A unified coding and tariff structure for Southern Africapcns.bhfglobal.com/files/bhf/Johann van Zyl.pdf · International Classification of Diseases for Oncology, Third Edition (ICD-O-3)

A unified coding and tariff structure for Southern Africa

Dr Johann van Zyl

Setting the scene

Current situation

Source: Towers Watson: Global Medical Trends Report, 2012

Current situation

Source: Towers Watson: Global Medical Trends Report, 2012

Current situation

Source: Towers Watson: Global Medical Trends Report, 2012

Current situation

Source: Towers Watson: Global Medical Trends Report, 2012

Key issues

• Supra-inflationary increases in the cost of the provision of healthcare

• Drivers of these increases will be:

• Burden of disease

• New technology

• Utilisation of services

• Profit motives

The response

Source: Towers Watson: Global Medical Trends Report, 2012

Management adage

“You cannot manage what you don’t measure”

• In this instance it is about measuring the impact of the problem as well as the impact of the intervention

Components of a coding structure

Building Blocks of Health Information

“A suite of classifications for internal use as meaningful information tools to capture the core

health dimensions such as deaths, disease, disability and health as well as related health

system parameters such as health interventions.”

Source: WHO Business Plan for Health Classifications, 2005

WHO Family of International Classifications (FIC)

Related Classifications

International Classification of Primary Care (ICPC)

International Classification of External

Causes of Injury (ICECI)

The Anatomical, Therapeutic, Chemical (ATC) Classification system

with Daily Defined Doses (DDD)

ISO 9999 Technical aids for persons with disabilities – Classification and

Terminology

Reference Classifications Derived Classifications

International Classification of Diseases for Oncology, Third Edition

(ICD-O-3)

The ICD-10 Classification of Mental and Behavioural Disorders

Application of the International

Classification of Diseases to Dentistry and Stomatology, Third Edition (ICD-

DA)

Application of the International Classification of Diseases to

Neurology (ICD-10-NA)

International Classification of Functioning, Disability and Health,

Children and Youth Version (ICF-CY)

International Classification

of Diseases (ICD)

International Classification of Functioning, Disability

and Health (ICF)

International Classification

of Health Interventions (ICHI)

Source: WHO Business Plan for Health Classifications, 2005

Why translate into codes?

• Clinical language is diverse and allows conditions to be expressed in multiple ways

• Case notes contain a wealth of clinical information

• Clinical coding organises clinical language into statistical groupings of similar entities

• Coding condenses this into a format which is easily aggregated, tabulated and referenced

• Creates manageable data

• Meaningful to the many legitimate users

What is coded?

• Discipline type

• The Primary Diagnosis – Main condition treated or investigated • Secondary conditions impacting upon treatment • Complications • Pre-existing conditions • History • Medical status

• Primary Procedure/Treatments • Secondary/Revision procedures/Treatments • Site/Laterality detail

• Medicine and Consumables

EXAMPLE of Diagnostic Clinical Codes

CLINICAL STATEMENT CODE

Benign Prostatic Hypertrophy N40X

Inguinal Hernia K40.9

Old Bucket handle tear medical meniscus M23.23

Acute Haemorrhagic Gastric ulcer Due to H pylori

K25.3 B98.0

Case study: Malaysia

• Pneumococcal disease kills over 1.6 mil people world wide each year

• No data on clinical and economic burden of pneumococcal disease

• Patients’ clinical data reviewed retrospectively and coded using ICD 10 diagnosis codes

• Result:

‒ 2 809 pneumococcal meningitis cases annually

‒ Total cost = RM3 737 584 of which 52% were due to paediatric cases and 48% due to adult cases

Source: 6th International Case mix Conference, 2012

International Classification of Health Interventions (ICHI) - Uses

• Driven by the need to explain healthcare expenditures

• Focussed on medical and surgical interventions – in-patient care

• Different and disallow international comparisons

Source: WHO, 2005

Purposes of tariffs

• Provide a benchmarks for the determination of fees and benefits

• Provide an indication of the healthcare resources that are required to perform a procedure or provide a service

• Case mix-based funding

Use of coded data

Global status of coding

ICD Challenges

• Many are continuing to use ICD-9

• Some use short lists rather

than the full classification

• Some use automated coding –

dependent upon language versions

→ Inconsistencies adversely affect comparisons of disease burden

→ Cost of implementation is an issue: The Information Paradox

Source: WHO, 2005

ICD Modifications

• United States – ICD-9 CM and ICD-10 CM

• Australia – ICD-10 AM

• Canada – ICD-10 CA

• Germany – ICD-10 GM

• Basis for case mix groupings (Diagnosis Related Groups)

Current situation

Source: Towers Watson: Global Medical Trends Report, 2012

• Does not currently exist – International Classification of Procedures in Medicine (ICPM is out of date)

• Many countries have their own classifications:

‒ Canadian Classification of Interventions (CCI)

‒ Nordic Medico-Statistical Committee (NOMESCO) Classification of Surgical Procedures (NCSP)

‒ French Classification des Actes Médicaux (CCAM)

‒ UK classification of Interventions (OPCS4)

‒ Australian Classification of Health Interventions (ACHI)

‒ ICD-10 Procedure Classification System (ICD-10 PCS)

‒ Current Procedural Terminology (CPT®)

‒ “National Reference Price List” (NRPL)

International Classification of Health Interventions (ICHI)

Drivers of change

• Health system payment reform – case mix-based funding

• Centralised focus on classification

• Accreditation of healthcare facilities and service providers

• Quality management in healthcare

• Evidence-based medicine

• Electronic health record

• Public health

Source: Health Information Management, 2004

Regional status of coding

South Africa

• ICD-10 diagnosis coding has been implemented to the extent that most claim lines are now accompanied by an ICD-10 code

• A working and fully functional medicine and surgical coding and classification system (NAPPI)

• A working and full functional Practice Code Numbering System (PCNS) with associated provider registration processes

• Albeit fraught with various challenges, a working procedure coding system

Challenges for South Africa

• Completion of the ICD-10 implementation process, notably the clinical validation aspects thereof

• Implementation of a universally acceptable procedure coding system: • Coding system per se • Determination of relative values • Determination of monetary conversion factors

• Finding a universally acceptable case-mix based funding system

→ The current problem evolves around the fact that there is a greater focus on the (potential) outcome than the merit of the process or the structure itself

Namibia

• There is recognition of the fact that they have very limited human resources

• The focus is therefore on balancing the cost of healthcare with the attraction/retention of resources

• Implemented a simple (low cost) model whereby: • Current practice was assumed to be a fair starting point • Year-on-year increases can be calculated by using objective

facts • Processes are put in place to analyse, consider and

implement incremental changes

Why is a regional approach important?

Information Paradox

.. countries with the greatest health burdens and needs have the biggest information gaps. They not

only have the least information but also limited capacity (skills, systems) to generate, analyse,

present and disseminate information.

Source: WHO Business Plan for Health Classifications, 2005

Drivers of change

• Health system payment reform – case-mix based funding

• Centralised focus on classification

• Accreditation of healthcare facilities and service providers

• Quality management in healthcare

• Evidence-based medicine

• Electronic health record

• Public health

Source: Health Information Management, 2004

Number of Health Care Workers

Source: Médecins Sans Frontières, “Help Wanted”

Country Number of doctors per

100,000 inhabitants Number of nurses per 100,000 inhabitants

Number of health providers per 100,000

inhabitants

Lesotho 5 63 68

Malawi 2 56 58

Mozambique 3 20 34

South Africa 74 393 468

USA 247 901 1,147

UK 222 1,170 1,552

WHO minimum standard 20 100 228

Medical Migrants to South Africa 2006 - 2010

-

100 000

200 000

300 000

400 000

500 000

600 000

2006 2007 2008 2009 2010

Source: South Africa Annual Tourism Reports, 2008-2011

92% from the rest of Africa

Reasons for choosing South Africa

Source: Ahwireng-Obeng and van Loggerenberg, “Africa’s Middle Class Women"

0%

10%

20%

30%

40%

50%

n = 320

Implications

• Understanding individual countries’ drivers of health care costs requires that medical migration be taken into account

• Parallel coding systems make this type of analysis extremely difficult

Other considerations

• We have interdependent health economies in terms of issues such as:

• Burden of disease

• Resource and capacity constraints

• Exposure to exchange rate fluctuations

• Provision of services

• None of us can truly afford to develop and implement home grown systems, even if this were to be a viable option

• Regional experience would (arguably) be more relevant than international experience and components of what is required are working currently

Thank you