ANALYSIS OF PROVIDED MEDICAL SERVICES IN THE MEDICAL GUARANTEES PROGRAM PACKAGE «CHEMOTHERAPY TREATMENT AND MAINTENANCE OF ADULTS AND CHILDREN WITH ONCOLOGICAL DISEASES IN OUTPATIENT AND INPATIENT SETTINGS»

Abstract

Background. The approaches to the criteria for assigning a treated case/interaction to the "Oncology" package and the principles of their payment introduced in the National Health Service of Ukraine need to be optimized in order to prevent the risks of introducing inadequate rates, namely: not providing services for the amount specified in the rate and double/triple funding.
 Aim: to investigate and identify the main defects and gaps in the existing U-Grouper rules regarding the assignment of a treated case/interaction to a package in the field of "Oncology" and to develop recommendations for improving the existing U-Grouper rules in this field based on the findings.
 Materials and methods. A single descriptive-analytical study of the analysis of medical services provided in the oncology package 17 "Chemotherapy treatment and maintenance of adults and children with oncological diseases in outpatient and inpatient settings" for the first 8 months of 2022 in Ukraine was performed. Statistical methods, structural-logical analysis and systematic approach were used.
 Results. The study found certain gaps in the coding of diagnoses under the diagnostically related group "R63 Chemotherapy", one of which is the incorrect coding of the main diagnosis during chemotherapy treatment, as only 20% of all Electronic Medical Records (EMRs) had the main diagnosis coded according to the Australian coding system (code Z51.1). Incorrect coding of oncological diseases was also detected, which may contribute to an increase in the payment of the case. Thus, in just 8 months of 2022, 19,368 interactions were registered, of which 35.7% (6,923) were without additional diagnoses, i.e., payment was made for such EMRs without clear criteria for the presence of a malignant neoplasm, which contradicts the requirements of the 17th package.
 Conclusions. Based on the findings, it is proposed to make changes to the Medical Guarantees Program in the field of "Oncology" and to introduce automatic medical monitoring of EMRs, in which the main diagnosis of certain categories of classes C and D is coded, which will allow to bring the medical services provided to patients with oncohematological diseases into compliance with the rate.