• Journal of Preventive Medicine and Public Health
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• v.45 no.3
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• pp.148-155
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• 2012

Since the reformation of the National Health Insurance Act in 2000, the Health Insurance Review and Assessment Service (HIRA) in the Republic of Korea has performed quality assessments for healthcare providers. The HIRA Value Incentive Program (VIP), established in July 2007, provides incentives for excellent-quality institutions and disincentives for poorquality ones. The program is implemented based on data collected between July 2007 and December 2009. The goal of the VIP is to improve the overall quality of care and decrease the quality gaps among healthcare institutions. Thus far, the VIP has targeted acute myocardial infarction (AMI) and Caesarian section (C-section) care. The incentives and disincentives awarded to the hospitals by their composite quality scores of the AMI and C-section scores. The results of the VIP showed continuous and marked improvement in the composite quality scores of the AMI and C-section measures between 2007 and 2010. With the demonstrated success of the VIP project, the Ministry of Health and Welfare expanded the program in 2011 to include general hospitals. The HIRA VIP was deemed applicable to the Korean healthcare system, but before it can be expanded further, the program must overcome several major concerns, as follows: inclusion of resource use measures, rigorous evaluation of impact, application of the VIP to the changing payment system, and expansion of the VIP to primary care clinics.

• The Korean Society of Law and Medicine
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• v.8 no.2
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• pp.69-118
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• 2007

In providing general medical treatments, the medical service contract between the patient and the doctor is the mutually responsible onerous contract. However, the nature of the mutually assumed contract standings of the patient and the doctor has been changing since the implementation of the national health insurance program. For instance, besides the cases of beyond excessive medical charges and medical negligence, if the doctor charged for his/her medical treatments violating the post-treatment/nursing cover criteria, the overpaid medical charge, regardless of being collected with the patient's consent, has to be refunded back to the patient. Medically needed aspects, treatment results, and unfair benefits favoring the patient are not at all taken into consideration in the health insurance scheme. This makes it easier for patients to get refunds for their share of the medical payments by involving the Health Insurance Review & Assessment Service or the National Health Insurance Corporation, without engaging in civil law suits (for reimbursement claim) against doctors. In other words, the doctor's responsibility to provide medical treatments and the patient's responsibility to pay for the medical treatment provided within the contractual realm are being demolished by the administrational arbitration of the National Health Insurance system. The basic rights of medical service providers, and the patient's right to choose are as important constitutional rights, as the National Health Insurance program, which is essential in the social welfare system. Furthermore, the development of the medical fields should not be prevented by the National Health Insurance system. If the medical treatment services can be divided into necessary treatments, general treatments, and high quality treatments, the National Health Insurance is supposed to guarantee the necessary and general treatments to provide medical treatments equally to all the insured with limited financial resources. However, for the high quality treatments, it is recommended that they should not be interfered by the National Health Insurance system, and that they should be left to the private contract between the patient and the doctor.

• Health Policy and Management
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• v.32 no.2
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• pp.137-153
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• 2022

In the process of promoting policies to strengthen health insurance coverage, the relationship between public health insurance and private health insurance, along with the management of non-benefit, is also emphasized as a policy issue. First, the concept and scope of non-benefit were comparatively analyzed by country. Second, the interaction between the public and private health insurance was classified as 'large or small,' and the government's regulation and management policy on private health insurance was classified as 'strong or weak.' Korea has relatively smaller benefits covered by public health insurance, higher copayment expenses, and more areas and scope of non-benefits. In countries where the interaction between public and private health insurance is small, private health insurance-related policies are weak. And in countries with large interactions had public-private partnerships and the government's management policies were also strong. On the other hand, Korea has a large interaction, but the actual structure of cooperation between public and private insurance and management policies were weak. Because the non-benefit sector in Korea is relatively wide, it is difficult to manage compared to other countries where the concept of non-benefit is limited. In addition, the health authorities rarely perform the role of supervision over private health insurance, and they have so few linkages and cooperation for public-private insurance. Therefore, practical policy enforcement is necessary to achieve the easing of the burden of national medical expenses through linkage and cooperation of public-private health insurance with reference to relevant other countries' cases.

• Korean Journal of Head & Neck Oncology
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• v.39 no.1
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• pp.15-18
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• 2023

A plunging ranula is a pseudocyst caused by mucus secreted from the sublingual glands, and it is mainly observed on the mouth floor. Nowadays, sclerotherapy using picibanil has been performed instead of invasive surgical treatment, and studies are reporting safe and effective outcomes. In our study, more than 92% of the 25 patients had marked response after picibanil sclerotherapy, and no serious complications were observed. Picibanil sclerotheraphy can be considered as the primary treatment of plunging ranula for patients who refuse surgery under general anaesthesia.

• Health Policy and Management
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• v.20 no.2
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• pp.104-127
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• 2010

To vitalize the link program of Korean long-term care insurance system to community-based services for non-eligible people, we analysed the claim data from the Korean National Health Insurance Corporation (NHIC), and conducted a questionnaire survey to charging employees of elderly service department at local governments. The subjects were all 81,377 people, 57,454 of them were arranged to community-based services. The link program was more necessary among the missed subjects rather than the arranged people due to the need for physical or psychological assistance. By the result of the survey to the local government employees, 59.5% of subjects responded their proportion of link service was over 10% and under 20%, and 54.3% of them responded their job boundary are not clear. Major type of linking was notification the subject list to local government, 91.4%; proportion of periodical notification on the status of their service link were 57.1%, only 7.1% were followed to manage after the link. Difficult factors at the link process were pointed out the overload by other side work, deficiency of resources, rigidity of priority of link, and so on. Considering these results, to vitalize the community-based services to the non-eligible people, it may be essential the active participation of the subjects, construction of parts working in coordination among the institutions including NHIC, local governments, and service providers; development of various services for maintenance or promotion of the non-eligible peoples' health and functional status; and active participation of institutions from the third sector, and so on.

• Health Policy and Management
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• v.26 no.4
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• pp.343-351
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• 2016

Background: This study aims to analyze the effects of insurance types on the medical service uses for heart failure inpatients using propensity score matching (PSM). Methods: 2014 National inpatient sample based on health insurance claims data was used in the analysis. PSM was applied to control factors influencing the service uses except insurance types. Negative binomial regression was used after PSM to analyze factors that had influences on the service uses among inpatients. Subjects were divided by health insurance type, national health insurance (NHI) and medical aid (MA). Total charges and length of stay were used to represent the medical service uses. Covariance variables in PSM consist of sociodemographic characteristics (gender, age, Elixhauser comorbidity index) and hospital characteristics (hospital types, number of beds, location, number of doctors per 50 beds). These variables were also used as independent variables in negative binomial regression. Results: After the PSM, length of stay showed statistically significant difference on medical uses between insurance types. Negative binomial regression provided that insurance types, Elixhauser comorbidity index, and number of doctors per 50 beds were significant on the length of stay. Conclusion: This study provided that the service uses, especially length of stay, were differed by insurance types. Health policy makers will be required to prepare interventions to narrow the gap of the service uses between NHI and MA.

• Health Policy and Management
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• v.21 no.4
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• pp.599-616
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• 2011

This research was performed to investigate the determination factors of medical service to cover the fee for selecting a doctor which is one of the most important causes of debilitating national health insurance in Korea. Data was from Korea Health Panel and analyzed by Dutton(1986)'s medical service model which was an extended Anderson Model and was widely used in the researches on determination factors of medical service. The results were as follows; In the determinants of selecting a doctor in specialized medical institutions and general hospitals, patients with serious diseases selected doctors more often than other patients. By industrial accident compensation insurance law and enforcement ordinances, insurance covers the fee of selecting a doctor in the hospitals appointed by Labor Welfare Corporation for the patients in critical conditions under industrial accident compensation insurance, while health insurance patients pay the fee themselves for selecting a doctor in all cases. It is suggested that patients with serious diseases proved by medical opinion be provided with health care insurance in selecting a doctor and that the health insurance benefit coverage be enhanced by staged lowering of patient's cost-sharing.

• The Korean Journal of Health Service Management
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• v.7 no.4
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• pp.143-151
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• 2013

The purpose of this study was to analyze the socio-economic factors, the factors affecting the private insurance, utilizing Korea National Health & Nutrition Examination Survey 2011. Findings of the study can be summarized as follows. First, participants with private insurance are young, high monthly income, low prevalence of chronic illness. Second, participants with private insurance and chronic illness were young and high monthly income. Third, Average monthly household income, the higher the age is younger. Private insurance and national health insurance was higher subscription rate. Consequently, participants with private insurance and uninsured of the major differences is the age and the average monthly income. Elderly, low income are needed health promotion and disease prevention for expanded medicare, welfare policies.

• Korea Journal of Hospital Management
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• v.26 no.3
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• pp.13-27
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• 2021

Purpose: We examined the relationship between operating income and volume of medical services provided at general hospitals in 2018 according to characteristics of general hospitals and measured as operating income(net income) and volume(adjusted inpatient days) covered or non-covered by National Health Insurance(NHI). Methodology: Finance data from income statement reports in 212 general hospitals and the national health insurance claim data of these hospitals were used. The characteristics of the general hospital were divided into structural, operational, financial, and patient aspects. Operating income and volume were divided into covered and non-covered by NHI. Findings: The results showed high volume hospitals tended to be more profitable than low volume hospitals, especially in non-covered services. Operating income was more likely to be sensitive to non-covered services volume than to covered services volume. Practical Implications: It is necessary to understand the volume of services in non-covered, in order to obtain reliable cost information to be used for the fee schedule. Researches on small size hospitals(<160 beds) are needed, with a large variation in the volume of services and a strong tendency to compensate for the loss in the covered part in non-covered part.

• Journal of Preventive Medicine and Public Health
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• v.50 no.5
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• pp.294-302
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• 2017

Objectives: The objectives of this study were to investigate the agreement between medical history questionnaire data and claims data and to identify the factors that were associated with discrepancies between these data types. Methods: Data from self-reported questionnaires that assessed an individual's history of hypertension, diabetes mellitus, dyslipidemia, stroke, heart disease, and pulmonary tuberculosis were collected from a general health screening database for 2014. Data for these diseases were collected from a healthcare utilization claims database between 2009 and 2014. Overall agreement, sensitivity, specificity, and kappa values were calculated. Multiple logistic regression analysis was performed to identify factors associated with discrepancies and was adjusted for age, gender, insurance type, insurance contribution, residential area, and comorbidities. Results: Agreement was highest between questionnaire data and claims data based on primary codes up to 1 year before the completion of self-reported questionnaires and was lowest for claims data based on primary and secondary codes up to 5 years before the completion of self-reported questionnaires. When comparing data based on primary codes up to 1 year before the completion of selfreported questionnaires, the overall agreement, sensitivity, specificity, and kappa values ranged from 93.2 to 98.8%, 26.2 to 84.3%, 95.7 to 99.6%, and 0.09 to 0.78, respectively. Agreement was excellent for hypertension and diabetes, fair to good for stroke and heart disease, and poor for pulmonary tuberculosis and dyslipidemia. Women, younger individuals, and employed individuals were most likely to under-report disease. Conclusions: Detailed patient characteristics that had an impact on information bias were identified through the differing levels of agreement.