Revisited the classifier of the main dental treatment-diagnostic activities and technologies

Full Text

In accordance with the applicable law, the provision of medical care for diseases of teeth and oral cavity is included into the basic program of compulsory medical insurance (CMI), since these diseases in accordance with International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) are treated as the digestive system diseases.

Features of accounting and regulation of primary dental care provided in the outpatient setting (PDC), as an important component of primary health care (PHC) determine the payment of PDC in the CMI system.

Currently in the CMI system we apply a retrospective payment system of PDC for given amounts of primary dental health care, pronounced in accordance with characteristics of accounting and regulation of PDC in standard units of labour input (SULI).

Materials and Methods

To account for the work of doctors and the amount of provided primary dental care we used "Classifier of basic health services for primary health specialized dental care, provided in outpatient settings, expressed in standard units of labour input (SULI)" (hereinafter – the Classifier).

We considered the time spent by a dental therapist for 1 visit in connection with the disease required for medical assistance in the outpatient setting (including the time required for the registration of medical documentation), on the basis of the Order N973н of the Ministry of health of the Russian Federation dated 19.12.2016 «About approval of the standard industry norms of the time for the execution of works related to the visit of one patient to the cardiologist, endocrinologist and dental therapist» [1].

The aim of this work is to assess the conformity of the "Classifier of basic health services for primary health specialized dental care, provided in outpatient settings, expressed in standard units of labour input (SULI)» to the standard time spent per 1 SULI, taking into account the new standard indicators; determine the rate of time for 1 SULI during the five-day 33-hour working week of a dental therapist.

Results and Discussion

Accounting and planning of PDC for a long time was carried out on the basis of quantitative accounting of labor costs of specialists (dentists and dental doctors), certain now not applied in the territory of the Russian Federation according to the Order No. 50 from the Ministry of Health of the USSR dated 25.01.1988, which determined the transition to the new meter of labor costs in SULI, instead of the previous temporary meter, expressed in minutes. The rate of the scope of work for doctors providing primary dental care, expressed in visits was replaced by individual work operations [2].

This order approved the standards (number) of SULI to account for the labor costs of dentists with a focus on the end result. Per one SULI it was adopted the amount of work of the doctor required for a tooth filling in case of median caries.

Since not only the minutes can serve as a unit of labor costs, but also some conventional units, for example, a massage unit, physiotherapy unit etc., the expression of labor cost of specialists who provide primary dental care in SULI is an acceptable methodological approach to the organization and regulation of labor in dentistry.

The above account of labour in SULI, a priori, was aimed to raise the interest of doctors in the final results of their own labor, to stimulate productivity growth and to develop the preventative work.

The accounting of the dentist's work in SULI aimed at implementation of the main principle of work organization – planned recreation activities, especially with children. The basis of the evaluation is the implementation of the plan of work at the site to achieve maximum coverage of the population and rehabilitation, medical examinations and other preventive care, organized by the team.

It is known that the work in the dental medical organizations (clinics) gives dentists the right to a shortened 33-hour working week [3].

The intensification of the work of a doctor during normal working hours, motivated by this order to provide maximum assistance for 1 visit, reduced a waste of time associated with re-visits: re-surveys, inspections, record in the patient card and other activities that had to be repeated on subsequent visits. Now the principle of maximum sanation of oral cavity for a single visit is met in the provision of PDC.

Realizing that the extent of this work varies considerably in different regions of the country in connection with the epidemiological and other characteristics, it is important to solve the problems of regional planning of PDC on the ground in connection with the development level of dental services in various regions.

In accordance with the Federal Fund of CMI for registration and payment of PDC for visits and access to a doctor (in case of illness) it is advised to consider conditional units of labour input (SULI) which for many years are used in dentistry for planning and accounting of medical services and in reporting on the activities of specialists and payment for their labor.

The formation of the territorial program of CMI for the next year the scope of PDC expressed in SULI must be calculated including: maximum coverage of the residents of the attached region with health program; reducing the number of persons who need sanitation, bringing it to a minimum; increasing the number of healthy people and those with a first degree of caries activity; to minimize complications of caries and cases of permanent teeth removal, especially in children.

Published classifications of dental services had a different occupancy and different differentiation: from 1502 up to 4003 individual services. To account for the scope of work of a dentist at the stage of formation of CMI system, there were regional classifications of dental services.

For example, in the Ryazan region "Classification of dental care for adults and children" (hereinafter – regional classification) was introduced to the work in the region in 2008 and was used to determine the rate of primary dental health care. Regional classifier contained the entire list of necessary dental services, had a comfortable alphanumeric coding indicating the number of the tooth, and clarified the localization and scope of work performed. Over 4 years of work is was not required to make any adjustments and there were no difficulties in the regional qualifier neither for medical personnel, no for medical insurance organizations, controlling and paying for PDC.

According to the current legislation the planning and control of provision and payment of PDC is carried out in the framework of the monitoring of the implementation of territorial programs of CMI in accordance with the standards and rules of rendering of medical aid. The rules of rendering of dental medical care for adults and children developed at the Federal level and approved by orders of Ministry of health of the Russian Federation [4, 5]. While, standards of primary health care provided on an outpatient setting, including primary dental care, hitherto not developed.

The Ministry of health of Russia as innovations in the organization of PDC in outpatient settings (including scope and price) recommended the «Classifier of major dental treatment and diagnostic measures and technologies, expressed in conditional units of labour input» (hereinafter – Federal Classifier) for use throughout the country.

This Classifier was developed by the FSBI «Central scientific research Institute of dentistry and maxillofacial surgery», with the participation of O.O. Ianushevich (the chief freelance dentist of Ministry of health of the Russian Federation, rector of the Moscow state medico-stomatological University named after A. I. Evdokimov).

The attitude of medical community to the Federal Classifier is ambiguous. Specialists believe that the transition to a new meter of the scope of work of dentists is incorrect: the accounting of the dentist's work in SULI – instead of visiting violated the basic requirements to performance standards on labor: a sufficient degree of consolidation, in which the calculation of norms becomes less time consuming process; the possibility of application in all medical institutions operating in accordance with regulations; simplicity and ease of use that ensures error-free calculation of labor standards; the compliance of labor indicators to the reporting and statistical documentation recorded in the organization, that provides a reliable basis for control of scope of executed works and their planning [6, 7].

The Classifier, as indicated in the document follows the nomenclature of medical services, approved by the Order No. 1664н from the Ministry of health and Social Development of Russia dated 27.12.2011. However, the nomenclature of medical services has a totally different meaning and is not a basis for the development of labour standards for each service [8].

For example, in the nomenclature for doctors of other specialities provides the following services, as collection of complaints and anamnesis, palpation, percussion, auscultation, measurement of blood pressure, tonometry of the eye, measurement of the joint volume , the determination of the neck and shoulder circumferences, etc., but for these labor operations time norms are not set for doctors in outpatient centres. At the best case these data can be the basis for a dictionary (list) of labor activities when carrying out timing, in order to carry out the consolidation, and to work out a standard time rates for one patient visit considering the frequency of realization of these labor activities.

According to Russian scientists it is unacceptable to include classifiers with the approval of the labor input in CULI in normative legal documents, which it is not designed to regulate labour standards, for example, in the methodological recommendations on the procedure of formation and economic substantiation of territorial programs of state guarantees, in the recommendations of the Ministry of health of the Russian Federation and Federal Fund of CMI according to the methods of payment for medical care [6].

However, the implementation of the Federal Classifier was carried out in the regions withing a year, for example, in the Ryazan region – in 2012. The difficulties encountered during the implementation of the Federal Classifier into the regions was eliminated by his adaptation to local conditions and by making the necessary adjustments. Thus, it was found that the list of dental services included into the Federal Classifier decreased in comparison with the regional classifier. It din’t include the following: the restoration of teeth using photopolymer composite materials, root canal obturation using lateral condensation technique, patchwork operations, frenulum plastic operation, etc., which have lowered the availability of PDC for the population. At the same time, the transition to a single "standardized" classification has streamlined the mutual settlement of regions for the provision of PDC to the people outside the insurance territory [9].

It is believed that by the reverse way – from the workload standard to the time rate it is possible to calculate a standard time expenditures for 1 SULI taking into account the duration of the above-mentioned working week of a dentist and common for outpatient doctors ratio of working time for core activities Rwt=0,923, however, according to the opinion of Russian scientists 1 SULI = 15 minutes [7]. But this figure is not confirmed officially.

According to the Federal Classifier, based on the standard time for the provision of dental services by a medical specialist (in minutes) and norms of workload –in the number of SULI corresponding to the definite dental service, we can determine that the average regulatory time spent for 1 SULI = 9.9 min, that is, if we compare two indicators raises doubts about the correctness of the Classifier.

Recall that the norms according to which the average time spent by dentist-internist for 1 visit = 44 minutes valid from 01.01.2017, i.e. there is an approved standard time for 1 visit to the dentist-therapist in connection with the disease, required to perform the labor actions for medical assistance (including the standard time for registration of medical documentation) [1].

The standard time for a patient’s visit to the dentist with the preventive purpose is recommended in the amount of 60,0-70,0% of the standard time associated with 1 visit to the dental therapist in connection with the disease. And the time that the doctor spends on the registration of medical documentation, taking into account the rational organization of labor, equipment of working place with computer hardware, shall be not more than 35,0% of the standard time associated with a visit of one patient to the specialist is the time during which the SULI are not executed [1].

Let's do the calculations of normative time for 1 SULI with account of the new regulatory indicators to assess their compliance with the Federal Classifier.

The conditions of the task: To determine the rate of time for 1 SULI during the five-day 33-hour working week of a dental therapist.

Task solution:

• 1) Define working hours per 1 working day of a dental therapist:

33 h / 5 working days = 6.6 hours (6 hours 36 min.).

• 2) Since, in accordance with the labour legislation for this category of workers there should be at least 1 break for meal and rest with the duration at least 15 min., we define the working hours excluding the break, expressed in hours:

15 min / 60 min = 0.25 h;

6.6 h – 0.25 h = 6.35 h.

• 3) Express the average time spent by a dental therapist for 1 visit in hours:

44 min / 60 min = 0.73 h.

• 4) Determine the time for the registration of medical documentation in 1 visit, which shall be not more than 35.0% of the standard time associated with one visit of a patient to a dental therapist:

0.73 h x 0.35 = 0.257 h.

• 5) Determine the total number of visits per one working day of a dental practitioner (excluding a break):

6.35 h / 0.73 h = 8.66 visits.

• 6) Calculate the time required for the registration of medical documentation during the working day:

8.66 visit x 0.257 h = 2.23 h

• 7) Calculate the time required for the execution of the SULI within 1 working day (excluding time for registration of medical documentation):

6.35 h – 2.23 h = 4.12 h

• 8) Calculate the standard time for 1 SULI at the five-day 33-hour working week of a dental therapist, when he needs to perform 25 SULI per day:

4.12 h / 25 SULI = 0.165 h

• 9) Convert the standard time for 1 SULI into minutes:

0,165 h х 60 min = 9,9 min.

Answer: the average regulatory time spent on 1 SULI = 9.9 minutes.

Conclusions

1. Standart time for 1 SULI is in line with the Federal Classifier.
2. The Federal Classifier is formed taking into account the standard time spent for 1 visit (44 min.), approved by the order of Ministry of health of Russian Federation dated 19.12.2016 N973н "About approval of the standard industry norms of the time for the execution of works related to 1 visit of a patient to the cardiologist, endocrinologist and dental therapist".

Authors have no conflict of interest to declare.

About the authors

I. V. Uspenskaya

Ryazan State Medical University

Author for correspondence.
Email: S.urina@mail.ru
ORCID iD: 0000-0002-3163-5688
SPIN-code: 6094-2737

MD, Grand PhD, Associate Professor, Professor of Department of Economics, Law and Health Management

Russian Federation, 9, Vysokovoltnaja, Ryazan, 390026

S. V. Yurina

Ryazan State Medical University

Email: S.urina@mail.ru
ORCID iD: 0000-0002-5107-3379
SPIN-code: 2731-5534

PhD student of Department of Public Health and Health, Nursing Organizations with a Course in Social Hygiene and Health Organization

Russian Federation, 9, Vysokovoltnaja, Ryazan, 390026

References

Supplementary files