• Journal of Preventive Medicine and Public Health
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• v.25 no.4 s.40
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• pp.333-342
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• 1992

The purpose of this study is to estimate the minimum optimal scale(MOS) of the self-employed health insurance associations. Considering the high proportion of operating expenses, the author have selected 254 regional health insurance associations eon the 1990 Finance Report of the self-employed health insurance programs. Both a quadratic function and a hyperbolic function were chosen for the analysis. The dependent variables are the average maintenance cost per insured person and per household, and the independent variables are the number of insured members and of household The minimum optimal scale was obtained from the differentiation of the quadratic function. Major findings are summarized as follows: 1. The M.O.S. was calculated as 166,174 members (27,442 households) for the rural self-employed health insurance associations and 258,462 members (75,446 households) for the urban. Providing that both the rural and urban health insurance associations would be integrated, the M.O.S. be found to become 231,687 members (68,101 households) 2. Compared with the optimal minimum scale, the magnitude of the current health insurance association found to be much smaller, less than half of the optimal scale. 3. In order to reduce the operating cost, it is necessary to enlarge the operational scale of self-employed health insurance associations.

• Korea Journal of Hospital Management
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• v.24 no.4
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• pp.33-42
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• 2019

Purpose: many domestic welfare programs use the amount of health insurance premiums as a way of measuring individuals' income levels for administrative convenience. As health insurance reform has been made, we examines the income level is still appropriately measured by the health insurance premiums for the employment success package as one of domestic welfare program. Methodology/Approach: we investigate whether the upper limit of the premiums of the self-employed health insured is appropriate or not after healthcare reform, which currently calculated by multiplying the insurance premium of the employee based insured by the adjustment factor (1.2). Findings: we examined appropriateness of the adjustment factors by comparing the premiums before and after the healthcare reform by utilizing the national health insurance data as well as Korea Welfare panel data. We found that the new value of adjustment factor (1.0~1.1) is smaller than the current one (1.2). Practical Implications: to improve the equity between the employee and the self-employed insured after the health insurance reform, the adjustment factor should be lower.

• Journal of Digital Convergence
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• v.11 no.10
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• pp.593-608
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• 2013

According to increasing number of injury claims, the challenge is reducing investigation of cases of injuries by selecting them more delicately, while also increasing the redemption rates and the amount of restitution. In this regards, we developed the fraud detection model for injury claims of self-employed insured by using decision tree after collecting medical claim data from 2006 to 2011 of the National Health Insurance in Korea. As a result of this model, subject types were classified into 18 types. If applying these types to the actual survey compared with if not applying, the redumption collecting rate will be increasing by 12.8%. Also, the effectiveness of this model will be maximize when the number of claims handlers considering their survey volume and management plans are examined thoroughly.

• The Korean Society of Law and Medicine
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• v.15 no.1
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• pp.185-209
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• 2014

While the local health insurance and the employment-based insurance were integrated in July 2000, the insured is divided into employment-based insured and the local insured and the relevant premium has been applied to both groups. The health insurance premium having the feature of social solidarity has to be determined depending on income, that is, the ability to pay in accordance with the principles of social insurance. While employment-based insurance premium has been determined depending on the earned income, the local insurance premium for the local insured has been determined by scoring gross income(evaluated income), property and possession of automobiles. A variety of improvement approaches has been implemented including introduction of the employment-based insurance premium ceiling system (2002) and the change of property scoring system for the local insured (2006). However, the health insurance system which was merged in 2000 has been implemented up to now without significant change even though there were lots of socio-demographic change including increase of income level and the population structure such as low birth and aging. In other words, it is required to implement the premium rating system securing the income-based equity. Nevertheless, it was inevitable to apply the diverse rating standards in the early stage because it was very difficult to verify the income of the self-employed. Although the income verification rate was significantly increased from 23% in 1989 to 44% in 2010, the irrational standards including property, automobiles, living standard and activity rate have been still applied to the local insured because it is difficult to secure the validity of insurance premium rating system and it severely lacks of security. This paper investigated whether the current insurance premium rating system for the local insured imposing the premium on the basis of 'gender' and 'age' complies with the basic human rights secured by the current Constitution of the Republic of Korea with respect to the practical and theoretic irrationality of insurance premium rating system and standards for he local insured. In accordance with the analysis results, this paper proposed the approach to improve the system.

• Health Policy and Management
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• v.5 no.1
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• pp.80-105
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• 1995

Assuming that we introduced integration of medical insurance society for self-employed, this study was conducted to examine effects and results after the integration and to research more effective method for integration. To assess effects and results of the finacial status of 266 insurance societies after intergration, the data were obtained from "The Medical Insurance Program for Self-Employeds Statistical Yearbook in 1992". The major finding are as follows : 1. Three alternative integration proposals were made. First alternative proposal was consisted of 232 medical insurance societies, second was 187, and third was 115. 2. As the results of average number of the insured per insurance societies of medical insurance program for self-employed every alternative proposal, first was 88, 119 persons, second was 108, 576, and third was 178, 967 from 76, 576 persons of present socienties. 3. It was true that the more average size of societies increased, the more average administration expenditure per 1, 000 insured reduced. 4. The average size of societies grew bigger, the rate of general expenditure to general revenue more improved. Also, the rate of benefits to contributions was changed for better. But if not to have had correct analysis and precise preparation for integration, effects and results of integration were always not optiized. 5. According to results of simple regression formulas, it was proved that the more the average size of societies was increased, the more result was advantaged. 6. The law of majority and the economy of scale were applied in this study, and it was necessary to analyze and assess effectiveness and efficiency of integration. Therefore, when the integration of medical insurance societies for self-employeds will be performed, it must be taken into consideration. Among three alternative proposals, third was showed more effective alternative than anothe, second was presented more ineffective result than present system. To achieve more effective and efficient integration of regional medical insurance societies throughout the result of the regression formula on present cost curve, it is necessary to operate well-integrated societies and to know appropriative countermeasures of present situation of each societies. Also, for integrating regional medical insurance societies, it is necessary to continue more deep research through practical model activity and to investigate the effective size and managed method of the societies.societies.

• Health Policy and Management
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• v.18 no.4
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• pp.66-84
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• 2008

Objectives: This study aimed to. offer some fundamental evidences for the stroke management policy by investigating the trends of medical care utilization and regionalization in stroke inpatients. Methods: We used the National Health Insurance claims and registry data for stroke inpatients from 1998 to 2005. Among all stroke inpatient claims data, self-employed insured and their dependents were only included in this study. The classification of stroke was based on ICD-10(I60-I69) and its subtype was divided by hemorrhage(I60-I62) and infarction(I63-I64) type. To evaluate regionalization of medical care utilization, relevance index was calculated by regions. The regions were classified 8 large catchment areas and 163 self authorized areas. Results: The overall medical care utilization rate of stroke inpatient has been increased, especially infarction subtype. Among medical care institutions, the utilization of hospital has been the most rapidly increased. Although considered annual rate of interest, total medical cost of stroke inpatients has been increased, Totally, more than 84% of stroke inpatient were admitted to medical care institutions in their own large catchment area during 1998-2005. The relevance indices in their own large catchment area (self sufficiency rates) were more than 70% in most areas regardless of stroke subtype except Chungbuk catchment area. Self sufficiency rates of stroke inpatients among 163 self authorized areas in 1998 and 2005 were 84.2% and 83.1% in metropolitan, 46.7% and 45.5% in urban, and 19.5% and 22.6% in rural areas, respectively. Conclusion: Stroke management policy for improvement of distribution at the district level, especially in rural areas, may be helpful for reducing regional inequality in stroke.

• Safety and Health at Work
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• v.9 no.4
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• pp.462-467
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• 2018

Background: This study was conducted to investigate the effects of work on medical expenditures by the elderly. Methods: Data pertaining to individuals aged 65 or older collected by the Korean Health Panel 2008-2013 were used. The effects of work on medical expenditures were analyzed in a panel tobit model adjusted for several variables of demographic factors, socioeconomic factors, and health factors for health care. Data were also analyzed based on age groups (65-74, $75{\leq}$), type of work (waged or self-employed), and working time (daytime work or night time work). Results: Among the elderly older than 65 years, 34-37% were workers. Work among the elderly reduced medical expenditures relative to nonworking elderly. Specifically, medical expenditures were lower in individuals older than 75 years, as well as among those who were self-employed insured and had medical aid insurance and those who exercised. However, medical expenditures were higher among females, married individuals, those with a higher household income, and those with a chronic disease. Elderly wageworkers showed reduced medical expenditures than nonworking elderly and elderly daytime workers did. Conclusion: The elderly population's work, especially wage work and daytime work, reduced medical expenditures relative to no work. These results provide valuable information for policymakers by indicating that work was associated with lower medical expenditures than no work. If elderly work is to be encouraged, it is necessary to provide a variety of high-quality wage work.

• 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.

• Korean Journal of Health Education and Promotion
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• v.6 no.2
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• pp.23-39
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• 1989

There have been a lot of considerable. discussion and debate surrounding the management model in the health insurance management system and opinions regarding the management operating cost. It is a well known fact that there have always been dissenting opinions and debates surrounding the issue. The management operating cost varies according to the scale of the management organization and component members characteristics of the insurance carrier. Therefore, it is necessary to examine and compare the management operating cost to the simulated management models developed to cover those eligible for the health insurance scheme in this country. Since the management operating cost can vary according to the different models of management, four alternative management models have been established based on the critical evaluation of existing theories concerned, as well as on the basis of the survey results and simulation attempts. The first alternative model is the Unique Insurance Carrier Model(Ⅰ) ; desigened to cover all of the people with no classification of insurance qualifications and finances from the source of contribution of the insured, nationwide. The second is the Management Model of Large-scale District Insurance Carrier(Ⅱ) ; this means the Korean society would be divided into 21 large districts; each having its own insurance carrier that would cover the people in that particular district with no classification of insurance qualifications arid finances as in Model I. The third is the Management Model of Insurance Carrier Divided by Area and Classified with Occupation if Largescale (Ⅲ) ; to serve the self-employed in the 21 districts divided as in Model Ⅱ. It would serve the employees and their dependents by separate insurance carriers in large-scale similar to the area of the district-scale for the self-employed, so that the insurance qualifications and finances would be classified with each of the insurance carriers: The last is the Management Model of the Multi - insurance Carrier (Ⅳ) based on the Si. Gun. Gu area which will cover their own self- employed people in the area with more than 150 additional insurance carriers covering the employees and their dependents. The manpower necessary to provide services to all of the people according to the four models is calculated through simulation trials. It indicates that the Management Model of Large-scale District Insurance Carrier requires the most manpower among the four alternative models. The unit management operating costs per the insured individuals and covered persons are leveled with several intervals based on the insurance recipients. in their characteristics. The interval levels derived from the regression analysis reveal that the larger the scale of the insurance carriers is in the number of those insured and covered. the more the unit management operating cost decreases. significantly. Moreover. the result of the quadratic functional formula also shows the U-shape significantly. The management operating costs derived from the simulated calculation. on the basis of the average salary and related cost per staff- member of the Health Insurance Societies for Occupational Labours and Korean Medical Insurance Corporation for the Official Servants and Private School Teachers in 1987 fiscal year. show that the Model of Multi-insurance Carrier warrants the highest management operating cost. Meanwhile the least expensive management operating cost is the Management Model of Unique Insurance Carrier. Insurance Carrier Divided by Area and Classified with Occupation in Large-scale. and Large-scale District Insurance Carrier. in order. Therefore. it is feasible to select the Unique Insurance Carrier Model among the four alternatives from the viewpoint of the management operating cost and in the sense of the flexibility in promoting the productivity of manpower in the human services field. However. the choice of the management model for health insurance systems and its application should be examined further utilizing the operation research analysis for such areas as the administrative efficiency and factors related to computer cost etc.

• Health Policy and Management
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• v.19 no.4
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• pp.66-77
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• 2009

This study aims to examine the effect of socioeconomic status (hereafter, SES) on healthcare utilization of the patients with rare and incurable diseases. Information of 2,973 patients who were self-employed insured and utilized healthcare service in 2007 was drawn from the National Health Insurance (hereafter, NHI) claim data. SES was set as four groups based on the monthly contribution. Outcome variable was the expense for outpatient and in-hospital services, which was log-transformed and square-rooted in oder to obtain normal distribution. Covariates included age, gender, residence and diagnosis. To examine the effects after controlling for covariates, we employed generalized estimating equation model, since patients with the same diagnosis are likely to have similar characteristics of demographics and healthcare utilization. Univariate statistics showed that lower SES was associated with less utilization of healthcare services. After controlling for covariates, a significantly smaller amount of money was expended for the lowest SES group compared to the highest one. Rural residence was associated with less utilization, except that residents in Seoul significantly more utilized outpatient services in tertiary hospitals. Considering that there is a subsidy program for the low income patients, such differences in healthcare utilization according to SES seems to result from the burden of out-of-pocket payments for uncovered services of the NHI.