1. EC TWINNING PROJECT Development of National Coding Standards within the Czech DRG System CZ2005/IB/SO/03

2. Development of National Coding Standards within the Czech DRG System Mission this week Preparatory visit to discuss: Creation of benchmark studies of DRG systems Classification system of medical services Short Term Experts Virginia Jordan – England Head of Standards & Classifications NHS Information Centre for Health & Social Care Brian McCarthy – Ireland Data/IT Manager The Economic and Social Research Institute (ESRI) Ivan Kalman – Germany DRG Expert NI-CO Associate

3. Development of National Coding Standards within the Czech DRG System Initial Observations following discussions with Members of visited Institutions Ministry of Health and participants of Introductory Round Table Motol University Hospital STAPRO NRC

4. Development of National Coding Standards within the Czech DRG System Key Stakeholders 1.Ministry of Health 2.Healthcare Committee 3.Professional Bodies 4.Clinicians 5.Healthcare Research Institutions 6.Educational Institutions 7.National Reference Centre (newly formed) 8.Healthcare delivery organisations 9.Public insurance 10.Healthcare IT and service providers 11.Accreditation and standard bodies 12.Patients 13.European Union

5. Development of National Coding Standards within the Czech DRG System Actions Coding The introduction of ICD-10 in 1994. (1) The introduction and maintenance of a procedure list in 1992. (1 + 9) General/Financing The introduction of a ‘fee for service’ reimbursement system. (1 + 9) The introduction of a “temporary cost containment” reimbursement (1 + 9) Case mix The introduction of AP-DRG and subsequently IR-DRG grouping. (1 + 9) Audits Annual audits of DRG coding undertaken by public insurance companies. (9) Independent audits in hospitals. (8)

6. Development of National Coding Standards within the Czech DRG System General/IT/Financial Strength There is an established process of recording treatment activity. (8) Few areas with waiting lists. (8) Weaknesses Lack of e-health and electronic health record solutions. (1 + 10) No independent data flow to a central casemix database nor is there a central database. (1 + 9) D No evidence of minimum data requirements and standards. (1 + 11) The ‘fee for service’ has the potential to support over capacity. (1 + 9) D

7. Development of National Coding Standards within the Czech DRG System General/IT/Financial Threats Change of ministerial support in the future. (1 + 13) Lack of buy-in by key stakeholders. (1 – 12) Withdrawal of EU funding in the future. (1 + 13) The lack of a framework, linkages and political support for both the DRGs and the supporting projects means that short term solutions are proposed which may not be optimal in the long term. (1) D

8. Development of National Coding Standards within the Czech DRG System Coding Strength The Ministry of Health introduction of ICD-10 in 1994 has resulted in familiarisation of the classification. (1) Weaknesses The lack of national standards and education on the day to day use of ICD-10. (1 or delegated authority) D The medical services classification is not comprehensive and not conducive to use within a DRG system and not reflective of current care practises. (1 or delegated authority) Coding is driven by the insurance reimbursement policies and use of coding for other purposes is limited as a result. (9) D

9. Development of National Coding Standards within the Czech DRG System Coding continued Weaknesses There is no continuing education programme for coding or DRGs. (1) Current coding systems have the potential to suppress the recording of “negative incidents” such as clinical error. (1) There is lack of motivation for hospitals to ensure accurate diagnosis coding. (1 + 8 + 9) D

10. Development of National Coding Standards within the Czech DRG System Audit Strength Process of data quality assurance by a governing body. (1) Some audit of information is done by public insurance companies. (9) Some independent coding audit performed in hospitals. (8) D Weaknesses Coding quality measures were being substituted with quantity of coding. (8) Lack of national coding quality measures or comprehensive audits. (1 or delegated authority) No accreditation for coders.(11) D

11. Development of National Coding Standards within the Czech DRG System Audit continued Threats Evidence of down and up coding which undermines the trust in the fairness of DRGs and coding. (8 + 11) D

12. Development of National Coding Standards within the Czech DRG System Case Mix Strength There is a recognition that DRGs have the potential to ensure equity and transparency of funding. (8 +9) Weaknesses There is lack of effective communication strategy of the benefits of DRGs; (1) Transparency Plurality Comparative analysis Commissioning Access/choice Reimbursement

13. Development of National Coding Standards within the Czech DRG System Case Mix Continued Weaknesses While there is central control and policy on groupers, there would seem to be variations in how the grouper is used. (1) The monopoly position may not be as beneficial to the Health Institutions as competition in grouper providers. (1 + 10) D The nature of the data flow to insurance companies has a potential for errors and the resulting DRG assignment maybe questionable. (9) D The lack of accurate relative values and its consistency across the casemix spectrum. (1)

14. Development of National Coding Standards within the Czech DRG System Case Mix Continued Weaknesses It would seem that the length of stay may be influenced by reimbursement. (8 + 9) The reliance on ’fee for service’ and the points’ system rather than DRG payments has potential to increase length of stay and suppress innovation. (1 + 9) The reimbursement of a patient who is involved in multiple hospital treatments particularly when a tertiary hospital is involved does not appear to be balanced correctly. (9) D

15. Development of National Coding Standards within the Czech DRG System Case Mix Continued Threats The financing principles underlying the casemix system are not fully understood by the stakeholders. (1 + 8 + 9) The lack of understanding as to whether capital costs would be included in DRG reimbursement. (1 + 8 + 9) The use of a single national base rate has the potential to destabilise individual hospitals and runs contrary to established international practise. (1 + 9) D The international trend of reduced length of stay and move to daycase and/or outpatient treatments is not being followed. (1 + 8 + 9) D

16. The way forward – A Suggestion for evaluation The following is a suggestion for a way forward. It is –Only a Suggestion for you to Evaluate. –Based on our experience this week and internationally trends. –It is an initial view of how you could move forward. Development of National Coding Standards within the Czech DRG System

17. The way forward – A Suggestion for evaluation The suggestion is the following –Move gradually to ICD-10-AM. –Move eventually to AR-DRG. –Move finally to ICD-10-CZ and CZ-DRG. This follows the German and Irish models in adopting the Australian system. Development of National Coding Standards within the Czech DRG System

18. The way forward – A Suggestion for evaluation The aim is have an easy Migration. –Avoid too much change. –Smalls steps  Big Changes. Small steps –Reduce the pain. –Keep Everyone Together. Development of National Coding Standards within the Czech DRG System

19. The way forward – A Suggestion for evaluation Development of National Coding Standards within the Czech DRG System Current Currently using ICD10 and a procedure list IR-DRG Grouper List Procedure ICD-10 Diagnosis Ideal Czech versions of Diagnosis, procedures and groups CZ-DRG Grouper ICD-10-CZ Procedure ICD-10-CZ Diagnosis Step 1 Move from ICD-10 and Procedure list to ICD-10-AM IR-DRG Grouper ICD-10-AM Procedure ICD-10-AM Diagnosis Step 2 Move from IR-DRG To AR-DRG Grouper ICD-10-AM Procedure ICD-10-AM Diagnosis Step 3 Czech versions of Diagnosis, procedures and groups CZ-DRG Grouper ICD-10-CZ Procedure ICD-10-CZ Diagnosis Ideal Czech versions of Diagnosis, procedures and groups CZ-DRG Grouper ICD-10-CZ Procedure ICD-10-CZ Diagnosis

20. The way forward – A Suggestion for evaluation Step 1 The benefits of Step 1 –Integrated Modern up-to-date Coding Classification. –Small Change from ICD-10 to ICD-10-AM. –Excellent Procedure Coding scheme. –Internationally used Classification. –Australian Coding Standards. –No change to the DRG system. –Support from Australia, Germany, Ireland. Gives the option to move away from IR-DRG Development of National Coding Standards within the Czech DRG System

21. The way forward – A Suggestion for evaluation Step 2 The benefits of Step 2 –Internationally used grouper. –Many commercial versions of grouper. –Costing model and weights in use in Australia and elsewhere. –Support from Australia, Germany etc. Development of National Coding Standards within the Czech DRG System

22. The way forward – A Suggestion for evaluation Step 3 The benefits of Step 3 –Diagnosis and Procedure scheme for Czech Republic. –DRG scheme for the Czech Republic. –Local modification to suit Czech Health Care. Development of National Coding Standards within the Czech DRG System

23. The way forward – A Suggestion for evaluation Development of National Coding Standards within the Czech DRG System Step 1 Implemented in one year or over a series of years. Step 2 Implemented once Step 1 is complete Step 3 Implemented when Step 2 is complete and local knowledge is cultivated

24. Development of National Coding Standards within the Czech DRG System Thank you