• Proceedings of the Korean Operations and Management Science Society Conference
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• 2008.10a
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• pp.342-345
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• 2008

산재 발생 시 산재근로자는 근로복지공단을 통해서 각종 급여를 받게 된다. 본 논문은 심사 과정과 급여지급 후에 부정수급으로 판명된 산재 청구 건을 데이터 마이닝을 통해서 분석하여 부정수급의 유형을 발견하고자 한다. 이 연구에서는 서울관내 4개 지사에서 8년 동안(2000년$\sim$2007년)의 총 61,536명의 최초요양 신청을 한 산재근로자 자료를 대상으로 하였고, 종속변수에 영향을 미치는 8개의 독립변수를 선택해서 사용한다. 데이터 마이닝을 적용함에 있어서 가장 효율적인 허위 부정 탐지 모델을 만들기 위해 의사결정나무분석(Decision Tree)과 로지스틱 회귀분석(Logistic Regresion)등의 다양한 기법을 적용하여 결과를 비교분석 하고, 오분류 비용을 적용하여, 최적의 분류결정 값을 가지는 모델을 도출한다. 분석결과, 로지스틱 회귀분석이 산재보험 부정수급 유형 발견에 보다 효과적인 모델로 판명되었다. 또한 판별점(Cut-Off) 0.01로 했을 때 4개변수(요양기간, 업종형태, 의료기관, 재해발생형태)가 부정수급에 탐지하는데 영향력이 큰 변수로 선정되었다.

• The Korean Society of Law and Medicine
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• v.18 no.2
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• pp.195-218
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• 2017

The increase in medical expenses for convalescent hospitals is increasing abnormally, which puts enormous burden on the National health insurance finances. This is a phenomenon that has been associated with the social phenomenon of rapid aging. The fact that the convalescent hospitals are paid the fixed amount per day for hospitalization became the incentive for some hospitals to use the patients as means of making money. And these hospitals intend to get regular care or take medicines at other hospitals in order to reduce medical expenses, even when the medical fee is paid. In order to prevent such financial leaks, the Health Insurance Review and Assessment Service adjusted the patient group for inpatients in a hospital with the above behavior, and then cut the cost of medical care benefits. However, Above decision was canceled by the court on the grounds that there was no basis rule. However, based on the above case, I think that it can be an opportunity to draw up the problem and to improve of the Medical Fee System of hospital. The modified medical fee system can strengthen the medical function of the convalescent hospital. In addition, it seems reasonable to exclude admission for "physically disabled group". Even if admission is allowed for the physically disabled group due to social needs, it should be excluded from the National health insurance for the fianacial soundness and the sustainability of the system.

• Journal of the Korea Society of Computer and Information
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• v.20 no.6
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• pp.141-150
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• 2015

The aim of this study is to analysis the efficiency of the Long-term Care facilities as well as make counterproposals to conduct of efficient management for the Long-term Care facilities. The data of professionals states of Long-term Care facilities and wages state of Long-term Care facilities from regions in 2014. To analyse the data, the number of professionals and facilities are an input variable whereas the size of number and wages are the output variables. The results showed as below. First, according to the CCR test, Kangwon, Gyeonggi, GyeongNam, Deajeon, Seoul, Ulsan, Incheon, Jeju, and Chong Buk showed significance, but Daegu and Busan showed no significance. Second, the BCC result showed that Kangwon, Gyeonggi, GyeongNam, Deajeon, Seoul, Ulsan, Incheon, Jeju, and Chong Buk has efficiency whereas Daegu and Busan has no efficiency. The result of excess efficieincy analysis confirmed 133.5% in Jeju as the highest area, 37.54% of the highest efficiency of the care provider, and 28.61% of imporvable possibility with doctor's number. The realization of increasing numbers, the ensure of the doctor's number, and consolidating of the care provider's the espertise are required for the future.

• 한국노년학
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• v.31 no.2
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• pp.259-276
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• 2011

If frail elderly could use home care services adequately, quality of their life might improve and their costs of service would be decreased. The purpose of this study is to examine the factors on institutionalization of elderly using home care services in Korean long-term care insurance system. This study used the data of '2009 satisfaction survey of Korean long-term care system'. The survey proceeded using sampling data by region, level of long-term care need, and insurance type among beneficiaries from August 2009 to September 2010. The onset dates of institutionalization of 1,230 participants were ascertained from long-term care insurance claim data. This study calculated hazard ratio through Cox Proportional Hazard Model. The results showed that if elderly using home care services suffer a fracture, the hazard ratio of institutionalization is higher significantly. Although not significant, if older persons have more items of damaged cognitive functions, the hazard ratio of institutionalization is higher. The results have policy implications to supplement of home care service system and postpone institutionalization of elderly.

• Journal of rehabilitation welfare engineering & assistive technology
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• v.7 no.2
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• pp.125-132
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• 2013

This research is focused on improvement of satisfaction of the assistive products, which is used by long term care elderly people. We investigated 1,200 long-term cared elderly and this survey was conducted by care-giver. The average satisfaction of the assistive products are in convenience 3.43, in function and effectiveness 3.33, in safety and secure 3.29 and in adequacy cost compared to effectiveness 2.69. Total average satisfaction of utilization is 3.19. Satisfaction with the use of assistive products in using motivation does not show a statistically significant difference, but in selection factors is a difference to be statistically significant. In conclusion, expert-consulting should be enhanced for the improvement of satisfaction and the provision of assistive products should be expanded in long-term care insuance schemes. Also, the rational index and evaluation method of the satisfaction of the assistive products should be developed through continuous studies.

• The Korean Society of Law and Medicine
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• v.20 no.3
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• pp.175-209
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• 2019

The bundled discounting which the dominant undertakings engage in is problematic in terms of competition restraint. Bundled discounts generally benefit not only buyers but also sellers. Specifically, bundled discounts usually costs a firm less to sell multiple products. In addition, Bundled discounts always provide some immediate consumer benefit in the form of lower prices. Therefore, competition authorities and courts should not be too quick to condemn bundled discounts and apply the neutral and objective standard in bundled discounting cases. Cascade Health v. Peacehealth decision starts ruling from this prerequisite. This decision pointed out that the dominant undertaking can exclude rivals through bundled discounting without pricing its products below its cost when rivals do not sell as great a number of product lines. So bundled discounting may have the anticompetitive impact by excluding less diversified but more efficient producers. This decision did not adopt Lepage case's standard which does not require the court to consider whether the competitor was at least as efficient of a producer as the bundled discounter. Instead of that, based on cost based approach, this decision said that the exclusionary element can not be satisfied unless the discounts result in prices that are below an appropriate measures of the defendant's costs. By adopting a discount attribution standard, this decision said that the full amount of the discounts should be allocated to the competitive products. As the seller can easily ascertain its own prices and costs of production and calculate whether its discounting practices exclude competitors, not the competitor's costs but the dominant undertaking's costs should be considered in applying discount attribution standard. This case deals with bundled discounting practice of multiple healthcare services by the dominant undertaking in healthcare market. Under the Korean healthcare system and public health insurance system, the price competition primarily exists in non-medical care benefits because public healthcare insurance in Korea is in combination with the compulsory medical care institution system. The cases that Monopoly Regulation and Fair Trade Law deals with, such as cartel and the abuse of monopoly power, also mainly exist in non-medical care benefits. The dominant undertaking's exclusionary bundled discounting in Korean healthcare markets may be practiced in the contracts between the dominant undertaking and private insurance companies with regards to non-medical care benefits.

• The Korean Journal of Applied Statistics
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• v.28 no.6
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• pp.1063-1073
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• 2015

In the long-term care insurance (LTCI) system, National Health Insurance Service (NHIS) provide counseling services for beneficiaries and their family caregivers, which help them use LTC services appropriately. The purpose of this study was to develop a Target Selection Model for the Counseling Services based on needs of beneficiaries and their family caregivers. To develope models, we used data set of total 2,000 beneficiaries and family caregivers who have used the long-term care services in their home in March 2013 and completed questionnaires. The Target Selection Model was established through various data-mining models such as logistic regression, gradient boosting, Lasso, decision-tree model, Ensemble, and Neural network. Lasso model was selected as the final model because of the stability, high performance and availability. Our results might improve the satisfaction and the efficiency for the NHIS counseling services.

• Journal of the Korea Academia-Industrial cooperation Society
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• v.13 no.12
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• pp.5816-5825
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• 2012

As the society has been ageing, senile dementia increase rapidly. Thus social costs of dementia treatment and management increase exceedingly. There is a desperate need of finding out improvements.. For example, foreign countries come with the solutions about this issue by establishing national strategy about Dementia, setting effective Dementia Management in national level and preparing legal systems. Older Welfare Act, Long Term Care Insurance Act for the Aged and Dementia Management Act exist as legal system of improvements. Improvement about this issue is needed due to more effective Dementia management and pushing ahead policies. First of all, the government needs to include dementia checkup into the list of national health insurance checkup toward senior citizen of older than 65-year-old. Secondly, as one of the characteristics of dementia, when more symptoms of dementia appear, there is less effect of treatment. Therefore, in order to reduce the social costs of Dementia, the government needs to promote Dementia prevention industry and early checkups. Thirdly, there is a need of setting a class judgement standard appeasement policy and expansion of using target. The reason of processing this statement is that there are difficulties of satisfying the needs of senior citizens due to current conformity of long-term pay recuperation according to laws of welfare.

• The Korean Society of Law and Medicine
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• v.16 no.2
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• pp.87-130
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• 2015

In a case in which National Health Insurance Corporation (NHIC) pays medical care expenses to a victim of a traffic accident resulting in injury or death and asks the assailant for compensation of its share in the medical care expenses, as the precedent treats the subrogation of a claim set by National Health Insurance Act the same as that set by Industrial Accident Compensation Insurance Act, it draws the range of its compensation from the range of deduction, according to the principle of deduction after offsetting and acknowledges the compensation of all medical care expenses borne by the NHIC, within the amount of compensation claimed by the victim. However, both the National Health Insurance Act and the Industrial Accident Compensation Insurance Act are laws that regulate social insurance, but medical care expenses in the National Health Insurance Act have a character of 'an underinsurance that fixes the ratio of indemnification,' while insurance benefit on the Industrial Accident Compensation Insurance Act has a character of full insurance, or focuses on helping the insured that suffered an industrial accident lead a life, approximate to that in the past, regardless of the amount of damages according to its character of social insurance. Therefore, there is no reason to treat the subrogation of a claim on the National Health Insurance Act the same as that on the Industrial Accident Compensation Insurance Act. Since the insured loses the right of claim acquired by the insurer by subrogation in return for receiving a receipt, there is no benefit from receiving insurance in the range. Thus, in a suit in which the insured seeks compensation for damages from the assailant, there is no room for the application of the legal principle of offset of profits and losses, and the range of subrogation of a claim or the amount of deduction from compensation should be decided by the contract between the persons directly involved or a related law. Therefore, it is not reasonable that the precedent draws the range of the NHIC's compensation from the principle of deduction after offsetting. To interpret Clause 1, Article 58 of the National Health Insurance Act that sets the range of the NHIC's compensation uniformly and systematically in combination with Clause 2 of the same article that sets the range of exemption, if the compensation is made first, it is reasonable to fix the range of the NHIC's compensation by multiplying the medical care expenses paid by the ratio of the assailant's liability. This is contrasted with the range of the Korea Labor Welfare Corporation's compensation which covers the total amount of the claim of the insured within the insurance benefit paid in the interpretation of Clauses 1 and 2, Article 87 of the Industrial Accident Compensation Insurance Act. In the meantime, there are doubts about why the profit should be deducted from the amount of compensation claimed, though it is enough for the principle of deduction after offsetting that the precedent took as the premise in judging the range of the NHIC's compensation to deduct the profit made by the victim from the amount of damages, so as to achieve the goal of not attributing profit more than the amount of damage to a victim; whether it is reasonable to attribute all the profit made by the victim to the assailant, while the damages suffered by the victim are distributed fairly; and whether there is concrete validity in actual cases. Therefore, the legal principle of the precedent concerning the range of the NHIC's compensation and the legal principle of the precedent following the principle of deduction after offsetting should be reconsidered.

• The Korean Society of Law and Medicine
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• v.23 no.2
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• pp.171-209
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• 2022

There were also many medical-related rulings in 2021, among which the rulings reviewed in this paper are as follows. The first relates to a case in which the medical record, which is the primary judgment data regarding the presence or absence of medical negligence, has been modified. The court judged whether there was negligence on the basis of the first written medical record without considering the contents of the medical record that was later modified. Next, the ruling on the case of asking for liability for damages for prescription of anti-obesity drugs recognized negligence related to prescription, but denied liability for property damage by denying a causal relationship, and recognized only alimony for violation of the duty of explanation. The a full-bench ruling on the scope of subrogation of the National Health Insurance Corporation, which subrogates the claims for compensation for medical expenses against the perpetrator of the patient, changed the existing precedent that had taken the 'deduction method after offsetting negligence' and judged it as 'the method of offsetting negligence after deduction'. In addition, in the ruling on whether or not there was negligence, the court was not bound by the medical record appraisal result. Lastly, in relation to the National Health Insurance Service's disposition of reimbursement for medical care benefit costs, we reviewed the ruling that discretion should be exercised even when a non-medical person makes a refund to a medical institution opened by a non-medical person. And we also reviewed the ruling that the scope of reimbursement for medical institutions jointly using facilities and manpower specifically should be determined.