• 보건의료산업학회지
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• 제9권1호
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• pp.57-66
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• 2015

This study was performed to provide efficient fund managing plans for hospitals by looking into the management of medical fees for accident insurance. Car insurance, industrial accident insurance and seamen's insurance at a general hospital which is located in Busan during 29 months from January 1, 2009 to May 31, 2011 were assessed. The research data is the total number of 6,293 cases, including 2,251 car insurance cases, 2,350 industrial accident insurance cases, and 1,692 seamen's insurance cases. There were some significant differences found, as car insurance and seamen's insurance, including accident insurance, are types of insurance for which employers or traffic accidents offenders shall be the final premium payer. In addition, medical examination fees or premium payers are applied under their respective related laws. The findings suggest that it is necessary for managers of hospitals to prepare differentiated management schemes based on the characteristics of each insurer and schemes to ensure proper recovery strategies of uncollected medical account receivables.

• Safety and Health at Work
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• 제2권2호
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• pp.148-157
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• 2011

Objectives: Although compensation for occupational injuries and diseases is guaranteed in almost all nations, countries vary greatly with respect to how they organize workers' compensation systems. In this paper, we focus on three aspects of workers' compensation insurance in Organization for Economic Cooperation and Development (OECD) countries - types of systems, employers' funding mechanisms, and coverage for injured workers - and their impacts on the actual frequencies of occupational injuries and diseases. Methods: We estimated a panel data fixed effect model with cross-country OECD and International Labor Organization data. We controlled for country fixed effects, relevant aggregate variables, and dummy variables representing the occupational accidents data source. Results: First, the use of a private insurance system is found to lower the occupational accidents. Second, the use of risk-based pricing for the payment of employer raises the occupational injuries and diseases. Finally, the wider the coverage of injured workers is, the less frequent the workplace accidents are. Conclusion: Private insurance system, fixed flat rate employers' funding mechanism, and higher coverage of compensation scheme are significantly and positively correlated with lower level of occupational accidents compared with the public insurance system, risk-based funding system, and lower coverage of compensation scheme.

• 동서간호학연구지
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• 제25권2호
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• pp.157-165
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• 2019

Purpose: This study aims to provide basic data for the development of measures and promoting home health nursing by examining the current status and trends in home health nursing for long-term care (LTC) insurance beneficiaries. Methods: Secondary data, including annual LTC insurance statistics reports for 2010-2017 and LTC manpower data, were used to compute current status and trends in the provision of home health nursing. Results: Beneficiaries of home health nursing under LTC insurance, insurance-covered costs for home health nursing, home health nursing provider, and home health nursing providing institution only accounted for 3% of all insurance-covered home care services, and were on a consistent decline since 2010. In particular, vulnerable rural regions with high proportion of individuals had poor infrastructure in terms of home health nursing institutions and manpower, but had a higher home health nursing utilization rate compared to urban regions. Conclusion: In addition to measures to support home health nursing service beneficiaries, policy measures are needed to support home health nursing service personnel and institutions. Furthermore, programs to cultivate the expertise of home health nurses and improve quality of home health nursing services should be developed in order to promote home health nursing utilization in vulnerable rural regions.

• Asian Pacific Journal of Cancer Prevention
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• 제13권12호
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• pp.6163-6168
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• 2012

Although much health services research has been conducted using national health insurance claims data in Korea, the validity of this method has not been ascertained. The objective of this study was to validate the use of claims data for health services research by comparing incidence rate of cancers found using insurance claims data against rates of the national cancer registry of Korea. An algorithm to estimate incidence rates using claims data was developed and applied. The claims data from 2005-2008 were acquired and the patients admitted to hospitals due to cancer in 2008 without admission to hospital from 2005-2007 by the same diagnosis code were regarded as incident cases. The acquired results were compared with the values from the National Cancer Registry of Korea. The incidence rate of all cancers found using claims data was 363.1 per 100,000 people, which is very similar to the 361.9 per 100,000 rate of the national cancer registry. Also the age-, gender- and disease-specific rates between the two data sources were similar. Therefore, national health insurance claims data may be a worthwhile resource for health services research if appropriate algorithms are applied, especially considering the cost effectiveness of this method.

• 보건행정학회지
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• 제23권2호
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• pp.152-161
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• 2013

Korea has a single National Health Insurance program and all citizens are covered under this program, accounting 97% of the population, approximately 50 million people. Claims submitted by Health care providers are reviewed by Health Insurance Review and Assessment (HIRA) for the reimbursement. HIRA database contains not only individual beneficiary's information, but also healthcare service information such as diagnosis, procedures, prescriptions and tests for them. HRA database has gained attention as importance source for research due to its rich healthcare information and the demand of HIRA database has increased. Due to its tremendous size, however, researchers have had problems in accessing the database to conduct research. To meet this demand, we conducted a study to develop the inpatient sample data from HIRA database for research. This study has two purposes: 1) to determine a needed sample size; 2) to test reliability and validity of the sample data. We determined an adequate sample size to ensure representativeness and generality with additional consideration for convenience of calculation. The minimum sample size was 729,904 for the generality, and 488,861 for representativeness. After considering the convenience of calculation, our final sample size was 13% of the population, which was about 7.7 million beneficiaries. Age (5 years interval) and gender were used as stratification variables for sampling. In order to examine whether this sample data appropriately reflect population, we tested the reliability and validity of the sample data. From the sample data, we computed average expenditure of total claims per inpatient for 2011, frequency of top 30 disease, estimation of the number of stroke patients from the sample data, and then compared them to those from the population. Results confirmed reliability and validity of the sample data.

• 대한한의학회지
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• 제34권1호
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• pp.35-51
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• 2013

Objectives: The purpose on this study was to analyze medical health insurance to provide useful data to reestablish oriental medical insurance fees for long-term care hospitals. Methods: First, comparative analysis on medical health insurance was performed, calculating insurance fees of patients admitted to Mungyung Long-term Care Hospital. The oriental medical insurance fee of the patients was calculated as if the patients have been admitted to oriental long-term care hospitals, and the ratio of oriental medical insurance fee to western was calculated. Results: 1. The ratios of total medical expenses were 90% within 3 months and 82% over 3 months. 2. The ratios of co-pays were 86% within 3 months and 82% over 3 months. Conclusions: Oriental medical insurance fees need to be reevaluated.

• Asia pacific journal of information systems
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• 제31권4호
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• pp.527-542
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• 2021

The government-driven open data policies are on the rise to protect consumers from misunderstandings and monitor the companies. However, in contract-based industries such as insurance, the contract-inherent characteristics make information asymmetry between consumers and companies. Our paper focuses on insurance contracts where the contingency has high uncertainty of occurrence, and the clauses may incur high costs of reading. Given those contracts, we hypothesized that the contract's clear statement decreases customer dissatisfaction and lowers the number of complaints. To empirically support the claim, we collected customers' complaint documents of insurance companies and insurance contracts from 2005 until 2017. Our econometric models showed that clearer statements and words significantly reduce the complaints after controlling for firm-specific heterogeneity and time-specific heterogeneity. We identify that insurance companies' complaint ratio significantly differ depending on the insurance contract, including specific clauses and words.

• 한국빅데이터학회지
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• 제2권2호
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• pp.17-31
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• 2017

빅데이터의 중요성이 증가함에 따라 공공기관에서는 다양한 빅데이터 관련 인프라를 제공하고 있으며, 그 중 하나가 공공데이터이다. 공공데이터 기반의 다양한 활용 사례가 공유되고 있으며, 공공기관에서도 데이터 기반의 모델을 통해 공공의 문제를 해결하려는 움직임을 보이고 있다. 대표적으로 사회 보험 중 하나인 고용보험 케이스가 있다. 고용보험은 근로자의 권익 보호를 위해 근로자를 고용한 모든 사업주가 필수적으로 가입하여야 하는 보험이지만 가입누락의 경우가 많다. 가입누락을 막기 위한 데이터 기반의 접근이 필요하지만, 분산된 형태의 공공데이터, 수집 시기의 차이로 인해 데이터 통합이 어렵고, 체계적인 방법론이 부재한 상황이다. 본 논문에서는 공공데이터를 기반의 고용보험 가입 예측을 위한 모델 도출방법론을 제시하고자 한다. 본 방법론은 데이터 수집, 데이터 통합 및 전처리, 데이터 탐색 및 이력 데이터 분석, 예측 모델 도출을 포함하며, 프로세스 마이닝 및 데이터 마이닝을 활용한다. 또한, 사례 연구를 통해 본 방법론의 유효성을 검증한다.

• KDI Journal of Economic Policy
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• 제30권2호
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• pp.99-128
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• 2008

민간보험은 공적보험과 보완적인 관계를 형성함에도 불구하고 우리나라의 민간보험은 소득계층에 따른 접근성 차이로 인한 사회적 불평등, 도덕적 해이로 인한 공적보험 재정악화 등의 우려를 낳고 있다. 그러나 이에 관한 실증적 분석은 그간 이루어지지 못하여 정책적인 방향을 정립하는 데 장애가 되어 왔다. 본 연구는 건강보험공단, 심사평가원, 민간보험사, 행정자치부 주민등록세대정보 등의 관련 정보를 종합하여 이에 대한 실증분석을 시도했다. 그 결과, 우리나라의 민간보험 가입률은 전 국민의 64%에 달하고 있으며, 고소득층과 저소득층 간에 민간보험 가입률의 차이가 나타나지 않았다. 이는 공적보험의 보장성이 미흡한 상황에서 저소득층 역시 갑작스런 의료지출에 대비하고 있으며, 민간보험이 의료접근성의 계층화를 초래하지 않고 있다는 것을 시사한다. 또한 민간보험 가입자는 평균적으로 미가입자에 비해 의료이용량이 높지 않았으며, Two-Part Model을 통해 다양한 변수를 통제했을 경우에도 동일한 결과가 나타났다. 연령대에 따른 차이로 미루어 이러한 결과는 노동시장과 연관된 한시적인 성격일 것으로 추측되나, 현재로서는 민간보험 가입에 따른 도덕적 해이가 강하게 나타나고 있다는 근거는 발견되지 않았다.

• 한국콘텐츠학회논문지
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• 제20권3호
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• pp.92-105
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• 2020

이 연구에서는 실손형 민간의료보험 가입의 영향요인과 실손형 민간의료보험이 외래 및 입원 의료이용에 미치는 영향에서 성별 차이를 파악하고자 하였다. 한국의료패널의 2010년부터 2016년까지 조사 자료를 패널자료로 구성하여 로짓모형과 회귀모형으로 분석하였다. 실손형 민간의료보험의 가입에서 남성은 여성보다 가입확률이 낮았고, 여성의 경우 미충족 의료 여부, 주관적 건강상태에 따라 가입확률의 차이가 있었고, 남성의 경우 결혼상태, 거주지에 따라 차이가 있었다. 실손형 민간의료보험은 여성군에서 외래 방문 당 진료비에 영향을 미치지 않았으나 남성군에서는 외래 방문 당 진료비를 증가시키는 것으로 분석되었다. 또한, 여성군에서 실손형 민간의료보험이 입원 당 진료비를 유의하게 증가시켰으나 남성군의 입원 당 진료비에는 영향을 주지 않았다. 실손형 민간의료보험의 가입과 실손형 민간의료보험이 의료이용에 미치는 영향에서 성별 차이가 있음을 확인하였으며, 이는 실손형 민간의료보험 관련 연구와 제도 운용에서 성별 차이를 고려할 필요가 있음을 시사한다.