• Health Policy and Management
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• v.19 no.1
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• pp.1-30
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• 2009

Korean medical fee contract system between the insurer and healthproviders was introduced in 2000. However, a continuous discord among contracting parties concerned and an irrational operation of an arbitration committee of Ministry for Health, Welfare and Family Affairs (MIHWAF) have made it difficult for them to reach to an agreement over last 8 years. The purpose of this study is to observe the current problems of contract system from the view of health insurance law and actual examples. Furthermore, I examined the of breakdown of negotiation by analyzing the eligibility of contracting parties, rationality of Resource Based Relative Value System (RBRVS) and contracting method and fairness of arbitration method in case of negotiation rupture. The results were as follows: First, since the introduction of medical fee contract system, there has been a problem in that both the president of National Health Insurance Corporation (NHIC) and health care provider association have not held strong negotiation power. Second, the frequent changes and notifications of Relative Value Units (RVUs) without any mutual consent between the insurer and provider association negatively have influenced the conversion factors and finally hindered the agreement of contract. Third, a current process that the conversion factors are mediated and determined at the arbitration committee of MIHWAF in the case of contract breakdown between contracting parties has some flaw in that the irrational composition of committee provoked the lack of fairness and objectivity of mediation. Fourth, we can not prospect a satisfactory outcome of arbitration committee because the mediation always has failed to proceed smoothly due to boycott of both committee members from insurer and providers over last 8 years. As a result, we have to make an every effort to resolve problems mentioned above and then dream of an advanced national health insurance system.

• Journal of Korean society of Dental Hygiene
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• v.20 no.4
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• pp.457-467
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• 2020

Objectives: This study confirms the current status of visiting oral health-care services for the elderly to draw policy implications for revitalization of the visiting oral health care services in the future. Methods: First, a survey was conducted on health centers about the current status of the elderly visiting oral health-care service and how to revitalize it. Next, the number of oral hygiene services provided to the elderly was checked in the long-term care insurance system. Results: Oral health education (100%) was the most common practice in visiting oral health-care service for the elderly, and the most difficult thing in providing services was the lack of dental hygienists (38.9%). The status of oral health-care services in the long-term care insurance system for elderly revealed that the total number of service claims has been confirmed to be zero since the introduction of the system. Conclusions: Despite the existence of a system that provides elderly visiting oral healthcare services, to revitalize it, the law must be amended to secure a dental hygienist as the main agent of the activity and to further take responsibility for autonomous authority and performance.

• 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.

• 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 Preventive Medicine and Public Health
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• v.28 no.1 s.49
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• pp.153-174
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• 1995

This study was conducted to examine the determinant factors for expenditure of the medical insurance program for self-employeds based on the analysis of 1991 'The Medical Insurance Program for Self-Employeds Statistical Yearbook', and also similar yearbooks in the metropolitan and other provinces. The major findings are as follows : We have divided benefits into these four components such as the utilization rate for out-patients, expenses per claim for out-patients as paid by the insurer, utilization rate for in-patients, and the expenses per claim for in-patients as paid by the insurer, in order to examine the determinant factors for it. The results of the study revealed the following findings, in urban areas, the supply of medical care had more influence on the benefits than other demographic and economic variables, while, in county areas, both the supply of medical care and the rate of those aged over 65 affected the provision of benefits. The determinant factors for financial balance of the medical insurance program for self-employeds are, first, the determinant factor for administrative expenses was the number of households. The more the number of households, the less the administrative expenses per the insured. This shows that the economy of scale is being. And so, the administrative district must be taken into consideration in the incorporation of small regional medical societies and should be re-organized for more efficient management. Second, in urban areas, the supply of medical care had more influence on utilization rate and expenses per claim as paid by insurer, and therefore it is necessary to control it. In county areas, the supply of medical care and the rate of those aged over 65 raised the utilization rate and expenses per claim as paid by insurer. For the financial stability of county areas, a common fund for medical care for the aged and expansion of finance stabilization fund would be necessary. But, in county areas, it would be unnecessary to control the supply of medical care because it was much more insufficient than in urban areas. The vitalization of public health facilities must be carried out in county areas, for they reduced benefits. Sice the more insured in a single household, the less the utilization of the medical insurance program, benefits for habilitation at home should be given consideration. The law of majority and the economy of scale were applied here, and therefore the incorporation of regional medical societies must be taken into consideration. In integrating regional medical societies, it would be absolutely necessary to review the structural differences among all regional medical societies, the medical demand of each region, and also the local characteristics of each region.

• The Korean Journal of Health Service Management
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• v.8 no.1
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• pp.51-64
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• 2014

The purpose of this study was to investigate the relationship among staffing, occupancy rate, upward level change of long-term care need, and evaluation grade of facility. Data were obtained from National Health Insurance Corporation Database. Occupancy rate and evaluation grade were highest in National/public operating facilities, while they were worst in individual operating facilities. The percents of A or B grade in evaluation grade (by newly enforced law) is highest in National/public operating facilities. Multiple regression analysis showed that upward level change of care needs was very weakly associated with the number of doctors. Evaluation grade showed a weak and significant association with occupancy ratey(by old-version law)(r=.20, p<.01), upward level change of care need in group home(r=.23, p<.01) Staffing in facility did not show significantly consistent association with upward level change of care needs, evaluation grade, and occupancy rate.

• 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.

• Perspectives in Nursing Science
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• v.14 no.1
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• pp.37-44
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• 2017

Purpose: This study aimed to provide information on the developmental process and current status of Advanced Practice Nurses (APN) and to suggest ways for activating APN roles in Korea. Methods: We reviewed literatures to explore domestic and international trends related to the roles, practice settings, scope of practice, regulatory policies, and political environment of APN. Results: Interest in the APN role has been gaining ground worldwide. While the roles of APN in the USA, Taiwan and Japan have been changed in terms of legislation and institutional regulations, the role of APN in 12 fields except for APN in home care has not been legislated since qualification was specified in Korean Medical Law. Many problems were found in vitalizing APN roles: absence of legal regulations on the scope of practice or health insurance coverage for APN, increase the number of medical support staffs who are not qualified, and a disagreement regarding the qualification field and practical field. Conclusion: This study presents snapshots and vitalizing strategies of practice, and regulation for APN to develop their unique roles in Korea. The tasks and duties of APN should be identified specifically to fulfill their roles. In terms of national health insurance policy APN's Nursing care should be reimbursed just as nursing care of APN in home care.

• The Korean Journal of Applied Statistics
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• v.24 no.1
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• pp.145-159
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• 2011

National long-term care insurance started in July, 2008. We try to make up for weak points and develop a long-term care insurance system. Especially, it is important to upgrade the rating model of the category of need for long-term care continually. We improve the rating model using the data after enforcement of the system to reflect the rapidly changing long-term care marketplace. A decision tree model was adpoted to upgrade the rating model that makes it easy to compare with the current system. This model is based on the first assumption that, a person with worse functional conditions needs more long-term care services than others. Second, the volume of long-term care services are de ned as a service time. This study was conducted to reflect the changing circumstances. Rating models have to be continually improved to reflect changing circumstances, like the infrastructure of the system or the characteristics of the insurance beneficiary.

• Journal of Society of Preventive Korean Medicine
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• v.14 no.1
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• pp.137-149
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• 2010

In recent decades, as the utilization of complementary and alternative medicine in the United State have been growing rapidly, regulatory controls surrounding complementary and alternative medicine(CAM) aims to ensure patient protection against unproven practices and to provide safe and effective treatments. Regulation and policy method on licensing CAM practitioners varies across the states. Over 85% of the states have the licensing system for acupuncturists, chiropractors, and naturopaths. For acupuncture, although the requirements for formal education are various across the states, a unified written examination has been adopted by almost entire states which have acupuncturist licensing law. Medicare, the public medical insurance, does not cover CAM practices except chiropractic and biofeedback. In some states, however, Medicaid programs cover some CAM therapies including acupuncture, naturopathy, and massage therapy. 67% of Health Maintenance Organizations, the private health plans, provide at least one modality of CAM services. In conclusion, government policies have been strengthened to ensure patient protection, and will continue to integrate CAM practices that are proven to be safe and effective into mainstream health care system.