• The Korean Society of Law and Medicine
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• v.21 no.1
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• pp.153-185
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• 2020

In principle, even if serious consequences such as death or serious injury of a patient occur as a result of a medical accident, if the medical malpractice of a health care worker is not recognized, the health care worker is not held liable for said consequences. However, with the opening of the Korea Medical Dispute Mediation and Arbitration Agency on April 7, 2012, a system was established to compensate health care personnel for their medical malpractices only in the case of "injuries caused by medical accidents in the course of childbirth" (hereinafter referred to as "program for compensation of medical accidents"). Article 46 paragraph 1 of the current Medical Dispute Mediation Act, which is the basis of the Force Majeure Medical Accident Compensation System, stipulates that "medical accidents under delivery" claims are to be determined by the Medical Accident Compensation Review Committee are subject to the compensation project. And the details of the compensation, ratio of sharing financial resources for compensation, scope of compensation, and the guidelines and procedure for the payment of compensations are prescribed by Presidential Decree. In other words, the Presidential Decree requires the state to pay 70 percent of the compensation funds, and 30 percent of the above funds among health care providers. The Constitutional Court has decided on the 2015Hun-Ga13 that the scope of the health care institution's founders and the share of the compensation funds cannot be directly determined by the law, and that the portion delegated by the Presidential decree does not violate the Principle of Legal Protection nor Comprehensive Nondelegation Doctrine. However, this can be seen as an exclusion of accountability for force-induced delivery accidents even if there is no negligence of the medical staff. If the nature of the system is a type of social security system with a social compensatory nature, it could consider eliminating the health care innovator's cost-sharing provisions, leaving the full cost to the state. However, it is also necessary to review institutional protocols that strengthen the efforts of medical institutions in areas such as analysis of the causes of medical accidents and measures to prevent their recurrence. In addition, I think that the conclusion of the Act is in line with the purpose of the Comprehensive Wage Support Regulations that at minimum the law sets an upper limit of the compensation funds that are to be paid by health and medical institutions. Moreover, it is reasonable for the Medical Accident Compensation Review Committee to specify gestational age and weight of births, which are the criteria for compensation, under the Enforcement Decree of the Medical Dispute Mediation Act, in relation to the criteria for payment of contributions by the Medical Accident Compensation Review Committee, and to set the detailed criteria.

• Journal of Preventive Medicine and Public Health
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• v.41 no.5
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• pp.287-294
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• 2008

Objectives : To estimate the economic burden of osteoporotic vertebral fracture (VF) from a societal perspective. Methods : From 2002 to 2004, we identified all National Health Insurance claims records for women ${\geq}50$ years old with a diagnosis of VF. The first 6-months was defined as a "clearance period," such that patients were considered as incident cases if their first claim of fracture was recorded after June 30, 2002. We only included patients with ${\geq}$ one claim of a diagnosis of, or prescription for, osteoporosis over 3 years. For each patient, we cumulated the claims amount for the first visit and for the follow-up treatments for 1 year. The hospital charge data from 4 hospitals were investigated to measure the proportion of the non-covered services. Face-to-face interviews were conducted with 106 patients from the 4 study sites to measure the out-of-pocket spending outside of hospitals. Results : During 2.5 years, 131,453 VF patients were identified. The patients had an average of 3.38 visits, 0.40 admissions and 6.36 inpatient days. The per capita cost was 1,909,690 Won: 71.5% for direct medical costs, 20.6% for direct non-medical costs and 7.9% for indirect costs. The per capita cost increased with increasing age: 1,848,078 Won for those aged 50-64, 2,084,846 Won for 65-74, 2,129,530 Won for 75-84and 2,121,492 Won for those above 84. Conclusions : Exploring the economic burden of osteoporotic VF is expected to motivate to adopt effective treatment options for osteoporosis in order to prevent the incidence of fracture and the consequent costs.

• The Journal of Korean Medicine Ophthalmology and Otolaryngology and Dermatology
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• v.34 no.2
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• pp.38-52
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• 2021

Objectives : The purpose of this study is to analyze the use of insured herbal extracts and Korean medicinal treatments, which are mainly used to treat allergic rhinitis in Korean medicine. Methods : Among all HIRA(Health Insurance Review and Assessment Service) claims data in 2016, we included all statements that included J30(vasomotor and allergic rhinitis) or a subcategory of J30(J30.0, J30.1, J30.2, J30.3, or J30.4) as the main disease, using the Korean Standard Classification of Diseases(KCD-7). This study analyzed the most frequently used insured herbal extracts and Korean medicinal treatments for allergic rhinitis in Korean medicine. We performed a frequency analysis on subgroups based on treatment type(inpatient or outpatient), sex, age, insurance type, and medical institution type. Results : The result shows the 10 most frequently used insured herbal extracts and Korean medicinal treatments for allergic rhinitis. The total number of insured herbal extracts prescriptions was 82,533, and the most commonly prescribed insured herbal extracts was socheongryong-tang(35,131 prescriptions), followed by hyeonggaeyeongyo-tang(18,157 prescriptions), samsoeum(6,257 prescriptions), and galgeun-tang(4,465 prescriptions). The total number of Korean medicinal treatments prescriptions was 1,878,541, of which the most common Korean medicinal treatments was acupuncture(922,977 prescriptions), followed by moxibustion(372,120 prescriptions), cupping(242,094 prescriptions), and segmental acupuncture(161,553 prescriptions). Conclusions : It is expected that the results of this study can be used as a basis for establishing the priorities of evidence-based clinical research topics in the field of Korean medicine and making health care policy decisions to strengthen coverage in the future.

• Health Policy and Management
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• v.25 no.3
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• pp.185-196
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• 2015

Background: Issues concerning with the classification accuracy of Korean Outpatient Groups (KOPGs) have been raised by providers and researchers. The KOPG is an outpatient classification system used to measure casemix of outpatient visits and to adjust provider risk in charges by the Health Insurance Review & Assessment Service in managing insurance payments. The objective of this study were to refine KOPGs to improve the classification accuracy and to evaluate the refinement. Methods: We refined the rules used to classify visits with multiple procedures, newly defined chemotherapy drug groups, and modified the medical visit indicators through reviews of other classification systems, data analyses, and consultations with experts. We assessed the improvement by measuring % of variation in case charges reduced by KOPGs and the refined system, Enhanced KOPGs (EKOPGs). We used claims data submitted by providers to the HIRA during the year 2012 in both refinement and evaluation. Results: EKOPGs explicitly allowed additional payments for multiple procedures with exceptions of packaging of routine ancillary services and consolidation of related significant procedures, and discounts ranging from 30% to 70% were defined in additional payments. Thirteen chemotherapy drug KOPGs were added and medical visit indicators were streamlined to include codes for consultation fees for outpatient visits. The % of variance reduction achieved by EKOPGs was 48% for all patients whereas the figure was 40% for KOPGs, and the improvement was larger in data from tertiary and general hospitals than in data from clinics. Conclusion: A significant improvement in the performance of the KOPG was achieved by refining payments for visits with multiple procedures, defining groups for visits with chemotherapy, and revising medical visit indicators.

• Health Policy and Management
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• v.19 no.3
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• pp.1-26
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• 2009

Objectives : To identify target areas and set priorities among those areas identified for national quality evaluation. Methods : Target areas were identified from: i) analysis of the national health insurance claims data, mortality and prevalence data ii) various group surveys, including representatives from 22 medical specialty associations, 19 physician associations, QI staffs in hospital, civil organizations, and commissioners of Health Insurance Review and Assessment Service(HIRA) ⅲ) literature reviews and RAM(RAND/UCLA appropriateness method). The priority areas for national quality evaluation represented the full spectrum of health care and the entire life span. The criteria for selecting the priority areas were impact, improvability, and measurability. The priority areas were divided into three categories : short-term, mid-term, long-term. Results: Based on the group surveys and the data analysis, 46 candidates were selected as quality evaluation priority areas. 13 areas were selected as having a short-term priority areas: tuberculosis, community acquired pneumonia, stroke, ischaemic heart disease, diabetes, hypertension, chronic lower respiratory disease(asthma, chronic obstructive pulmonary disease), intensive care unit, emergency room, nosocomial infection, use of antibiotics, multiple medication and renal failure. This results suggested that we need to enlarge the target priority areas to the chronic diseases in short-term. Conclusions: The priority areas identified from the study will assist healthcare quality associated institutions as well as HIRA in selecting quality evaluation areas. It is required to develope and implement strategies for improving the quality of care within the next 5 years.

• Health Policy and Management
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• v.16 no.1
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• pp.17-40
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• 2006

With the prospect of rapidly growing health insurance expenditures, particularly spending for ambulatory care, the introduction of a case-based payment method is discussed as an alternative to the current fee-for-service based method. A system to measure case mixes of providers is a core component of such payment systems. The objective of this study were to develop a classification system for ambulatory care, Korean Ambulatory Patient Group (KAPG) based on the U.S. APG version 2.0 and to evaluate the classification accuracy of the system. A database of 64,258,386 records was constructed from insurance claims submitted to the Health Insurance Review Agency (HIRA) during three months from August 2002. A total of 41,347,307 records with a single visit was used for the development and 7% random sample of the database was used for the evaluation. Additional groups were defined to include both physician and hospital fees in the classification, age splits were added to classify the entire population as well as the population older than 65, and the definition of medical groups used by the HIRA was adopted. The variance reduction in charges achieved by KAPGs was computed to evaluate the accuracy of classification. A total of 474 KAPGs was defined compare to 290 groups in the U.S. APG. The variance reduction for charges of all visits ranged from 20% to 37% depending on the type of provider, and ranged from 22% to 42% for non-outliers, that were better than those achieved by the system currently used by the .HIRA for its internal review purpose. Although further study is required to improve the classification for complicated care in larger hospitals, the results indicated that KAPGs could be used for better management of costs for ambulatory care.

• Journal of Preventive Medicine and Public Health
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• v.51 no.1
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• pp.15-22
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• 2018

Objectives: The use of administrative data is an affordable alternative to conducting a difficult large-scale medical-record review to estimate the scale of adverse events. We identified adverse events from 2002 to 2013 on the national level in Korea, using International Classification of Diseases, tenth revision (ICD-10) Y codes. Methods: We used data from the National Health Insurance Service-National Sample Cohort (NHIS-NSC). We relied on medical treatment databases to extract information on ICD-10 Y codes from each participant in the NHIS-NSC. We classified adverse events in the ICD-10 Y codes into 6 types: those related to drugs, transfusions, and fluids; those related to vaccines and immunoglobulin; those related to surgery and procedures; those related to infections; those related to devices; and others. Results: Over 12 years, a total of 20 817 adverse events were identified using ICD-10 Y codes, and the estimated total adverse event rate was 0.20%. Between 2002 and 2013, the total number of such events increased by 131.3%, from 1366 in 2002 to 3159 in 2013. The total rate increased by 103.9%, from 0.17% in 2002 to 0.35% in 2013. Events related to drugs, transfusions, and fluids were the most common (19 446, 93.4%), followed by those related to surgery and procedures (1209, 5.8%) and those related to vaccines and immunoglobulin (72, 0.3%). Conclusions: Based on a comparison with the results of other studies, the total adverse event rate in this study was significantly underestimated. Improving coding practices for ICD-10 Y codes is necessary to precisely monitor the scale of adverse events in Korea.

• Journal of Korean society of Dental Hygiene
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• v.15 no.5
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• pp.899-905
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• 2015

Objectives: This study aimed to investigate the regional difference of chronic periodontal care services in Korea by the analysis of 2010 raw data from Health Insurance Review and Assessment Service. Methods: The subjects were the chronic periodontitis patients over 35 years old from dental care facilities in Korea. The study population was 278,319 including 264,994 claims made by dental clinics, 8,084 by dental hospitals, 3,509 by general hospitals, and 1,732 by tertiary hospitals. Results: There was a significant difference in medical care cost benefit between the provinces(p<0.0001). The age groups showed a clear difference in the patient charge, cost of insurance, and medical care cost benefit(p<0.0001). In consideration of the first visit or revisit, there were differences in the rate of prescription, dental examination, and surgical procedures of the chronic periodontal patients from dental facilities. The radiographic use rate in the tertiary hospitals was 2.6 times higher than that of the dental clinic in the treatment of the new chronic periodontal patients. Conclusions: The use of dental services in the periodontitis is influenced by the types of medical services facility, cost of medical insurance, and patient charge. In consideration of cost benefit analysis, prevention is the most important care for the periodontitis. Regional difference in peridontitis is cause by the use of medical services and quality of treatment.

• Korean Journal of Clinical Pharmacy
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• v.28 no.1
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• pp.57-64
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• 2018

Background: Patients experience significant differences in aspects of mortality, quality of life, and costs between during the year of receiving liver transplant (LT) and the subsequent years (post-LT). This study aimed to estimate the medical utilization and cost of LT for patients compared to post-LT patients by using a recent National Patient Sample (NPS) data provided by the Korean Health Insurance Review and Assessment Service (HIRA). Methods: This study used a subset of the 2015 HIRA-NPS. Patient claims data that included Z944 (Korean Standard Classification of Diseases code for LT status) were selected. Within the selected data, LT patients were identified based on whether the national health insurance number code of Q80 (procedure code for LT surgery) was included, and they were compared to post-LT patients. Results: In the analysis, 330 patients were included. The average cost per patient was $90,066{\pm}36,959$ thousand KRW and $10,557{\pm}9,668$ thousand KRW for LT and post-LT patients, respectively. Especially, LT patients' costs for injection/procedure, surgery/treatment, and examination were higher than other costs, being $35,983{\pm}18,115$ thousand KRW, $28,246{\pm}9,408$ thousand KRW, and $12,131{\pm}6,604$ thousand KRW, respectively. For inpatients, the average number of hospitalized days was $63.5{\pm}66.0$ days for LT patients and $22.3{\pm}35.1$ days for post-LT patients. Conclusion: Compared to post-LT patients, LT patients had higher costs, especially for injection/procedure, surgery/treatment, and examination. Additionally, the LT group had longer hospitalization duration and higher costs for their hospital admission, whereas they did not show a significant difference in number of visits and medical costs for outpatient-care.

• Archives of Plastic Surgery
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• v.44 no.4
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• pp.283-292
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• 2017

Background Settlements between doctors and patients provide a solution to complicated disputes. However, some disputes may be renewed as a result of negligence by both parties. The purpose of this study was to review the legal issues that may potentially arise during the preparation of settlement agreements and to propose a list of requirements for ensuring the effectiveness of these settlement agreements. Methods Data from 287 civil cases concerning aesthetic surgery that took place between 2000 and 2015 were collected from a court database in South Korea. Factors that influenced the effectiveness of settlement agreements were analyzed. Results Among the 287 court precedents, there were 68 cases of covenant not to sue. Eighteen cases were dismissed because the settlement agreements were recognized as effective, and 50 cases were sent forward for judgment on their merits because the agreements were not recognized as effective. The types of surgery and types of complications were classified by frequency. We evaluated the geographical distribution of the precedents, the settlement timing, and the effectiveness and economic impact of the settlements. We found that there was no statistically significant relationship among these factors. Four major factors that made a settlement agreement legally effective were identified, and the data showed that fee-free reoperations were not considered by the court in determining the compensation amount. Conclusions When preparing a settlement agreement, it is advisable to review the contents of the agreement rather than to take the preparation of a settlement agreement per se to be legally meaningful.