• 한국병원경영학회지
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• 제12권2호
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• pp.1-24
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• 2007

The medical fee reimbursement denied by HIRA(Health Insurance Review Agency) amounted to about 1.2% of the total medical fee claim to HIRA for reimbursement. Most of the denials stem from the inappropriate prescriptions of medical staff violating the medical fee review standards issued by HIRA. Considering the significant impacts of the standards observance behavior on the hospitals' financial viability, we attempted to analyze the predisposition factors of medical staffs' review standards observance behavior. The TPB(Theory of Planned Behavior) was adopted as the theoretical framework of the analysis. Data were collected by administrating a survey on the concepts included in TPB model to the 187 medical staff of a tertiary care hospital. Of the 187 questionaries distributed, 150 were responded resulting 80.2% of response rate. The mean differences among the groups classified by age group, years of experience, medical specialty and gender were analysis using ANOVA. The relationships among the TPB concepts were analysed by applying the Structural Equations Modeling method. The TPB model consists of three exogenous concepts (attitude toward the behavior, subjective norm, and perceived behavioral control) and two endogenous concepts (intention and the behavior). The results of ANOVA indicated significant mean differences among the groups classified by the medical staff's age, years of experience, and medical specialty. The older and the more experienced had the higher mean of observance behavior score. The results of Structural Equations analysis showed that the subjective norm and perceived behavioral control had statistically significant influences on intention, but the influence of attitude to intention was not statistically significant. The influences of perceived behavioral control and intention on behavior were significant. Based on these results the theoretical and practical implications were discussed.

• 의학교육논단
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• 제15권2호
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• pp.61-68
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• 2013

During the Japanese colonial period in the Korean Peninsula, Chosun (ethnic Korean) physicians were trained in vocational clinical schools, but Japanese physicians in medical school. Therefore, the Japanese government treated the Japanese physicians as medical doctors but Chosun physicians as dealers or traders in clinical services. This colonial discriminatory policy became a habitual concept to Korean physicians. Because of these traditional concepts regarding physicians, after the colonial period, the newly established Korean government also had the same concept of physicians. Therefore, in 1952, the Korean graduate medical education system was launched under a government clearance system with the claim of supporting medical specialties as clinical dealers or clinical businesspeople. During the last 60 years, this inappropriate customary concept and the unsuitable system have evolved into medical residency training education, and then into graduate medical education. Today graduate medical education has become inextricably linked to postdoctoral work in Korean hospitals.

• 한국의료질향상학회지
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• 제26권2호
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• pp.95-103
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• 2020

Purpose: This study was to examine whether a health care model that provides comprehensive medical services based on population groups to members of the medical cooperative is applicable as a policy alternative in terms of medical use and cost. Methods: Data were derived from National Health Insurance claim data in 2019. We compared the medical volume and expenses of patients who visited social cooperative-type medical clinics with other patients, control group who visited other clinics in a local area. Results: The average number of visit days was 25.3 days in social cooperative-type medical clinics, more than 24.2 days in the control group (p=.004). However, the average medical cost per visit was KRW 46 thousand in social cooperative-type medical clinics, which was significantly lower than KRW 51 thousand in the control group (p<.001), and the total medical cost was also KRW 16.1 billion in social cooperative-type medical clinics and KRW 16.9 billion in the control group. Conclusion: We identified that a population-based health care model might change patients' behaviors to health care services and decrease total medical cost. Further population based experiment is needed to develop alternative healthcare model.

• 한국치위생학회지
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• 제11권3호
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• pp.325-341
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• 2011

Objectives : This research has investigated the reality of the education of the claim and the degree of the education for the claimed of the dentistry recuperation organization in the Daejeon and Chuncheong are for the improvement of the problem in the medical expenses. Methods : It use as a basic data for the vitalizations of the education and performed the survey in the dentistry recuperation organization in the Daejeon and ChungCheong Nam BukDo which are registered in the evaluating organization for judging the health insurance in the present May 2010, and concluded just like the below. Results : 1. The education of the claim in the requirer in the dentistry recuperation organization, and the education of the claim was especially lacking when the dentist was studying in the university, and the dental hygienist had the similar educational experience in the school and the clinic (p<0.05) 2. Most of the requirer in the dental recuperation organization was hoping to get the education related to the claim work, but the dentist and the nurse's aid was relatively low (p<0.05) 3. For fixing the error of the claim, the participation and the extension of the judging standard of the insurance was the highest among the university subordinate dental hospital/dental hospital, but the health center was relatively low (p<0.05). 4. The dentist feels the economic burden in employing the special employee because the raising of the special judging people, compared to others, but the staffs such as the dental hygienist preferred it as one of ways to fix the error of the claim of the dental insurance (p<0.05) 5. Both dentists and the dental hygienist said proper time to teach the insurance was all needed in the school, and the clinic, but other workers relatively believed it should be held in the clinic (p<0.05). 6. The important factors to decide the participation of the lecture was in order of the contents of the lecture, the place of the lecture, the amount for the lecture, the superintendent of the lecture, whether it has gone through the educational score, and whether it has passed the conserving educational score was relatively less important in the university subordinate dentist/dentist, but the medical center was very effective as 4.50 (p<0.05) 7. Health Insurance Review and assessment service was very high as the managing department for supplying the lecture and the information, 70.5%, and the next was the Korean Dental Association/ Korean dental hygiene association, but dentists were preferring the association to manage in than the Health Insurance Review and assessment service to manage (p<0.05) 8. In preferring lecture for the inquiring the insurance, periodontal surgery was the highest as 4.51, the diagnosis standard for injection was high in the university subordinate hospital/dentists, and the more the year of the insurance inquiry, the less the doctor who was hoping for the lecture about the basic treatment. Conclusions : Taken together, it is decided that the inquiry education about the medical expense in the dentist, so the consistent and systematic education should be held to the related people, and from this, it is thought to reduce the problem of the inquiry of the medical expenses by fostering the knowledge and supplying the information which are related to the inquiry of the dentists.

• 의료법학
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• 제10권2호
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• pp.287-307
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• 2009

A person is injured in car accident caused by his/her slight negligence except he / she causes accident by his / her willfulness or gross negligence. Because the National Health Insurance Corporation (hereinafter called "Corporation") shall not provide any insurance benefit "when he has intentionally or through gross negligence caused a criminal conduct or intentionally contributed to the occurrence of an accident" referred to in Article 48 (1) 1 of the National Health Insurance Act. So, if he / she is insured by his / her own bodily injury coverage, he / she can be compensated for his / her medical expenses. The injured have the rights to file either National Health Insurance claim and Automobile Insurance claim but there is no clear and definite adjustment clause. The claim disputes between National Health Insurance (hereinafter called "NHI") and Automobile Insurance (hereinafter called "AI") in the own bodily injury coverage makes some problems. Firstly, there are some differences in co-payments which he / she chooses between NHI and AI. Profit per a patient is higher in the NHI than in the AI. Secondly, it can provoke criticism that people shall unnecessarily pay double contributions. Lastly, it can raise moral hazards. For example, if he / she can cover the compensations when the insured receives the compensations from his / her insurer, the Corporation can be claimed by medical care institution payment of the health care benefit costs. In conclusion, first of all, to improve the national health and preserve the insured's rights the Corporation shall keep notice these facts.

• 한국임상약학회지
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• 제31권2호
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• pp.153-159
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• 2021

Background: With increasing economic evaluation studies on the treatment of or screening tools for liver diseases that cause hepatocellular carcinoma (HCC), interest in the analysis of the medical utilization and costs of HCC treatment is increasing. Therefore, we aimed to estimate the medical utilization and costs of HCC patients, and calculate the cost of main procedures for HCC treatment, including liver transplant (LT), hepatic resection (HR), radiofrequency ablation (RFA), and transarterial chemoembolization (TACE). Methods: We analyzed claim data from January to December 2018 from the Health Insurance and Review and Assessment Service-National Patient Sample (HIRA-NPS-2018) dataset, including data of patients diagnosed with HCC (Korean Standard Classification of Diseases code C22.0) who had at least one inpatient claim for HCC. Results: A total of 715 HCC patients were identified. In 2018, the yearly average medical cost per HCC patient was ₩18,460K (thousand), of which ₩14,870K was attributed to HCC. Among the total medical costs of HCC patients, the inpatient cost accounted for the largest portion of both the total medical and HCC-related costs. The major procedures of HCC treatment occurred most frequently in the order of TACE, RFA, HR, and LT. The average medical cost per treatment episode was the highest for LT (₩87,280K), followed by HR (₩10,026K), TACE (₩4,047K), and RFA (₩2,927K). Conclusion: By identifying the medical costs of HCC patients and the costs of the main procedures of HCC treatment, our results provide basic information that could be utilized for cost estimation in liver disease-related economic evaluation studies.

• 의료법학
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• 제13권1호
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• pp.199-247
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• 2012

According to the review and analysis of medical cases that are assigned to the Supreme Court and all local High Court in 2011 and that are presented in the media, it was found that the following categories were taken seriously, medical and pharmaceutical product liability, the third principle of trust between medical institutions, negligence and causation estimation, responsibility limit, the meaning of medical records and related judgment of disturbed substantiation, Oriental doctors' duties to explain the procedures, IMS events, whether one can claim for each medical care operated by non-physician health care institutions to the nonmedical domain in the National Health Insurance Corporation, and the basis of norms for each claim. In the cases related to medical pharmaceutical product liability, Supreme Court alleviated burden of proof for accidents with medical and pharmaceutical products prior to the practice of Product Liability Law and onset the point of negative prescription as the time of damage strikes to condition feasibility of the specific situation. In the cases related to the 3rd principle of trust between medical institutions, the Supreme Court refused to sentence the doctor who has trusted the judgment of the same third-party doctors the violations of the care duty. With respect to proof of a causal relationship and damages in a medical negligence case, the Supreme Court decided that it is unjust to deny negligence by the materials of causal relationship rejecting the original verdict and clarified that the causal relationship shall not deny the reasons to limit doctors' responsibilities. In order not put burden on patients with disadvantages in which medical records and the description of the practice or the most fundamental and important evidence to prove negligence and causation are being neglected, the Supreme Court admitted in the hospital's responsibility for the case of the neonate death of suffocation without properly listed fetal heart rate and uterine contraction monitor. On the other hand, the Seoul Western District Court has admitted alimony for altering and forging medical records. With respect to doctors' obligations to description, the Supreme Court decided that it is necessary to explain the foreseen risks by the combination of oriental and western medicines emphasizing the right of patient's self-determination. However, questions have arisen whether it is realistically feasible or not. In a case of an unlicensed doctor performing intramuscular stimulation treatment (IMS), the Supreme Court put off its decision if it was an unlicensed medical practice as to put limitation of eastern and western medical practices, but it declared that IMS practice was an acupuncture treatment therefore the plaintiff's conduct being an illegal act. In the future, clear judgment on this matter should be made. With respect to the claim of bills from non-physical health care institutions, the Supreme Court decided to void it for the implementation of the arrangement is contrary to the commitments made in the medical law and therefore, it is invalid to claim. In addition, contrast to the private healthcare professionals, who are subject to redemption according to the National Healthcare Insurance Law, the Seoul High Court explicitly confirmed that the non-professionals who receive the tort operating profit must return the unjust enrichment and have the liability for damages. As mentioned above, a relatively wide range of topics were discussed in medical field of 2011. In Korea's health care environment undergoing complex changes day by day, it is expected to see more diverse and in-depth discussions striding out to the development in the field of health care.

• 한국임상약학회지
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• 제18권2호
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• pp.124-131
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• 2008

The impacts of guideline for digestives on physicians' prescription of GI medication Clinical practice guidelines provide benefits to physicians, patients, and researchers. It also helps doctors to make decisions in medical services. In many countries, practice guidelines lead to activities of quality improvement and are developed using evidence based methods. This research was to assess the impacts of Korean Medical Association's guideline for digestives on the change of physicians' behavior. This study was progressed as one-group pre-test post-test quasi-experimental design using health insurance claims data. The unit of analysis was institution. Data was analyzed using paired t-test for change of prescription rate before and after the distribution of practice guidelines. And the multiple regression analysis was performed to examine the independent impact of the guideline on the prescribing rate of GI medication. Prescription rates of GI medication per claim by medical institution increased significantly, 1.98%point (from 50.27% to 52.25%) and multivariate regression analysis showed significant increase in the prescription rate of GI medication after the distribution of guideline (p<0.001). In conclusion, the distribution of guideline for digestive might not have the effects on the change in provider's behavior. Furthermore, to activate the use of practice guideline, it would be necessary to educate the contents to physicians as well as to develop practice guideline.

• 의료법학
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• 제11권1호
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• pp.91-116
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• 2010

As Complex Regional Pain Syndrome (CRPS) is a new and rare illness, medical cause for it has not yet been clearly found out. Nevertheless, the patients continue to file lawsuits for damage compensation against wrongdoers or their insurers, claiming that the cause of the illness is certain actions of the wrongdoers. Moreover, the claim amount reaches to hundreds of millions of won through billions of won unlike other illnesses. Therefore, CRPS has become an important legal issue in the damage compensation lawsuit. Even though the wound is slight, the development and result may be serious in the case of CRPS. As a result, a sharp conflict arises even regarding medical diagnosis of CRPS in the lawsuit. And, even if the medical diagnosis of CRPS is admitted, severe debates occurs with regard to many issues, which include the causation between accident and CRPS in connection with establishment of damage compensation liability and scope of liability like anamnesis, determination standard of aftereffect disability, and scope of admitted aftereffect medical expense in connection with scope of damage compensation. In this study, I will review fundamental medical research on CRPS up to now and discuss principal legal issues in the damage compensation lawsuit focusing on lower court rulings.

• 한국산업정보학회논문지
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• 제28권2호
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• pp.1-9
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• 2023

유방암 관련 기존 AI 연구는 보조적인 진단 예측이나 임상적 요인에 따른 진료 결과를 예측하는 주제가 많았다. 또한 연구기관의 코호트 자료나 일부 환자 자료를 이용하는 경우가 대부분이었다. 본 논문에서는 건강보험심사평가원이 보유하고 있는 전 국민 유방암 환자의 전수 데이터를 활용하여 유방암 환자의 40~50대와 다른 연령대 간의 생존 여부 예측과 생존 여부에 미치는 요인의 차이점을 분석했다. 그 결과, 환자들의 생존 여부 예측 정밀도는 40~50대가 평균 0.93으로 60~80대 0.86 보다 높았으며, 요인에 있어서도 40~50대는 치료횟수(46%)가, 60~80대는 나이(32%)의 변수 중요도가 제일 높았다. 기존 연구와 성능 비교 결과, 평균 정밀도가 0.90으로 기존 논문의 정밀도 0.81보다 높았다. 적용 알고리즘별 성능 비교 결과, 의사결정나무(Decision Tree), 랜덤포레스트(Random Forest) 및 그래디언트부스팅(Gradient Boosting)의 전체 평균 정밀도는 0.90, 재현율은 1.0으로 연령대 그룹 내에서 동일하였으며, 다층퍼셉트론(Multi-Layer Perceptron)의 정밀도는 0.89, 재현율은 1.0 이었다. 심평원의 전 국민 심사청구 빅데이터 가치 활용을 제고하기 위해 비전문가용 머신러닝 자동화(Auto ML) 도구를 사용한 더 많은 연구가 진행되기를 바란다.