• 대한장애인치과학회지
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• 제14권1호
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• pp.11-16
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• 2018

In order to increase the accessibility of dental care for people with disabilities, National Health Insurance Service has implemented an additional point system of National Dental Insurance for dental treatment of patients with a special health care need (AID). The purpose of this study is to investigate the types and status of AID in Korea using data of the Health Insurance Review and Assessment Service from 2011 to 2017. The basic consultation fee is increased by 9.03 points (713 won) for brain disorder, intellectual disability, mental disability, or autistic disorder. From 2011 to 2015, the number of claims with a basic consultation fee increased from 90,456 to 141,179. Dental treatment and surgical treatment fee is increased by 100% of the defined insurance score for each of the 15 items. During the five years from 2012 to 2016, the number and amount of claims for each item increased steadily. Of the total claims for 5 years, endodontic treatment was highest, with 107,477 cases, followed by 51,641 cases of scaling. There are two types of dental safety observation fee, simple and complex. The simple safety observation fee is 10,370 won per day, and the complex safety observation fee is 20,750 won per day. Dental safety observation fees were charged 34 times in 2015, 14 times in 2016, and 41 times through May 2017. From 2011 to 2017, the number and amount of claims using AID for dental care for people with disabilities increased. However, considering that the number of registered dental users with disability was about 560,000 in 2016, the number of claims using AID is 1-20,000, which is less than 2% of registered dental users with disability. Therefore, it is necessary to expand dental services for people with disabilities including AID.

• Journal of Preventive Medicine and Public Health
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• 제34권1호
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• pp.28-34
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• 2001

Objectives : To investigate the changing pattern of medical utilization claims following the economic crisis in Korea. Methods : The original data consisted of the claims of the 'Medical insurance program of self-employees' between 1997 and 1998. The data was selected by medical treatment day ranging between 8 January and 30 June. Medical utilizations were calculated each year by the frequency of claims, visit days for outpatients, length of stay for inpatients, total days of medication, and the sum of expenses. Results : The length of stay as an inpatient in 1998 was decreased 4.7 percent in comparison to 1997. However, inpatient expenses in 1998 increased 10.8 percent as compared to 1997. Inpatient hospital claims in 1998 increased 6.2 percent over 1997, although general hospital inpatient claims in 1998 decreased 3.3 percent in comparison to 1997. The outpatient claim frequency decreased 7.3 in 1998 percent as compared to 1997 Outpatient visit days of in 1998 were decreased 8.5 percent in comparison to that recorded in 1997. Outpatient claim frequencies of 'gu region' in 1998 decreased 10.5 percent comparison to that in 1997, but 'city and gun region' decreased less than 'gu region'. Conclusions : Medical utilization in 1998 deceased in relation to 1997 Medical utilization by outpatients decreased more than that of inpatients. Medical utilization by 'gu region' decreased mere than the other regions.

• 한국임상약학회지
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• 제24권4호
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• pp.255-264
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• 2014

Objective: The aims of this study are to investigate the total volume of prescribed medicines against Alzheimer's disease (AD) and the trends of usage by analyzing the claims-data from the Korea National Health Insurance Service. Method: The demographic and claims-data were included the major AD treating medicines such as donepezil, galantamine, rivastigmine and memantine, and analyzed during the period of 2010~2012. The assessing criteria were gender, age, habitation, types of medical institution, code of ingredients, outcomes of treatment, volume and amount of claims, and the numbers of patients with dementias. After trimming the data, it were analyzed by the market size, demographic traits, characteristics of medical service, characteristics of each anti-AD medicine, etc. Results: Among the chosen 4 medicines, donepezil had the top prescription volumes. Most prevalent prescribing preparations of donepezil were conventional types. However, among the non-conventional types, oro-dispersible formulation is the fast increasing one in both volume and growth rate. This specialized preparations to improve both toleration and adherence, tend to being prescribed generally at the tertiary medical institutions. While the younger patients with mild-to-moderate AD mostly treated by expensive medicines in resident at the tertiary hospitals, the rest older patients with severe AD have been treated non-expensive one at long-term care facilities. Conclusion: AD is a chronic illness therefore, long-term use of therapeutic medications are highly important. If an anti-AD treatment was applied steadily in the earlier stages, it would be achieved not only improving the quality of life of patient but also reducing the expenses in the medical and nursing cares. As the socioeconomical impacts of AD is expanding, healthcare professionals need to aware the importance of pharmacotherapy and to improve sociopolitical fundamentals.

• 보건행정학회지
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• 제25권3호
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• pp.197-206
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• 2015

Background: The purpose of this study was to propose a method for developing a measure of hospital-wide all-cause risk-standardized readmissions using administrative claims data in Korea and to discuss further considerations in the refinement and implementation of the readmission measure. Methods: By adapting the methodology of the United States Center for Medicare & Medicaid Services for creating a 30-day readmission measure, we developed a 6-step approach for generating a comparable measure using Korean datasets. Using the 2010 Korean National Health Insurance (NHI) claims data as the development dataset, hierarchical regression models were fitted to calculate a hospital-wide all-cause risk-standardized readmission measure. Six regression models were fitted to calculate the readmission rates of six clinical condition groups, respectively and a single, weighted, overall readmission rate was calculated from the readmission rates of these subgroups. Lastly, the case mix differences among hospitals were risk-adjusted using patient-level comorbidity variables. The model was validated using the 2009 NHI claims data as the validation dataset. Results: The unadjusted, hospital-wide all-cause readmission rate was 13.37%, and the adjusted risk-standardized rate was 10.90%, varying by hospital type. The highest risk-standardized readmission rate was in hospitals (11.43%), followed by general hospitals (9.40%) and tertiary hospitals (7.04%). Conclusion: The newly developed, hospital-wide all-cause readmission measure can be used in quality and performance evaluations of hospitals in Korea. Needed are further methodological refinements of the readmission measures and also strategies to implement the measure as a hospital performance indicator.

• 보건행정학회지
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• 제19권2호
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• pp.36-50
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• 2009

Korean Government had performed three pilot programs to introduce the long term care insurance system. Persons aged 65 or older who are dependent on others for daily living could use long term care services in the pilot program. The long-term care insurance covered nursing home services, home care services and cash benefits. The cash benefits are included that for elderly at home and for patients in geriatric hospital. This study investigated whether there had been any change in the medical care utilization according to cash benefits for geriatric hospitalization. This study used National Health Insurance claims and Long term Care Insurance claims 2003 through 2006. Data were composed of subjects who undertook both insurance coverage. The subjects was divided into two groups. Case group included participants with the cash benefits of geriatric hospitalization. Control group included persons without the cash benefits selected by random sampling according to the distribution of case group. This study showed that the amount of medical care utilization of the case group is more significantly increased than the control group after adjusted their health condition and functional condition. This result will be helpful for making decisions on whether the cash benefit of geriatric hospitalization can be introduced into long term care insurance system.

• 보건행정학회지
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• 제15권3호
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• pp.17-39
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• 2005

Social solidarity, equity in financing, and efficiency in administration have been core issues in the development of Korean health insurance reformation since 1988. This study is to investigate the trend of administrative cost in Korean National Health Insurance from various aspects. For the analysis of administrative cost, the expenditures of each insurance society and the National Health Insurance Corporation are divided into 4 items of (1) insurance benefit, (2) administrative cost, (3) an agency provision accounts, (4) other expenses, and then they are reorganized. The analyses based on 5 types of the health insurance administrative cost showed that efficiency in administration has been improved generally. We, however, should consider qualitative aspects such as customer's satisfaction with health insurance administration, prompt service, control of unjust expenditure (unjust claims), and provision of medical service including health consultation in assessing efficiency of administration. And, in order to connect the administrative costs of health insurance with efficiency, we need to give a fundamentally new definition, which can contain elaborateness of expenditure in details including the structure and evaluation method of administrative costs. It may be necessary to develop new indicators or analyzing methods hereafter.

• 보건행정학회지
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• 제31권4호
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• pp.451-461
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• 2021

Background: Readmissions related to lack of quality care harm both patients and health insurance finances. If the factors affecting readmission are identified, the readmission can be managed by controlling those factors. This paper aims to identify factors that affect readmissions of convalescent rehabilitation patients. Methods: Health Insurance Review and Assessment Service claims data were used to identify readmissions of convalescent patients who were admitted in hospitals and long-term care hospitals nationwide in 2018. Based on prior research, the socio-demographics, clinical, medical institution, and staffing levels characteristics were included in the research model as independent variables. Readmissions for convalescent rehabilitation treatment within 30 days after discharge were analyzed using logistic regression and generalization estimation equation. Results: The average readmission rate of the study subjects was 24.4%, and the risk of readmission decreases as age, length of stay, and the number of patients per physical therapist increase. In the patient group, the risk of readmission is lower in the spinal cord injury group and the musculoskeletal system group than in the brain injury group. The risk of readmission increases as the severity of patients and the number of patients per rehabilitation medicine specialist increases. Besides, the readmission risk is higher in men than women and long-term care hospitals than hospitals. Conclusion: "Reducing the readmission rate" is consistent with the ultimate goal of the convalescent rehabilitation system. Thus, it is necessary to prepare a mechanism for policy management of readmission.

• 보건행정학회지
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• 제16권2호
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• pp.49-76
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• 2006

The aim of this study was to explore the effects of a computerized review program which was introduced in August 1, 2003, using claims data for acute respiratory infection related diseases. National Health Insurance (NHI) claims data on respiratory infection related diseases before and after the introduction, with six month intervals respectively, were used for the analysis. Clinic was the unit of observation, and clinics with only one physician whose specialty was internal medicine, pediatrics, otorhinolaryngology and family medicine and clinics with a general practitioner were selected. The final sample had 7,637 clinics in total. Indices used to measure practice pattern was prescription rates of antibiotics, prescription rates of injection drug per visit, treatment costs per claim, and total costs per claim. Changes in the number of claims for major disease categories and upcoding index for disease categories were used to measure claiming behavior. Data were analysed using descriptive analysis, t-test for indices changes before and after the introduction, analysis of variance (ANOVA) for practice pattern change for major disease categories, and multiple regression analysis to identify whether new system influenced on provider' practice patterns or not. Prescription of antibiotics, prescription rates of injection drug, treatment costs per claim, and total costs per claim decreased significantly. Results from multiple regression analysis showed that a computerized review system had effects on all the indices measuring behavior. Introduction of the new system had the spillover effects on the provider's behavior in the related disease categories in addition to the effects in the target diseases, but the magnitude of the effects were bigger among the target diseases. Rates of claims for computerized review over total claims for respiratory diseases significantly decreased after the introduction of a computerized review system and rates of claims for non target diseases increased, which was also statistically significant. Distribution of the number of claims by disease categories after the introduction of a computerized review system changed so as to increase the costs per claims. Analysis of upcoding index showed index for 'other acute lower respiratory infection (J20-22)', which was included in the review target, decreased and 'otitis media (H65, H66)', which was not included in the review target, increase. Factors affecting provider's practice patterns should be taken into consideration when policies on claims review method and behavior changes. It is critical to include strategies to decrease the variations among providers.

• 대한예방한의학회지
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• 제10권2호
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• pp.95-120
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• 2006

The purpose of this paper is to investigate the structure of cost-sharing for oriental medical services in the national health insurance. Out-of-pocket payment in ambulatory oriental medical care is a co-payment of KRW3,000 up to total expenses of KRW15,000, and co-insurance rate of 30% thereafetr. The empirical analysis based on medial claims data shows that the frequency of medical claims for outpatient care are mostly concentrated just below a total expenses of KRW15,000, and it decreases beyond a total expense of KRW15,000, while it rebounds between KRW17,000${\sim}$20,000. This means the current co-payment(KRW3,000) in oriental medical services should be applied up to a total payment of KRW17,000${\sim}$20,000, or the level of co-payment should be adjusted upward to KRW45,000 in order to be consistent in cost-sharing, between co-payment and co-insurance.

• 보건행정학회지
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• 제7권2호
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• pp.109-146
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• 1997

This study explores the feasibility of activating private health insurance in Korea. The rationale for expanding private supplementary health insurance can be found in many cases of health care reforms in the European countries. Private health insurance can not only relieve the financial distress of the government health insurance programs but also offer the medical institutions incentives to improve the quality of medical care. In Korea there is no supplementary health insurance that reimburses for various kinds of diseases based on a well designed fee schedule. Recently, the cancer insurance is the best seller in the health related insurance market. As observed in the U. S. case, the cancer insurance which pays the predetermined amount (indemnity coverage) regardless of the medical charges incurred to the patient is limited in its coverage for the insured. To provide better protection against catastrophic diseases, the government should give insurance companies incentives to develop health insurance products that cover multiple diseases rather than a single disease. Consumers can hardly understand and compare complex insurance products. To resolve the information asymmetries, the government should publish a consumer report that compare various health insurance products in a user friendly way. In the long run, insurance companies will plan to sell health insurance products that charge risk related premium only when insurers accumulate the underwriting know-hows, the government shares data on various health statistics including claims and demographics, and risk pool for high risk patients is well established and subsidized by the government.