree of severity of persistent violations of body functions (in the range from 40 to 60 percent), due to diseases, the consequences of injuries or defects.
In paragraph 13. The category "disabled child" is established if the child has II, III or IV degree of severity of persistent violations of body functions (in the range from 40 to 100 percent) caused by diseases, the consequences of injuries and defects.
That is, Order No. 664n clearly indicated the correspondence between the severity of persistent violations of the functions of the human body and the severity of restrictions on the categories of human life activity.
There is no clear concept in Order No. 1024n that the II degree of severity of persistent violations of body functions (in the range from 40 to 60 percent) can correspond to the 1st degree of severity of two or more categories of human life in their various combinations.
For example, when establishing the third disability group, persistent impairment of statodynamic functions of the II degree of severity (in the range from 40 to 60 percent) may correspond to the 1 degree of severity of the category of movement and self-service (or 1 degree of severity of the category labor activity and movement), etc.
It would be clearer if the old criteria were left in Order No. 1024n, adding only a range of percentages.
For children, as well as in Order No. 664, and in Order No. 1024n, there is also no clear concept for establishing the category of a disabled child.
Thus, according to paragraph 13 of the new Order No. 1024n, the category "disabled child" is established if the child has II, III or IV degree of severity of persistent violations of body functions (in the range from 40 to 100 percent) caused by diseases, consequences of injuries and defects. From which it can be understood that a child, like an adult, should have a disability group.
Order No. 1024n, as well as Order No. 664n, includes the most common diseases. But, in Order No. 1024n, they indicated that “if the annex to these classifications and criteria does not provide for a quantitative assessment of the severity of persistent violations of a particular function of the human body due to diseases, consequences of injuries or defects that the person being examined, then the severity of persistent violations functions of the human body in percentage terms is established by the federal state institution of medical and social expertise in accordance with paragraphs three - six of this paragraph based on the clinical and functional characteristics of diseases, the consequences of injuries or defects that caused the above violations, the nature and severity of complications, stage, course and prognosis pathological process. That is, it still remains unclear where to get the clinical and functional characteristics of diseases that are not in the List. Probably, as before, from the generally accepted classifications of dysfunctions adopted in clinical practice, of which there are many. That is, it turns out - again a subjective approach.
Thus, on the one hand, the New Classifications and Criteria corrected many shortcomings of the previous classifications and criteria. On the other hand, there are many questions that require clarification from the higher organizations from the side federal agencies medical and social expertise.
Cerebral vascular pathology is characterized by a significant polymorphism of clinical manifestations, including dyscirculatory, focal and cerebral disorders, which requires in most specific cases individual approach to a quantitative assessment of the severity of persistent dysfunctions of the human body caused by cerebrovascular diseases. Cerebrovascular diseases often occur on the basis of atherosclerosis, hypertension, complicated by chronic cerebrovascular insufficiency (encephalopathy), acute violation cerebral circulation in the system of internal and vertebral arteries. In the development of cerebrovascular insufficiency, many factors are important: atherosclerosis of cerebral vessels, aortic arch and brachiocephalic branches, stenosis, bends and deformities of extra- and intracranial sections carotid arteries, anomalies in the structure of cerebral vessels, etc. The methodological basis for assessing disability in people with cerebrovascular diseases is determined by a complex set of pathomorphological changes and pathophysiological mechanisms of cerebrovascular accident. The severity of the latter depends on the location and nature of the lesion of the vessel, the topic of the focus, its depth and extent, the degree of damage nerve cells and pathways. Among the pathomorphological substrates, the following are of primary importance: vascular changes - atherosclerotic plaques, aneurysm, thrombosis, pathological tortuosity, vasculitis; changes in the substance of the brain - heart attack, hemorrhagic infarction, hemorrhage, edema, dislocation and wedging, cerebral scar, brain atrophy, cyst. Pathophysiological mechanisms are presented as:
changes vascular system - arterial hypertension, hypotension, angiospasm, vasoparesis, collateral circulatory failure, steal phenomenon, increased blood-brain barrier permeability, cardiovascular and respiratory failure, metabolic and regulatory disorders - hypoxia, hypercoagulability, tissue acidosis, isothermia, etc.
The course of a vascular disease of the brain (progressive, stationary or stable, relapsing) is determined depending on the dynamics of the process, the rate of its progression, or the period of exacerbation. Vascular disease of the brain is often characterized by a progressive course, while it is necessary to take into account the rate of development of the vascular process. It is necessary to distinguish between a slowly progressive course with chronic cerebrovascular insufficiency and a rapidly progressive course with the development of II, III degree chronic insufficiency cerebral circulation with pronounced focal and cerebral changes. When assessing the nature of the recurrent course of cerebral vascular pathology it is necessary to take into account the frequency of exacerbations: rare exacerbations with an interval of more than a year; exacerbations of average frequency - 1-2 times a year; frequent exacerbations - 3-4 times a year. The duration of transient disorders of cerebral circulation is determined: short-term duration (seconds, minutes, up to one hour); medium duration(2-3 hours); long duration (from 3 to 23 hours). The clinical prognosis in vascular pathology of the brain is aggravated by emerging cerebral crises, transient disorders of cerebral circulation, strokes, i.e. manifold clinical course and outcomes of vascular pathology determine a diverse clinical prognosis (favorable, unfavorable, doubtful). The latter depends on many factors - the nature and course of a general vascular disease (atherosclerosis, hypertension), the condition of the main and intracerebral arteries, the possibilities of collateral circulation, early diagnosis, the type and degree of dysfunction, etc.
Vascular pathology of the brain can lead to the following violations of the basic functions of the human body: violations of static-dynamic functions due to paralysis, paresis of the extremities, vestibular-cerebellar, amyostatic, hyperkinetic disorders and etc.; violations of sensory functions (reduced visual acuity, hemianopsia, concentric narrowing of the visual field, sensorineural hearing loss, etc.); visceral and metabolic disorders, eating disorders, blood circulation, respiration, etc.; disorders of mental functions (mnestic-intellectual decline, motor, sensory, amnestic aphasia, dysarthria, anartria, agraphia, alexia, disorders of praxis, gnosis, etc.).
The listed violations can be manifested in severity by all four degrees of severity of persistent violations of body functions: minor, moderate, pronounced, significantly pronounced.
Leading clinical manifestations vascular pathology of the brain are motor disorders (hemiplegia, hemiparesis, paraparesis lower extremities, vestibular-cerebellar, etc.), leading to varying degrees violations of static-dynamic function and limitations of the ability to move independently. When assessing the degree of restriction of movement of patients with this pathology, the following are taken into account:
a complex of clinical and functional indicators characterizing the degree and prevalence of disorders of the motor function of the lower extremities or their segments - the amplitude of active movements in the joints of the extremities (in degrees), the degree of decrease in muscle strength, the severity of the increase in muscle tone, statics, coordination of movements, the main function of the lower extremities, nature of gait, use additional funds supports when walking;
a complex of clinical and functional indicators characterizing the degree and prevalence of disorders of motor functions upper limb or its segments - the volume of active movements in the joints of the limb (in degrees), the degree of decrease in muscle strength, the severity of the increase muscle tone, coordination of movements, the main static-dynamic function of the upper limb - grasping and holding objects;
a set of indicators characterizing the functional state of the vestibular analyzer (caloric, rotational tests);
a complex of electromyographic signs indicating the nature and severity of changes in the bioelectrical activity of muscles;
a complex of biomechanical indicators (walking pace, double step duration, etc.) with the calculation of the walking rhythm coefficient as a general indicator of the degree of movement restriction severity.
Ministry of Labor and Social Protection of the Russian Federation dated December 17, 2015 No. 1024n “On the classifications and criteria used in the implementation of medical and social examination of citizens by federal state institutions of medical and social examination”. It was adopted instead of a similar document No. 664n, which had to be canceled due to numerous complaints: it turned out that many seriously ill people, primarily children, could not be recognized as disabled, and did not receive appropriate treatment and rehabilitation opportunities.
About what will change after the entry into force of the new document, and what results its use can give, the Mercy.ru portal was told Artur Kushakov and Lin Nguyen– employees of the legal department of ROOI “Perspektiva”:
“At one time, the order of the Ministry of Labor of Russia dated September 29, 2014 N 664n made changes to the concept of establishing disability, marking the transition from the medical and social model of establishing disability to an exclusively medical one. This approach had its positive and negative sides. Thus, the conduct of a medical and social examination, for example, in children was complicated by a serious difference in diseases in adults and children. It must be understood that some diseases are more easily tolerated by adults, but seriously affect the normal development of the child, and some of them do not occur in adults at all.
It also turned out that the document does not take into account certain types of diseases (diabetes mellitus, cystic fibrosis). In addition, a change in the approach to determining disability led to the fact that during the re-examination, not all people with disabilities remained in this status. This often caused resentment.
New Order of the Ministry of Labor of Russia dated December 17, 2015 N 1024n “On the classifications and criteria used in the implementation of medical and social examination of citizens by federal state institutions of medical and social examination”, which comes into force on February 2, 2016. solves most of the previous problems - many diseases are included and clarified, which were not in the previous Order.
A detailed study of the formulations of the clinical and functional characteristics of persistent violations of body functions due to diseases, consequences of injuries or defects has been made. This means that the subjective factor is now excluded when conducting a medical and social examination and establishing disability.
For example, each person who applied to the medical and social examination authorities with an application for an examination can assess the prospects, as well as the correctness of establishing disability, by comparing the existing disease from the medical report with the application of the new Order, which clearly spells out a quantitative system for assessing the severity of persistent violations bodily functions. This means that the risk of corruption is minimized, and a uniform application of the classifications and criteria used in the conduct of medical and social expertise is introduced.
In our opinion, the new classifications and criteria correct many shortcomings of the previous formulations. However, only application in practice can show whether everything is taken into account in them and how a purely medical approach to determining disability is correct.”
MINISTRY OF LABOR AND SOCIAL PROTECTION OF THE RUSSIAN FEDERATION
ORDER
ON CLASSIFICATIONS AND CRITERIA,
USED IN THE IMPLEMENTATION OF MEDICAL AND SOCIAL EXAMINATION
MEDICAL AND SOCIAL EXPERTISE
In accordance with subparagraph 5.2.105 of the Regulations on the Ministry of Labor and Social Protection of the Russian Federation, approved by Decree of the Government of the Russian Federation of June 19, 2012 N 610 (Collected Legislation of the Russian Federation, 2012, N 26, Art. 3528; 2013, N 22, 2809; N 36, item 4578; N 37, item 4703; N 45, item 5822; N 46, item 5952; 2014, N 21, item 2710; N 26, item 3577; N 29 , item 4160; N 32, item 4499; N 36, item 4868; 2015, N 2, item 491; N 6, item 963; N 16, item 2384), I order:
1. Approve the attached classifications and criteria used in the implementation of medical and social examination of citizens by federal state institutions of medical and social examination.
2. Recognize invalid the order of the Ministry of Labor and Social Protection of the Russian Federation of September 29, 2014 N 664n "On the classifications and criteria used in the implementation of medical and social examination of citizens by federal state institutions of medical and social examination" (registered by the Ministry of Justice of the Russian Federation 20 November 2014, registration N 34792).
M.A.TOPILIN
Approved
order of the Ministry of Labor
and social protection
Russian Federation
CLASSIFICATIONS AND CRITERIA,
USED IN THE IMPLEMENTATION OF MEDICAL AND SOCIAL EXAMINATION
CITIZENS BY FEDERAL STATE INSTITUTIONS
MEDICAL AND SOCIAL EXPERTISE
I. General provisions
1. Classifications used in the implementation of medical and social examination of citizens by federal state institutions of medical and social examination determine the main types of persistent disorders of the functions of the human body due to diseases, the consequences of injuries or defects, and the degree of their severity, as well as the main categories of human life and degree the severity of the limitations of these categories.
2. The criteria used in the implementation of the medical and social examination of citizens by federal state institutions of medical and social examination determine the grounds for establishing disability groups (the category "disabled child").
II. Classifications of the main types of persistent disorders
functions of the human body and the degree of their severity
3. The main types of persistent disorders of the functions of the human body include:
disorders of mental functions (consciousness, orientation, intelligence, personality traits, volitional and incentive functions, attention, memory, psychomotor functions, emotions, perception, thinking, high-level cognitive functions, mental functions of speech, sequential complex movements);
violations of language and speech functions (oral (rhinolalia, dysarthria, stuttering, alalia, aphasia); written (dysgraphia, dyslexia), verbal and non-verbal speech; impaired voice formation);
violations of sensory functions (vision; hearing; smell; touch; tactile, pain, temperature, vibration and other types of sensitivity; vestibular function; pain);
violations of neuromuscular, skeletal and movement-related (static-dynamic) functions (movements of the head, trunk, limbs, including bones, joints, muscles; statics, coordination of movements);
dysfunction of cardio-vascular system, respiratory system, digestive, endocrine systems and metabolism, blood and immune systems, urinary function, skin function and related systems;
violations caused by physical external deformity (deformities of the face, head, torso, limbs, leading to external deformity; abnormal openings of the digestive, urinary, respiratory tract; violation of body size).
4. The degree of severity of persistent violations of the functions of the human body due to diseases, the consequences of injuries or defects, is estimated as a percentage and is set in the range from 10 to 100, in increments of 10 percent.
There are 4 degrees of severity of persistent violations of the functions of the human body:
I degree - persistent minor violations of the functions of the human body due to diseases, consequences of injuries or defects, in the range from 10 to 30 percent;
II degree - persistent moderate violations of the functions of the human body due to diseases, consequences of injuries or defects, in the range from 40 to 60 percent;
III degree - persistent pronounced violations of the functions of the human body due to diseases, consequences of injuries or defects, in the range from 70 to 80 percent;
IV degree - persistent, significantly pronounced violations of the functions of the human body, caused by diseases, the consequences of injuries or defects, in the range from 90 to 100 percent.
The degree of severity of persistent violations of the functions of the human body, caused by diseases, consequences of injuries or defects, is established in accordance with the quantitative assessment system provided for in the appendix to these classifications and criteria.
If the annex to these classifications and criteria does not provide for a quantitative assessment of the severity of persistent violations of a particular function of the human body due to diseases, consequences of injuries or defects that the person being examined, then the severity of persistent violations of the functions of the human body in percentage terms is established by the federal state institution medical and social expertise in accordance with paragraphs three - six of this paragraph based on the clinical and functional characteristics of diseases, the consequences of injuries or defects that caused the above violations, the nature and severity of complications, the stage, course and prognosis of the pathological process.
In the presence of several persistent violations of the functions of the human body due to diseases, consequences of injuries or defects, the degree of severity of each of these violations in percentage is separately assessed and established. First, the maximum percentage violation of a particular function of the human body is established, after which the presence (absence) of the influence of all other existing persistent violations of the functions of the human body on the most pronounced violation of the function of the human body is determined. In the presence of this influence, the total assessment of the degree of dysfunction of the human body in percentage terms may be higher than the most pronounced violation of body functions, but not more than 10 percent.
