The Ministry of Labor “overestimated” disabled people: experts on new disability criteria. Experts: what does the new order on disability criteria change? Diabetes mellitus and phenylketonuria are weak links

Cerebral vascular pathology is characterized by a significant polymorphism of clinical manifestations, including dyscirculatory, focal and cerebral disorders, which in most specific cases requires an individual approach to quantifying the severity of persistent dysfunctions of the human body caused by cerebrovascular diseases. Cerebrovascular diseases often occur due to atherosclerosis, hypertension, complicated by chronic cerebral circulatory insufficiency (encephalopathy), acute cerebrovascular accident in the system of internal and vertebral arteries. In the development of cerebrovascular insufficiency, importance is attached to many factors: atherosclerosis of the cerebral vessels, aortic arch and brachiocephalic branches, stenosis, bends and deformations of the extra- and intracranial sections of the carotid arteries, anomalies in the structure of cerebral vessels, etc. Methodological basis for assessing disability in persons with cerebrovascular diseases are determined by a complex complex of pathomorphological changes and pathophysiological mechanisms of cerebral circulation disorders. The severity of the latter depends on the location and nature of the damage to the vessel, the topic of the lesion, its depth and extent, the degree of damage to nerve cells and pathways. Among the pathomorphological substrates, the main ones are: changes in blood vessels - atherosclerotic plaques, aneurysm, thrombosis, pathological tortuosity, vasculitis; changes in the substance of the brain - infarction, hemorrhagic infarction, hemorrhage, edema, dislocation and wedging, cerebral scar, brain atrophy, cyst. Pathophysiological mechanisms are presented as:

changes in the vascular system - arterial hypertension, hypotension, vasospasm, vasoparesis, insufficiency of collateral circulation, steal phenomenon, increased permeability of the blood-brain barrier, cardiovascular and respiratory failure, metabolic and regulatory disorders - hypoxia, hypercoagulability, tissue acidosis, isothermia, etc.

The course of vascular disease of the brain (progressive, stationary or stable, recurrent) 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, and 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 cerebral circulatory failure and a rapidly progressive course with the development of II, III degrees of chronic cerebral circulatory failure 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 cerebrovascular accidents 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 for vascular pathology of the brain is aggravated by emerging cerebral crises, transient cerebrovascular accidents, strokes, i.e. the variety of clinical courses and outcomes of vascular pathology determine a varied clinical prognosis (favorable, unfavorable, doubtful). The latter depends on many factors - the nature and course of 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: disturbances of static-dynamic functions due to paralysis, paresis of the limbs, vestibular-cerebellar, amyostatic, hyperkinetic disorders, etc.; sensory dysfunction (decreased visual acuity, hemianopsia, concentric narrowing of the visual field, sensorineural hearing loss, etc.); visceral and metabolic disorders, nutritional disorders, circulatory disorders, breathing disorders, etc.; disorders of mental functions (mnestic-intellectual decline, motor, sensory, amnestic aphasia, dysarthria, anarthria, agraphia, alexia, disorders of praxis, gnosis, etc.).

The listed disorders can manifest themselves in severity in all four degrees of severity of persistent impairment of body functions: minor, moderate, severe, significantly pronounced.

The leading clinical manifestations of vascular pathology of the brain are movement disorders (hemiplegia, hemiparesis, paraparesis of the lower extremities, vestibular-cerebellar, etc.), leading to varying degrees of disturbances in static-dynamic function and limitations in 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 set 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 increased muscle tone, statics, coordination of movements, the main function of the lower extremities, nature of gait, use of additional means of support when walking;

a set of clinical and functional indicators characterizing the degree and prevalence of disorders of the motor functions of the 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 increased muscle tone, coordination of movements, the main static-dynamic function of the upper limb - grip 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 set of biomechanical indicators (walking pace, double step duration, etc.) with the calculation of the walking rhythm coefficient as a general indicator of the severity of movement limitation.

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.

The portal Miloserdie.ru was told about what will change after the new document comes into force and what results its use can produce Arthur Kushakov And Linh Nguyen– employees of the legal department of the ROOI “Perspective”:

“At one time, Order No. 664n of the Ministry of Labor of Russia dated September 29, 2014 introduced 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, conducting a medical and social examination, for example, in children was complicated by the serious difference in diseases in adults and children. You need to understand 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 some types of diseases (diabetes mellitus, cystic fibrosis). In addition, a change in the approach to defining disability led to the fact that during the re-examination, not all people with disabilities remained in this status. This often caused dissatisfaction.

New Order of the Ministry of Labor of Russia dated December 17, 2015 N 1024n “On 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 02.02.2016. most of the previous problems are solved - many diseases are included and clarified that were not in the previous Order.

A detailed study of the formulations of the clinical and functional characteristics of persistent disorders of body functions caused by 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 has applied to the medical and social examination authorities with an application for an examination can assess the prospects, as well as the correctness of the determination of disability, by comparing the existing disease from the medical report with the appendix of the new Order, which clearly states a quantitative system for assessing the severity of persistent impairments body functions. This means that the risk of corruption is minimized, and a uniform application of classifications and criteria used in conducting medical and social examinations is introduced.

In our opinion, the new classifications and criteria correct many of the shortcomings of the previous formulations. However, only practical application can show whether everything is taken into account in them and whether an exclusively medical approach to establishing disability is correct.”

After monitoring the application of classifications and criteria used in the implementation of medical and social examination of citizens by federal state institutions of medical and social examination, approved. Order of the Ministry of Labor and Social Protection of the Russian Federation dated September 29, 2014 No. 664n, actually after a year of application, 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 citizens by federal state institutions of medical and social examination.
On February 2, Order of the Ministry of Labor and Social Protection of the Russian Federation dated December 17, 2015 No. 1024n “On 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).
A change in the approach to defining 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 when conducting a medical and social examination and establishing disability was not excluded. 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 eliminated their unequal interpretation in different regions and further objectified approaches to medical treatment. social expertise.
Order No. 1024n included diseases and defects that occur in children, such as insulin-dependent diabetes mellitus that occurs in childhood, cleft lip and palate (cleft lip and cleft palate), phenylketonuria, and bronchial asthma that occurs in childhood.
New Order No. 1024n defines the main types of persistent disorders of the functions of the human body caused by diseases, consequences of injuries or defects, and the degree of their severity, as well as the main categories of human life and the degree of severity of restrictions in these categories.
As in Order No. 664n, six main groups of types of persistent disorders of the functions of the human body are identified: mental disorders; disorders of language and speech functions; sensory dysfunction; disorders of neuromuscular, skeletal and movement-related functions; dysfunctions of the cardiovascular, respiratory, digestive, endocrine systems and metabolism, blood and immune systems, urinary function, skin function and related systems; disorders caused by physical external deformity.
An algorithm for assessing the severity of persistent dysfunctions of the human body caused by diseases, consequences of injuries or defects has also been preserved - as a percentage in the range from 10 to 100, in increments of 10%. There are still four degrees of severity of persistent disorders of the functions of the human body - I degree - disturbances in the range from 10 to 30%, II degree - disturbances in the range from 40 to 60%, III degree - disturbances in the range from 70 to 80%, IV degree – violations in the range from 90 to 100%.
There is no fundamental difference in establishing disability groups. But, in Order No. 1024n there is no clear statement of the formulation of criteria that would be understandable not only to an MTU specialist, but also to an ordinary citizen or a doctor of a medical organization who referred the patient for MTU.
Let’s say, according to clause 8 of Order No. 1024n, the criterion for establishing disability is a health disorder with a II or more pronounced degree of severity of persistent impairment of the functions of the human body (ranging from 40 to 100 percent), caused by diseases, consequences of injuries or defects, leading to limitation 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 a citizen has been identified as disabled in accordance with the criterion for establishing disability provided for in paragraph 8 of these. And further, specifically by disability group, the categories of life activity corresponding to one or another 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 impairment of the functions of the human body (in the range from 90 to 100 percent), caused by diseases, consequences of injuries or defects.
Clause 11 states: the criterion for establishing the second group of disability is a person’s health impairment with the third degree of severity of persistent impairment of body functions (ranging from 70 to 80 percent), caused by diseases, consequences of injuries or defects.
Clause 12 states: the criterion for establishing the third group of disability is a person’s health impairment with the second degree of severity of persistent impairment of body functions (ranging from 40 to 60 percent), caused by diseases, consequences of injuries or defects.
In paragraph 13. The category “disabled child” is established if the child has II, III or IV degrees of persistent impairment of body functions (ranging from 40 to 100 percent) caused by diseases, consequences of injuries and defects.
That is, Order No. 664n clearly indicated the correspondence between the degree of severity of persistent impairments in the functions of the human body and the degree of severity of restrictions on the categories of human life activity.
In Order No. 1024n there is no clear concept that the II degree of severity of persistent impairment 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 activity in their various combinations.
For example, when establishing the third disability group, persistent violations of static-dynamic functions of the second degree of severity (in the range from 40 to 60 percent) may correspond to the 1st degree of severity of the category of movement and self-care (or 1st degree of severity of the category of work activity and movement), etc.
It would be clearer if Order No. 1024n left the old criteria, adding only a range of percentages.
For children, both 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 degrees of persistent impairment of body functions (ranging from 40 to 100 percent) caused by diseases, consequences of injuries and defects. From which we can understand that a child, like an adult, must 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 appendix to these classifications and criteria does not provide for a quantitative assessment of the severity of persistent impairments of one or another function of the human body caused by diseases, consequences of injuries or defects present in the person being examined, then the severity of persistent impairments functions of the human body in percentage terms is established by the federal state institution of medical and social examination in accordance with paragraphs three to 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 that this is again a subjective approach.
Thus, on the one hand, the New classifications and criteria corrected many of the shortcomings of the previous classifications and criteria. On the other hand, many questions remain that require clarification from higher organizations from federal institutions of medical and social examination.

MINISTRY OF LABOR AND SOCIAL PROTECTION OF THE RUSSIAN FEDERATION

ORDER

ABOUT CLASSIFICATIONS AND CRITERIA,

USED ​​IN CARRYING OUT MEDICAL AND SOCIAL EXAMINATION

MEDICAL AND SOCIAL EXAMINATION

In accordance with subclause 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, Art. 2809; N 36, Art. 4578; N 37, Art. 4703; N 45, Art. 5822; N 46, Art. 5952; 2014, N 21, Art. 2710; N 26, Art. 3577; N 29 , Art. 4160; N 32, Art. 4499; N 36, Art. 4868; 2015, N 2, Art. 491; N 6, Art. 963; N 16, Art. 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 as invalid the order of the Ministry of Labor and Social Protection of the Russian Federation dated September 29, 2014 N 664n “On 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 on 20 November 2014, registration N 34792).

M.A.TOPILIN

Approved

by order of the Ministry of Labor

and social protection

Russian Federation

CLASSIFICATIONS AND CRITERIA,

USED ​​IN CARRYING OUT MEDICAL AND SOCIAL EXAMINATION

CITIZENS BY FEDERAL STATE INSTITUTIONS

MEDICAL AND SOCIAL EXAMINATION

I. General provisions

1. The 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 caused by diseases, consequences of injuries or defects, and the degree of their severity, as well as the main categories of human activity and the degree severity of restrictions of these categories.

2. The criteria used when carrying out 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 expression

3. The main types of persistent disorders of the human body’s functions include:

disturbances of mental functions (consciousness, orientation, intelligence, personality characteristics, volitional and incentive functions, attention, memory, psychomotor functions, emotions, perception, thinking, high-level cognitive functions, mental functions of speech, sequential complex movements);

disorders of language and speech functions (oral (rhinolalia, dysarthria, stuttering, alalia, aphasia); written (dysgraphia, dyslexia), verbal and non-verbal speech; voice disorder);

disturbances of sensory functions (vision; hearing; smell; touch; tactile, pain, temperature, vibration and other types of sensitivity; vestibular function; pain);

disorders of neuromuscular, skeletal and movement-related (static-dynamic) functions (movements of the head, torso, limbs, including bones, joints, muscles; statics, coordination of movements);

dysfunctions of the cardiovascular system, respiratory system, digestive, endocrine and metabolic systems, blood and immune systems, urinary function, skin function and related systems;

disorders caused by physical external deformity (deformations of the face, head, torso, limbs, leading to external deformity; abnormal openings of the digestive, urinary, respiratory tracts; violation of body size).

4. The severity of persistent dysfunctions of the human body, caused by diseases, 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 dysfunctions of the human body:

I degree - persistent minor dysfunctions of the human body caused by diseases, consequences of injuries or defects, in the range from 10 to 30 percent;

II degree - persistent moderate impairment of the functions of the human body, caused by diseases, consequences of injuries or defects, in the range from 40 to 60 percent;

III degree - persistent severe impairment of the functions of the human body, caused by diseases, consequences of injuries or defects, in the range from 70 to 80 percent;

IV degree - persistent, significant impairment of the functions of the human body, caused by diseases, consequences of injuries or defects, in the range from 90 to 100 percent.

The degree of severity of persistent dysfunctions 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 appendix to these classifications and criteria does not provide for a quantitative assessment of the severity of persistent impairments of one or another function of the human body caused by diseases, consequences of injuries or defects present in the person being examined, then the severity of persistent impairments of the functions of the human body in percentage terms is established by a federal government agency medical and social examination in accordance with paragraphs three to six of this paragraph based on the clinical and functional characteristics of diseases, consequences of injuries or defects that caused the above violations, the nature and severity of complications, stage, course and prognosis of the pathological process.

If there are several persistent dysfunctions of the human body, caused by diseases, consequences of injuries or defects, the severity of each of these disorders is separately assessed and determined as a percentage. First, the maximum expressed impairment of one or another function of the human body is established, after which the presence (absence) of the influence of all other existing persistent dysfunctions of the functions of the human body on the maximum expressed impairment of the function of the human body is determined. In the presence of the indicated influence, the total assessment of the degree of dysfunction of the human body in percentage terms may be higher than the maximum expressed impairment of body functions, but not by more than 10 percent.

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 (as amended on 07/05/2016)

(Registered with the Ministry of Justice of Russia on January 20, 2016 N 40650)

In accordance with subclause 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, Art. 2809; N 36, Art. 4578; N 37, Art. 4703; N 45, Art. 5822; N 46, Art. 5952; 2014, N 21, Art. 2710; N 26, Art. 3577; N 29 , Art. 4160; N 32, Art. 4499; N 36, Art. 4868; 2015, N 2, Art. 491; N 6, Art. 963; N 16, Art. 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 as invalid the order of the Ministry of Labor and Social Protection of the Russian Federation dated 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 on November 20, 2014 city, registration N 34792).

CLASSIFICATIONS AND CRITERIA USED IN THE IMPLEMENTATION OF MEDICAL AND SOCIAL EXAMINATION OF CITIZENS BY FEDERAL STATE INSTITUTIONS OF MEDICAL AND SOCIAL EXAMINATION

I. General provisions

1. The 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 caused by diseases, consequences of injuries or defects, and the degree of their severity, as well as the main categories of human activity and the degree severity of restrictions of these categories.
2. The criteria used when carrying out medical and social examination of citizens by federal state institutions of medical and social examination determine the grounds for establishing disability groups (categories of disabled children).

II. Classification of the main types of persistent disorders of the functions of the human body and the degree of their severity

3. The main types of persistent disorders of the human body’s functions include:

• disturbances of mental functions (consciousness, orientation, intelligence, personality characteristics, volitional and incentive functions, attention, memory, psychomotor functions, emotions, perception, thinking, high-level cognitive functions, mental functions of speech, sequential complex movements);
• disorders of language and speech functions (oral (rhinolalia, dysarthria, stuttering, alalia, aphasia); written (dysgraphia, dyslexia), verbal and non-verbal speech; voice disorder);
• disturbances of sensory functions (vision; hearing; smell; touch; tactile, pain, temperature, vibration and other types of sensitivity; vestibular function; pain);
• disorders of neuromuscular, skeletal and movement-related (static-dynamic) functions (movements of the head, torso, limbs, including bones, joints, muscles; statics, coordination of movements);
• dysfunctions of the cardiovascular system, respiratory system, digestive, endocrine and metabolic systems, blood and immune systems, urinary function, skin function and related systems;
• disorders caused by physical external deformity (deformations of the face, head, torso, limbs, leading to external deformity; abnormal openings of the digestive, urinary, respiratory tracts; violation of body size).

4. The degree of severity of persistent dysfunctions of the human body, caused by diseases, 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 dysfunctions of the human body:

I degree - persistent minor dysfunctions of the human body caused by diseases, consequences of injuries or defects, in the range from 10 to 30 percent;

II degree - persistent moderate impairment of the functions of the human body, caused by diseases, consequences of injuries or defects, in the range from 40 to 60 percent;

III degree - persistent severe impairment of the functions of the human body, caused by diseases, consequences of injuries or defects, in the range from 70 to 80 percent;

IV degree - persistent, significant impairment of the functions of the human body, caused by diseases, consequences of injuries or defects, in the range from 90 to 100 percent.

The degree of severity of persistent dysfunctions 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.

Application

to classifications and criteria,

used in the implementation

medical and social examination

citizens federal state

medical and social institutions

examination approved by order

Ministry of Labor and Social

protection of the Russian Federation

QUANTITATIVE SYSTEM FOR ASSESSING THE DEGREE OF SEVERITY OF PERSISTENT DISORDERS IN THE HUMAN BODY FUNCTIONS CAUSED BY DISEASES, CONSEQUENCES OF INJURIES OR DEFECTS (IN PERCENTAGE, IN APPLICATION TO THE CLINICAL-FUNCTIONAL CHARACTERISTICS OF PERSISTENT DISORDERS FUNCTIONS OF THE HUMAN BODY)