• 보건행정학회지
• /
• 제16권2호
• /
• pp.49-76
• /
• 2006

The aim of this study was to explore the effects of a computerized review program which was introduced in August 1, 2003, using claims data for acute respiratory infection related diseases. National Health Insurance (NHI) claims data on respiratory infection related diseases before and after the introduction, with six month intervals respectively, were used for the analysis. Clinic was the unit of observation, and clinics with only one physician whose specialty was internal medicine, pediatrics, otorhinolaryngology and family medicine and clinics with a general practitioner were selected. The final sample had 7,637 clinics in total. Indices used to measure practice pattern was prescription rates of antibiotics, prescription rates of injection drug per visit, treatment costs per claim, and total costs per claim. Changes in the number of claims for major disease categories and upcoding index for disease categories were used to measure claiming behavior. Data were analysed using descriptive analysis, t-test for indices changes before and after the introduction, analysis of variance (ANOVA) for practice pattern change for major disease categories, and multiple regression analysis to identify whether new system influenced on provider' practice patterns or not. Prescription of antibiotics, prescription rates of injection drug, treatment costs per claim, and total costs per claim decreased significantly. Results from multiple regression analysis showed that a computerized review system had effects on all the indices measuring behavior. Introduction of the new system had the spillover effects on the provider's behavior in the related disease categories in addition to the effects in the target diseases, but the magnitude of the effects were bigger among the target diseases. Rates of claims for computerized review over total claims for respiratory diseases significantly decreased after the introduction of a computerized review system and rates of claims for non target diseases increased, which was also statistically significant. Distribution of the number of claims by disease categories after the introduction of a computerized review system changed so as to increase the costs per claims. Analysis of upcoding index showed index for 'other acute lower respiratory infection (J20-22)', which was included in the review target, decreased and 'otitis media (H65, H66)', which was not included in the review target, increase. Factors affecting provider's practice patterns should be taken into consideration when policies on claims review method and behavior changes. It is critical to include strategies to decrease the variations among providers.

• 한국병원경영학회지
• /
• 제8권2호
• /
• pp.93-110
• /
• 2003

Fiscal crisis in the medical insurance has put the pressure upon hospitals by increasing the rate of curtailment, since the implementation of the separation between prescription and dispensing of Drug. The purpose of this study is to analyze the curtailment for antibiotics, injected drug and other drugs expenditure before and after the system of separation between prescribing and dispensing. Data were gathered from 13 general hospitals and used for analysis of trends on antibiotics and injected drug expenditure, and curtailment in 2000-2001 at three months intervals. The results were as follows; The curtailment rate of antibiotics expenditure has been increased in outpatient and inpatient since 2000. The curtailed antibiotics cost and injected drug cost in outpatient under the prescription within the hospital and in inpatient increased. The ratios of curtailment versus expenditure had increased in antibiotics, injected drugs, anticancer drugs, antiulcer drugs, albumine, antiinflammatory drugs. These results suggest that claim review system in social health insurance were over-focused mainly to control the cost and it might to impede the validity of claim review function in health insurance system. Therefore, it's needed to develope the scientific and reasonable parameter & criteria for claim review of drug expenditure.

• 한국병원경영학회지
• /
• 제28권2호
• /
• pp.9-20
• /
• 2023

Purpose: This study classified the actual functions of geriatric hospitals and examined the differences in their characteristics, in order to provide a basis for discussions on defining the functions of geriatric hospitals and how to pay for care. Methodology: This study used various administrative data such as health insurance data and long-term care insurance data. Cluster analysis was used to categorize geriatric hospitals. To examine the validity of the cluster analysis results, we conducted a discriminant analysis to calculate the accuracy of the classification. To examine cluster characteristics, we examined structure, process, and outcome indicators for each cluster. Findings: The cluster analysis identified five clusters. They were geriatric hospitals with relatively short stays for cancer patients(cluster 1; cancer patient-centered), geriatric hospitals with relatively large numbers of patients using rehabilitation services(cluster 2; rehabilitation patient-centered), geriatric hospitals with a high proportion of relatively severe elderly patients(cluster 3; severe elderly patient-centered), geriatric hospitals with a high proportion of mildly ill elderly patients with various conditions(cluster 4; mildly ill elderly patient-centered), and geriatric hospitals with a significantly higher proportion of dementia patients(cluster 5; dementia patient-centered). The largest number of geriatric hospitals were categorized in clusters 4 and 5, and the structure and process indicators for these clusters were generally lower than for the other clusters. Practical Implications: We have confirmed the existence of geriatric hospitals where the medical function, which is the original purpose of a geriatric hospital, has been weakened. It has been observed that the quality level of these geriatric hospitals is likely to be lower compared to hospitals that prioritize enhanced medical functions. Therefore, it is suggested to consider the conversion of these geriatric hospitals into long-term care facilities, and careful consideration should be given to the review of care-giver payment coverage.

• 한국치위생학회지
• /
• 제15권3호
• /
• pp.353-361
• /
• 2015

Objectives: The purpose of the study is to investigate the level of knowledge and screening review rates of dental health insurance claims in dental hygienists. This analysis will provide the educational information to the dental hygienists. Methods: A self-reported questionnaire was completed by dental hygienists in Jeonbuk from December 17, 2012 to January 24, 2013. The questionnaire was distributed by ordinary mail or direct visit. Except incomplete answers, 350 data were collected and analyzed. The study instrument was adapted from the structured questionnaire by Hong and Yoo. The questionnaire consisted of education experience of health insurance management, subjective and objective knowledge, insurance screening review, and need for health insurance education. Data were analyzed by SPSS 12.0 program. Cronbach alpha in the objective knowledge on health insurance rate criteria was 0.836 and this was a reliable figure. Results: The subjective knowledge level of dental insurance was higher in the senior dental hygienists. Subgingival curettage was the lowest percentage of correct answers in the objective knowledge. In recent six months, higher review control rate was shown in the higher claim for health insurance and insurance screening review. Conclusions: The majority of the respondents had lower level of knowledge of health insurance claims. The continuous education of dental health insurance will be necessary in the dental hygienists.

• 한국산업정보학회논문지
• /
• 제28권2호
• /
• pp.1-9
• /
• 2023

유방암 관련 기존 AI 연구는 보조적인 진단 예측이나 임상적 요인에 따른 진료 결과를 예측하는 주제가 많았다. 또한 연구기관의 코호트 자료나 일부 환자 자료를 이용하는 경우가 대부분이었다. 본 논문에서는 건강보험심사평가원이 보유하고 있는 전 국민 유방암 환자의 전수 데이터를 활용하여 유방암 환자의 40~50대와 다른 연령대 간의 생존 여부 예측과 생존 여부에 미치는 요인의 차이점을 분석했다. 그 결과, 환자들의 생존 여부 예측 정밀도는 40~50대가 평균 0.93으로 60~80대 0.86 보다 높았으며, 요인에 있어서도 40~50대는 치료횟수(46%)가, 60~80대는 나이(32%)의 변수 중요도가 제일 높았다. 기존 연구와 성능 비교 결과, 평균 정밀도가 0.90으로 기존 논문의 정밀도 0.81보다 높았다. 적용 알고리즘별 성능 비교 결과, 의사결정나무(Decision Tree), 랜덤포레스트(Random Forest) 및 그래디언트부스팅(Gradient Boosting)의 전체 평균 정밀도는 0.90, 재현율은 1.0으로 연령대 그룹 내에서 동일하였으며, 다층퍼셉트론(Multi-Layer Perceptron)의 정밀도는 0.89, 재현율은 1.0 이었다. 심평원의 전 국민 심사청구 빅데이터 가치 활용을 제고하기 위해 비전문가용 머신러닝 자동화(Auto ML) 도구를 사용한 더 많은 연구가 진행되기를 바란다.

• 통상정보연구
• /
• 제9권1호
• /
• pp.169-186
• /
• 2007

The purpose of this study analyzes laying stress on Japan example that background of electronic issue of international meritime insurance policy is what, and is marched in some degree present. and this study presented what hereafter subject of electronic insurance plice is. The this paper is to study the current situations of trade financial EDI in Japan and problems in application of marine insurance contracts. The subject of electronic marine policy issue is as following in trade financing EDI. (1) application of electronic document in claim demand. (2) standardization of various documents and insurance plice data. (3) insurance compensation document that become Jeonjahwa in insurance accident settlement. (4) maritime Insurance policy agreement's establishment. (5) when is monopolized to third party, realization of electronic maritime insurance policy offer.

• 보험의학회지
• /
• 제27권2호
• /
• pp.68-74
• /
• 2008

Medical verification of cancer diagnosis in insurance claims is a very important procedure in insurance administrations. Claims staffs are in need of medical experts' opinions about claim administration. This procedure is called medical claim review (MCR) and is composed of verification and advice. MCR verification evaluates the insured’s physical condition by medical records and compares it with product coverage. It is divided into assessment of living assurance benefit, verification of cancer, and assessment of the cause of death. Actually cancer verification of MCR is applicable to coding because the risk ratio in product development is usually coded data. There are some confusing neoplastic diseases in assessing the verification of cancer. This article reviews gastrointestinal stromal tumors (GIST) and mucosa-associated lymphoid tissue tumors (MALToma) of the stomach. The second most common group of stromal or mesenchymal neoplasms affecting the gastrointestinal tract is GIST. Nowadays there are many articles about the pathophysiology of GIST. However there are few confirmative theories except molecular cell biology of KIT mutation and some tyrosine kinase. Therefore, coding the GIST, which has previously been classified as an intermediate risk group according to NIH2001 criteria, for cancer verification of MCR is suitable for D37.1; neoplasm of uncertain or unknown behavior of digestive organs and the stomach. The gastrointestinal tract is the predominant site of extranodal non-Hodgkin's lymphomas. B-cell lymphomas of the MALT type, now called extranodal marginal zone B-cell lymphoma of MALT type in the REAL/WHO classification, are the most common primary gastric lymphomas worldwide. Its characteristics are as follows. First, it is different from traditional stomach cancers such as gastric adenocarcinoma. Second, the primary therapy of MALToma is the eradication of H. pylori by antibiotics and the remission rate is over 80%. Third, it has a different clinical course compared to traditional malignant lymphoma. Someone insisted that cancer verification is not possible for the above reasons. However, there have been findings on pathologic mechanism, and according to WHO classification, MALToma is classified into malignant B-cell lymphoma and it must be verified as malignancy in MCR.

• Journal of Acupuncture Research
• /
• 제27권3호
• /
• pp.137-146
• /
• 2010

Objectives : While there are many studies about treatments of facial palsy, no study has been performed on general population of Korea, especially concerning about comparison between western medicine and oriental medicine. This study aimed to investigate magnitude of health visits and treatment patterns for Korean patients with facial palsy through the computerized database of Health Insurance Review and Assessment Service(HIRAS). Methods : According to the HIRAS database over 5 years' period from 2004 to 2008, the medical records of patients with facial palsy as a main diagnosis were extracted. Inclusion criteria of facial palsy are Bell's palsy(G510), Geniculate ganglionitis(G511), Melkersson's syndrome(G512), Other disorders of facial nerve(G518), Disorder of facial nerve, unspecified(G519) in western medicine. And Paralytic face(G016), Deviated eye and mouth(J01), The other facial palsy(J013) were included in oriental medicine. We compared the claim number of western medical care with that of oriental medicine treatment by year and month. Results : The total claim number of facial palsy was increasing on both western medicine and oriental medicine from 2004 to 2008. In western medicine, the claim number of Bell's palsy(G510) is the most. In oriental medicine the inpatients claim number of Deviated eye and mouth(J01) is the most, while outpatients claim number of the other facial palsy(J013) is the most. Conclusions : Medical database of HIRAS provided comprehensive and vast information on epidemiologic characteristics and treatment, which can be more reliable data to expect medical demand for facial palsy in condition that accurate diagnosis and standardized treatment is delivered in clinical settings.

• 한국임상약학회지
• /
• 제18권2호
• /
• pp.124-131
• /
• 2008

The impacts of guideline for digestives on physicians' prescription of GI medication Clinical practice guidelines provide benefits to physicians, patients, and researchers. It also helps doctors to make decisions in medical services. In many countries, practice guidelines lead to activities of quality improvement and are developed using evidence based methods. This research was to assess the impacts of Korean Medical Association's guideline for digestives on the change of physicians' behavior. This study was progressed as one-group pre-test post-test quasi-experimental design using health insurance claims data. The unit of analysis was institution. Data was analyzed using paired t-test for change of prescription rate before and after the distribution of practice guidelines. And the multiple regression analysis was performed to examine the independent impact of the guideline on the prescribing rate of GI medication. Prescription rates of GI medication per claim by medical institution increased significantly, 1.98%point (from 50.27% to 52.25%) and multivariate regression analysis showed significant increase in the prescription rate of GI medication after the distribution of guideline (p<0.001). In conclusion, the distribution of guideline for digestive might not have the effects on the change in provider's behavior. Furthermore, to activate the use of practice guideline, it would be necessary to educate the contents to physicians as well as to develop practice guideline.

• 경영과학
• /
• 제11권3호
• /
• pp.153-167
• /
• 1994

Credibility theory has provided with a useful tool the assignment of weighting factor that reflects the credibility of the observed individual and collective experience to secure fair experience rate-,making. We review credibility models which can effectively estimate risk premiums using credibility theory, and suggest an empirical Bayed model based on the collective statistics to estimate the structural parameters. To illustrate the use of evolutionary models, the models are applied to the actual data, such as loss ratio, claim frequencies and severity, in the Korean automobile insurance. Also the possibilities of generalizations and applications of empirical models are discussed.