• Health Policy and Management
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• v.16 no.3
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• pp.37-51
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• 2006

This study evaluates the reliability of the discharge status variable m health insurance claims for identifying in-hospital patient deaths. This study used 2002 national health insurance claims and the cause of death statistics from Korean national statistical office. The Study data set included acute myocardial infarction (AMI) and coronary artery bypass graft (CABG) surgery patients in 133 general and tertiary hospitals. The gold standard containing patient death information was made and then compared with that of claims data. The hospitals were classified into four groups based on the number of deaths in each hospital. Simple kappa coefficients were calculated to evaluate the agreements of patient deaths between the gold standard and the insurance claims. CABG (83.9%) showed higher agreements than AMI(73.0%) in matched in-hospital patient death information between data sets. Simple kappa coefficients of CABG (0.63) and AMI (0.59) showed moderate or good agreements. The agreements, however, varied depending on the disease or hospital types. The fact that the agreements are only moderate to good indicates that the accuracy of in-hospital death information in claims is not high. n the variable is used to identify patient deaths, it may mislead people. Therefore, efforts should be made to improve the reliability of the discharge status variable in health insurance claims.

• Journal of Technologic Dentistry
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• v.38 no.1
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• pp.9-22
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• 2016

Purpose: The Purpose of this study are to describe the Dental field of present health insurance for custom-made prosthetic implant by dental technicians' work. Results: A total of 300 dental technicians working at dental laboratories in Korea were randomly selected and surveyed, 206(68.7%) of them were used for the statistical analysis. Conclusion: Average daily working time was 10 hours 66%. The average cumulative credit of the clinic for dental prosthesis fabrication rates was Less than 10 million won(21.8%), 10~80 million won(11.7%), more than one hundred million won(1.5%). Remake dental prosthesis was one more than the monthly average of 98.5%. Causes of remake dental prosthesis was dentist impression 83% but did not pay 62.5%. Dental technicians Implant production period was 7 days(48.5%), 10 days(35%) was commissioned by dentists production time is 5 days(46.1%), 7 days(36.5%). President of dental laboratories 3.86 points and dental technicians 3.06 points knew differently about starting of implant health insurance coverage(p<.001). They alike were in favor of insurance coverage for the implant. Dental technicians were lower by 2.36 points for work do you know whether your health insurance application of dental prostheses. Dental technicians are 2.16 points on whether confidence in the pores payment of insurance coverage dental prosthesis, dental laboratory president was lower by 1.85 points. They are very low with 1.97 points on whether confidence in the rate payment of health insurance coverage dental prosthesis(p<.01). The implant prosthesis abutment selected, the abutments designed, design of the implant upper prosthetic, the upper prosthetic fitting dental technicians participate of dental laboratory president showed higher score (p <.05). Conclusion: Hours of dental technicians were making this short period of remake dental prosthesis-related dental prosthesis. Dental clinic and a detailed representation of the dental prosthodontic fabrication request is required for communication between the laboratory in order to reduce the remake of a dental prosthesis, dental insurance coverage written dental prosthodontic fabrication request should be legislated. Implant classification standard medical practice 1-3 Step conduct a thorough costing a total of no. 73 of the correct classification standard medical practice in addition to eight times defined by the act of dental technicians should be defined.

• Health Policy and Management
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• v.22 no.1
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• pp.145-162
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• 2012

The purpose of this study is to understand magnitude and its related factors of user's cost-sharing for non-covered services in long-term care facilities. We corrected data for 1,016 subjects, based on the long-term care benefits cost specification. Eighteen subjects were excluded from the data analysis due to missing data on family care-givers characteristics. Finally, 998 subjects were included in the study. The average cost of non-covered services per month was 209,093 won and distributed from 0 to 1,011,490 won. There was a significant difference by the characteristics of family care-givers and long-term care facilities. The monthly average cost for meal materials per person was 199,181 won(0~558,000), average cost of additional charge caused by using private bed was 232,992 won (50,000~600,000), and costs for haircut and cosmetics were 8,599 won. For the rest, there were various programs costs(93,328 won), diaper and its disposal cost(109,628 won), purchase cost for daily necessaries(24,435 won) and etc. The related factors for the magnitude of non-covered services expenditures were education level of family care-givers, occupancy rate and location of LTC facilities, and the costs of using private bed, haircut and cosmetics, and various programs among non-covered services. These findings suggest that present level range of LTC facilities users' cost-sharing is wide and it is urgent to prepare the standard guideline for cost and level in non-covered services.

• The Korean Journal of Applied Statistics
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• v.30 no.3
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• pp.391-401
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• 2017

This study develops an indicator to manage regional variations of approval rates for long-term care (LTC) service. We used LTC insurance data for grade assessment that include 433,155 applicants from 227 LTC centers across Korea in 2015. The approval rate for each center was defined as the proportion of the numbers of approved applicants out of all applicants. We assumed that the approval rates depended on the characteristics of applicants. We estimated the 'standard' approval rates from a multiple linear regression analysis using the characteristics of applicants as independent variables. The difference between the observed and the standard rates was then defined as an indicator for deviation. A center having a large difference could be considered as a center with a potential error in grade assessment. We also examined if the characteristics of investigators affected the approval rates. We found that the socio-demographic characteristics of applicants and reapplication rate for LTC grade were independent factors affecting the approval rates. Centers having the management indicator values falling outside the middle 95% of the distribution were identified as centers with an error in grading. We expect that this study will contribute to enhancing reliability and equity in LTC grading.

• Korean Journal of Clinical Pharmacy
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• v.20 no.3
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• pp.262-267
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• 2010

Therapeutic duplication of prescriptions is the most frequently reported inappropriate drug use in Korea. To prevent significant problems during drug prescribing and dispensing, prospectively, development of standard including drug lists considered as therapeutic duplications for the prioritized drug classes first would be necessary. This study was aimed to analyze frequent drug classes of therapeutic duplications by healthcare providers in clinical practice settings. National health claims data for drug review and reimbursement (1,426,065 prescriptions dated March 19, 2008) were analyzed. Therapeutic duplication was defined as the prescription including more than 2 ingredients belonging to the same KFDA drug classification numbers that considered to have therapeutic similarities. The following 3 drug classes were mostly frequent therapeutic duplication classes: 114 anti-pyretics, analgesics and anti-inflammatory drugs; 117 drugs for psycho-nervous system; 141 Antihistamines. About 3.5% of overall prescriptions analyzed showed therapeutic duplications. This result might be starting step to develop DUR therapeutic duplication standard.

• 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.

• Journal of the Korean Society of Radiology
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• v.14 no.6
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• pp.801-810
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• 2020

In this study, the health insurance application of PET and the change in the pay standard were examined, and the amount of health insurance use over the past 10 years was analyzed. Positron tomography was applied as health insurance in 2006, and after ¹⁸F-FDG was first applied as health insurance, positron tomography tests using various radioactive isotopes have been applied as health insurance. As of 2019, the number of positron emission tomography tests was 198,651 cases, and the treatment amount was about 88.3 billion won, and the number of tests according to general characteristics was higher in men than in women, and by age, the number of tests was the highest in 60s. The number of outpatient examinations was higher than that of inpatient examinations, and the number of examinations in tertiary hospitals(68.2%) was significantly higher than that of general hospitals and hospitals. As for the test site, torso test was the most common at 86.6%, and radioisotope was the most at 93.6% using ¹⁸F-FDG. The change in the use of PET for 10 years increased steadily from 2010 to 2014, but the amount of use decreased sharply afterwards as the recognition of asymptomatic long-term follow-up tests was deleted due to the government's change in health insurance application standards in 2014. As changes in health insurance standards have a great influence on changes in health insurance usage, continuous monitoring will be required in the future.

• Health Policy and Management
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• v.29 no.2
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• pp.195-205
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• 2019

Background: The food and food service influence the quality of life and the general health condition of older persons living in long-term care (LTC) facilities. Purchasing good food materials is a ground of good food service. In Korea, the residents in LTC facilities should pay for the cost of food materials and ingredients out of their pocket because it is not covered by LTC insurance. This study explored what factors affect the cost of food materials paid by LTC facility residents and which factor affects most. Methods: We used data from the study on out-of-pocket payment on national LTC insurance, which surveyed 1,552 family caregivers of older residents in LTC facilities. We applied conditional multi-level model, of which the first level represents the characteristics of care receivers and caregivers and its second level reflects those of LTC facilities. Results: We found that the facility residents with college-graduated family caregivers paid 11,545 Korean won more than those with less than elementary-graduated ones. However, the income level of family caregivers did not significantly affect the amount of the food material cost of the residents. The residents in privately owned, large, metropolitan-located facilities were likely to pay more than those in other types of facilities. The amount of the food material cost of the residents was mainly decided by the facility level factors rather than the characteristics of care recipients and their family caregivers (intra-class correlation=82%). Conclusion: These findings suggest that it might be effective to design a policy targeting facilities rather than residents in order to manage the cost of food materials of residents in LTC facilities. Setting a standard price for food materials in LTC facilities, like Japan, could be suggested as a feasible policy option. It needs to inform the choice of LTC users by providing comparable food material cost information. The staffing requirement of nutritionist also needs to be reviewed.

• Health Policy and Management
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• v.30 no.1
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• pp.72-81
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• 2020

Background: The out-of-pocket maximum is one of the distinctive healthcare systems which sets a ceiling on co-payment in order to reduce the burden of households from the unpredictable medical expenditure. However, this leads to an increase in the demand for healthcare services especially in long-term care hospitals (LTCHs) in Korea. Methods: This study analyzed the influence factor of medical service overuse of 165,592 inpatients in LTCHs which out-of-pocket maximum is applied, by utilizing data from the National Health Insurance Service (2016). Based on Anderson Model, the medical service overuse, as a dependent variable, was defined as long-stay admission more than 180 days at the LTCHs. Independent variable was comprised of predisposing factors (gender, age), enabling factors (income level, types of out-of-pocket maximum) and need factors (illness level, patient use of tertiary hospital). Results: The most powerful factor of medical service overuse in LTCHs was availability of pre-payment for the out-of-maximum (odds ratio [OR], 191.66; p<0.001). This tendency was found in high income level status (p<0.001). Furthermore, mild inpatients (OR, 1.50; p<0.001) which had no experience with the tertiary hospitals (OR, 2.06; p<0.001) were more relevant to the medical service overuse in LTCHs, compared to the severe inpatients. Conclusion: It is suggested that a separate standard of out-of pocket maximum with regards to LTCHs is required to secure the beneficial functions of long-term hospitals and prevent unnecessary financial leakage to achieve sustainable and financially sound National Health Insurance.

• Health Policy and Management
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• v.25 no.2
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• pp.107-117
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• 2015

Background: The purpose of this study is to analyze the cost for the denture treatment in accordance with the government's plan to expand the National Health Insurance coverage for dental prothesis from July 1, 2012. Methods: We developed the draft of classification of the treatment activities based on the existing researches and expert's review and finalized the standard procedures through confirming by Korean Dental Association. We also made the list of input at each stage of treatments. We conducted survey of 100 dental clinics via post from April 4 to May 20 in 2011 and 37 clinics took part in the survey. The unit of cost calculation is the process from the first visit for denture treatment to setting of denture and adjustment. The manufacturing process performed by dental technician was not included in the cost analysis. Results: The process for the complete denture treatment was classified with 10 stages. The partial denture treatment was classified with 8 stages. The treatment time per each denture is about 5.6 hours for complete dentures and about 6.6 hours for partial dentures. The treatment cost were from 591,108 won to 643,913 won for complete denture and from 670,219 won to 738,840 won for partial denture in 2011, depending on the location, type of the clinics and the types of physician's income. Conclusion: This study shows the example of cost analysis for the treatment to set the fee schedule. Measures to get representative and accurate information need to be made.