DOI QR코드

DOI QR Code

Trend and Characteristics of High Cost Patients in Health Insurance

건강보험 고액진료비 환자의 추이 및 특성 분석

  • Jeong, Seo Hyun (Department of Health Information and Management, Chungbuk National University College of Medicine) ;
  • Jang, Ho Yeon (Department of Health Information and Management, Chungbuk National University College of Medicine) ;
  • Kang, Gil Won (Department of Health Information and Management, Chungbuk National University College of Medicine)
  • 정서현 (충북대학교 의과대학 의료정보학 및 관리학교실) ;
  • 장호연 (충북대학교 의과대학 의료정보학 및 관리학교실) ;
  • 강길원 (충북대학교 의과대학 의료정보학 및 관리학교실)
  • Received : 2018.07.31
  • Accepted : 2018.08.21
  • Published : 2018.12.31

Abstract

Background: The purpose of this study is to propose an analysis of trends and characteristics of high-cost patients who take over 40% of total national health insurance medical expenses. Methods: It has been analyzed the tendency of high-cost patients by open data based on the medical history information of 1 million people among national health insurance subscriber from 2002 to 2015. To conduct detailed study of characteristics of high-cost patients, multiple regression has been performed by sex, age, residence, main provider, and admission status based on the top 5% group. Results: The amount of medical expenses and the number of high-cost patients have gradually increased in decades. The number of high-cost patients for Korean won (KRW) 5,000,000 category has increased by 7.6 times, KRW 10,000,000 category has increased by 14.1 times in comparing of year 2002 and 2015. Top 5% medical expenses have increased by 4.6 times. In consideration of the characteristics of patients, the incidence of high medical expenses has been higher in female patients than male ones, the older patients than in the younger. Patients residence in Gyeonsang or Jeonla province have had a high incidence of medical expenses than other area. The disease including dementia, cerebral infarction, and cerebrovascular disease for high-cost patients has been also increased. Conclusion: The major increase factor for high medical expenses is the aging of population. The elderly population receiving inpatient care residing in the province that increases high medical costs have to management. There is an urgent need to develop a mechanism for predicting and managing the cost of high-cost medical expenses for patients who have a heavy financial burden.

BGHJBH_2018_v28n4_352_f0001.png 이미지

Figure 1. Trends of the proportion of high-cost patients in total medi-cal expense. KRW, Korean won.

Table 1. Annual medical expense by quartile

BGHJBH_2018_v28n4_352_t0001.png 이미지

Table 2. Proportions of high-cost patients in total ME

BGHJBH_2018_v28n4_352_t0002.png 이미지

Table 3. General characteristics of top 5% high-cost patients

BGHJBH_2018_v28n4_352_t0003.png 이미지

Table 4. Multiple regression model of high-cost patients

BGHJBH_2018_v28n4_352_t0004.png 이미지

Table 5. Average LOS and visit number by patients group

BGHJBH_2018_v28n4_352_t0005.png 이미지

Table 6. Diseases characteristics of high-cost patients

BGHJBH_2018_v28n4_352_t0006.png 이미지

References

  1. Kim YH. Financial forecast of benefit extension strategies of the Korea national health insurance. Seoul: National Assembly Budget Office; 2017.
  2. National Health Insurance Service. 2015 National health insurance statistical annual report. Wonju: National Health Insurance Service, Health Insurance Review and Assessment Service; 2016.
  3. National Health Insurance Service. Survey of medical expenses. Wonju: National Health Insurance Service, Health Insurance Review and Assessment Service; 2016.
  4. Blumenthal D, Chernof B, Fulmer T, Lumpkin J, Selberg J. Caring for high-need, high-cost patients: an urgent priority. N Engl J Med 2016; 375(10):909-911. DOI: https://doi.org/10.1056/NEJMp1608511. https://doi.org/10.1056/NEJMp1608511
  5. Pope GC, Kautter J, Ellis RP, Ash AS, Ayanian JZ, Lezzoni LI, et al. Risk adjustment of Medicare capitation payments using the CMS-HCC model. Health Care Financ Rev 2004;25(4):119-141.
  6. Wodchis WP, Austin PC, Henry DA. A 3-year study of high-cost users of health care. CMAJ 2016;188(3):182-188. DOI: https://doi.org/10.1503/cmaj.150064. https://doi.org/10.1503/cmaj.150064
  7. Kim KA, Shine EK, Baek SJ, Choi YS, Jung KT. A study on catastrophic user-paid expenditure attributes for patient in national health insurance. Korean J Health Econ Policy 2011;17(3):75-99.
  8. Lee HJ, Lee TJ. Impact of unmet medical need and payment for uncovered services on household catastrophic health expenditure. Korean J Health Econ Policy 2015;21(3):55-79.
  9. Lee YJ. Family income inequality and medical care expenditure in Korea. J Korea Contents Assoc 2016;16(8):366-375. DOI: https://doi.org/10.5392/jkca.2016.16.08.366. https://doi.org/10.5392/JKCA.2016.16.08.366
  10. Moon OR, Kang SH, Lee EP, Jwa YK, Lee HS. An analysis on the characteristics of high cost patients in the regional medical insurance program. Korean J Health Policy Adm 1993;3(1):53-83.
  11. Woo KS, Shin YJ. The effect of catastrophic health expenditure on household economy: focusing on financial coping and poverty. Health Soc Welf Rev 2015;35(3):166-198. DOI: https://doi.org/10.15709/hswr.2015.35.3.166. https://doi.org/10.15709/hswr.2015.35.3.166
  12. Yang DW, Kim H, Kang E, Kim D, Bae EY, Kim J. Patterns and determinants of catastrophic health expenditure in the households with cancer patients. Korean J Health Econ Policy 2017;23(1):53-70.
  13. Kim YH, Shin SJ, Park JY, Jeong YJ, Kim JM, Lee TJ, et al. Costing methods in Healthcare. Seoul: National Evidence-based Healthcare Collaborating Agency; 2013.
  14. Korean Statistical Information Service. Population projections for Korea: 2015-2065 years [Internet]. Daejeon: Statistics Korea; c2018 [cited 2018 Apr 22]. Available from: http://www.kosis.kr.
  15. Song KM, Kim YW, Kim YS. A study on improvement of the Korean national health insurance (NHI) reimbursement system to prepare the aged society. J Korean Aging Health Friendly Policy Assoc 2013;5(1):27-37.
  16. Shin YS, Hwang DK, Nam-Kung EH, Choi ID. Financial evaluation of national health insurance system. Sejong: Korea Institute for Health and Social Affairs; 2010.
  17. Shin YS, Sakong J, Jeong HS. A study on the sustainability of the Korean national health insurance. Sejong: Korea Institute for Health and Social Affairs; 2011.