• Health Policy and Management
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• v.11 no.2
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• pp.29-57
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• 2001

Since the inauguration of the medical insurance system in 1977, the increasing medical expenses which can be menace to tile finance of the medical insurance system, have become major concern in the medical insurance field In Korea. This study focuses on the determinants of the medical expenses in the health insurance in Korea and analyzes the impact of these factors on the increase in the medical expenses. The empirical work is done using the pooled cross-section and time-series data of the medical insurance for the self-employeds and the industrial workers from the year 1995 to 1997. The result of this study shows that the main determinants of the medical expenses in the health insurance are the ratio of the population of the aged to the total population, the frequency of the utilization, number of doctors per capita and the regime changes. Although the increasing trend in the medical expenses seems to be unavoidable, we probably need to add some efficiency to the medical expenses by suppressing the supply and the utilization of the unnecessary medical services. The fee-for-service reimbursement system of today can't suppress the supply of the unnecessary medical services effectively. So we need to convert the present fee-for-service system into DRG's which is known to reduce the medical costs. The increase in the medical expenses comes from a lot of factors. Therefore, we should develop more systematic and comprehensive measures to control the soaring medical expenses in consideration of the various factors such as demand, supply, and the organizational side of the medical system.

• The Korean Society of Law and Medicine
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• v.8 no.1
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• pp.137-177
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• 2007

The medical expenses review system in Korea has developed under fee-for-service system with its own unique structure. The importance of reviewing medical expenses has been emphasized, as the size of medical expenditures moving through the health insurance legal context and its weight in the national economy have increased very rapidly. It is, however, analyzed that the feuds and arguments continue among the stakeholders for the lack of laws supporting the medical expenses review system. The medical expenses review is a series of administrative procedures, deciding whether claims from medical care institutions to the insurer are legal and valid or not. It mainly controls the increase of unnecessarily excessive health insurance claim and prevents fraudulent claim and abuse and checks the less use or unsuitable use of medical resources. It also works a function guarantees medical benefits for the appropriate treatment according to the object of health insurance system as a social insurance scheme. The dispute on legal base of the medical expenses review is about the source of law in the medical expenses review. There are the Health Insurance Act and administrative laws as jus scriptum and the guidelines of review as administrative orders. The medical expenses review should reflect various factors, such as the development of medical healthcare technologies, the health expenditures distribution, the financial situation of the health insurance, and the evaluation on the level of appropriate benefits. It is also likely to adapt to the traits of characters of medicine, and trends and transition, Besides it should judge the legality and the validity of medical benefits expenditures by synthesizing these all factors. And the evaluation system of appropriateness of medical benefits was administrative procedure which was consecutive with reviewing the medical expenses system and it was intended to make up for the result of reviewing the medical expenses in more comprehensive levels.

• Health Policy and Management
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• v.23 no.2
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• pp.132-144
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• 2013

Background: The purpose of this study was to analyze the medical expense change and influencing factors after introducing longterm care insurance system. The study period was 2 years before and after introduction of the system. Methods: We analyzed data collected from two divided group lived in Incheon. Four hundred and eighty-five elderly who received long-term care wage for one year were selected for experimental group. For control group, 1,940 elderly were selected by gender and age stratified random sampling. Difference-In-difference analyses was used for evaluating policy effectiveness. Also multiple regression analyses were conducted to identify the factors associated with total medical expenditures. The control variables were demographic variables, economic status, diseases, and medical examination variables. Results: Difference-in-difference analyses showed that total average medical expenses among long-term patients has decreased by 61.85%. Of these, the hospitalization expenses have decreased by 91.63% and the drug expenses have increased by 31.85%. Multiple regression analyses results showed that total average medical expenses among long-term patients have significantly decreased by 46.5% after introducing the long-term care insurance. The hospitalization expenses have significantly decreased by 148.5%, whereas the drug expenses have increased by 53.6%. And outpatient expenses have increased by 10.4%, but the differences were not statistically significant. Conclusion: The results showed that total medical expenses and hospitalization expenses have decreased after introducing the long-term care insurance. These results could support the opinion that the health insurance spending among long-term patients will be reduced gradually by long-term care insurance through changing medical demand.

• The Korean Journal of Health Service Management
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• v.10 no.4
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• pp.1-11
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• 2016

Objectives : The aim of this study is to investigate the actual condition of the occurrence and recovery of medical expenses through seafarers insurance and to provide basic data that will be helpful in the establishment of efficient hospital management strategies for medical expenses of insurance companies depending on the type of seafarers insurance. Methods : Three general hospitals located in Busan, Korea, were selected, and seafarers insurance claim data was collected from January 1, 2012 to December 31, 2013(24 months) and analyzed. There were 5,490 cases in total. Results : There was a significant difference in the distribution of disease incidence, accrued medical expenses, reimbursement of medical expenses, and the actual condition of medical receivables depending on the insurance company. Conclusions : Therefore, differentiated payback strategies for medical expenses are needed that consider the various seafarers insurance companies and their treatment characteristics.

• Journal of Family Resource Management and Policy Review
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• v.16 no.2
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• pp.123-143
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• 2012

This study, based on a health belief model, examines how baby boomers perceive health and how they are financially preparing for future medical expenses. In addition, the study analyzes which factors influence baby boomers' preparation behaviors for future medical expenses and their perceived sufficiency of the preparation for medical expenses. Through such activities, this study examines baby boomers' current preparation status for future medical expenses, and based on this outcome, will turn the attention of individuals and society toward becoming more concerned with health and increasing health expectancy. For this study, an online survey was conducted targeted at men and women who were born between 1955 and 1963 and live nationwide, and its resultant data were collected. After conducting a 15-day survey in November 2011, a total of 418 questionnaire responses were used for the final analysis. The major findings of this study and their implications are as follows: First, baby boomers' health beliefs and their perceptions of health identified by subjective health conditions were very positive. Second, while there were some partial differences in the influencing factors, health beliefs and perceived health influenced the sufficiency of future medical expenses in the three groups, which were segmented according to how they prepare for future medical expenses-insurance-based, pension-based, and insufficiently prepared groups. Third, the baby boomers selected the national health insurance as the primary means of preparing for post-retirement medical expenses, and backed it up with private health insurance or the national pension. In addition, when baby boomers' perceived sufficiency of future medical expenses were examined, 57.6% of the respondents expressed that their old-age medical expenses were not sufficient. Fourth, in terms of baby boomers' preparation behaviors for future medical expenses, it was revealed that as one recognizes old-age health more seriously, he/she has a higher chance of using insurance and lower chance of using a pension to prepare for medical expenses. Fifth, regarding baby boomers' sufficiency of preparations for future medical expenses, economic factors such as total assets, the sufficiency of retirement assets, and the number of insurance policies, as well as health perceptions, including health beliefs and subjective health conditions, were important influencing factors.

• Health Policy and Management
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• v.27 no.1
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• pp.30-38
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• 2017

Background: This study aims to analyze the behavioral changes of healthcare providers and influencing factors after the reviewer unification of auto insurance medical benefit claims by an independent review agency. Methods: The comparison data were collected from the second half of 2013 and the same period of 2014. The key indicators are the number of admission days, the number of outpatient visits, inpatient ratio, inpatient medical expenses, and outpatient medical expenses. Results: Four indicators (number of admission days, number of outpatient visits, inpatient ratio, and outpatient medical expenses) showed statistically significant drops, while one indicator (inpatient medical expenses) showed no significant change. Conclusion: The reviewer unification of auto insurance medical benefit claims by an independent review agency showed significant reduction in cost and patient days.

• Health Policy and Management
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• v.28 no.4
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• pp.352-359
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• 2018

Background: The purpose of this study is to propose an analysis of trends and characteristics of high-cost patients who take over 40% of total national health insurance medical expenses. Methods: It has been analyzed the tendency of high-cost patients by open data based on the medical history information of 1 million people among national health insurance subscriber from 2002 to 2015. To conduct detailed study of characteristics of high-cost patients, multiple regression has been performed by sex, age, residence, main provider, and admission status based on the top 5% group. Results: The amount of medical expenses and the number of high-cost patients have gradually increased in decades. The number of high-cost patients for Korean won (KRW) 5,000,000 category has increased by 7.6 times, KRW 10,000,000 category has increased by 14.1 times in comparing of year 2002 and 2015. Top 5% medical expenses have increased by 4.6 times. In consideration of the characteristics of patients, the incidence of high medical expenses has been higher in female patients than male ones, the older patients than in the younger. Patients residence in Gyeonsang or Jeonla province have had a high incidence of medical expenses than other area. The disease including dementia, cerebral infarction, and cerebrovascular disease for high-cost patients has been also increased. Conclusion: The major increase factor for high medical expenses is the aging of population. The elderly population receiving inpatient care residing in the province that increases high medical costs have to management. There is an urgent need to develop a mechanism for predicting and managing the cost of high-cost medical expenses for patients who have a heavy financial burden.

• Journal of Trauma and Injury
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• v.25 no.4
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• pp.178-187
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• 2012

Purpose: In Korea, the nation's medical expenses were 12 billion won in 2010. The medical costs for individuals can also be overwhelming. If a patient has sustained severe trauma, his/her insurance company responsible may pay only part of the medical bills. In Korean, there are diverse types of medical insurance, such as health insurance, automobile insurance, and industrial accident compensation insurance. And each insurance system has a different type of payment system. Our study will be essential for establishing the optimal medical expense payment system. Methods: From January to December 2011, we retrospectively reviewed the medical charts of 161 patients who were admitted to our hospital's emergency room after having undergone severe trauma. Of those 161 patients, 125 were retrospectively reviewed. Written permission was obtained from all of the patients. We analysed the demographic characteristics, clinical outcomes, data of the trauma, type of the patient's insurance, and the entire bill when the patient was discharged. Results: Seventy-one patients had health insurance, 48 automobile insurance, and six industrial accident compensation insurance. High-deductible insurance included health insurance and industrial accident compensation insurance, with the deductibles up to 20.6% and 19.1%, respectively. We attempted to analyze the cause of the high deductible rate. In patients with health insurance, medicines, primarily sedatives, pain killers, antibiotics, and fluids. comprised a large proportion. On the other hand, industrial accident compensation insurance deducted for a high-grade hospital room charge. Conclusion: We found that medical expenses were diverse according to the type of insurance. In particular, health insurance forced patients to pay too much of the medical expenses. Therefore, in Korea we should try to identify the insurance problems and improve the wage system.

• Journal of Society of Preventive Korean Medicine
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• v.15 no.1
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• pp.71-87
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• 2011

Objective : The present study is aimed at providing basic data to help oriental medical hospitals devise efficient operational plans by analyzing the medical expenses of in-patients in an oriental medical hospital and the factors affecting such expenses. Methods : PASW 18.0 was used to analyze the medical insurance program data of 929 patients who were discharged from a university oriental medical hospital(with 105 sick-beds) during the period from January 1 to December 31, 2010 after treatment under the coverage of health insurance and medical aid. Results : 1) Of all the patients hospitalized, 63.3% were females, their mean age was 52.73 years old, and 87.7% was covered by the health insurance program. The biggest number or 31.2% of the patients were treated by the department of acupuncture, 31.5% suffered mainly from the diseases of musculoskeletal system and connective tissues, and the average length of stay at the hospital was 19.49 days. 2) There were statistically significant differences in total medical expenses by age, clinical department in charge, principal diagnosis, and number of days hospitalized while daily average medical expenses differed depending on age, type of medical security, clinical department, principal diagnosis, and number of days staying at the hospital. 3) Total medical expenses were found significantly influenced by age, type of medical security, clinical department, principal diagnosis, and number of days hospitalized(explanatory power : 95.9%), whereas type of medical security, clinical department and principal diagnosis turned out to exercise significant influence on the daily average medical expenses(explanatory power : 26.9%). Conclusion : Oriental medical hospitals are suggested to make efforts to ensure geographical and economical accessibility for their main clients, the elderly and middle-aged, as well as to improve satisfaction of the clients with the medical service provided. They are also encouraged to work out systems to specialize in treatment with a focus on chronic degenerative and adult diseases. In addition, they are expected to try to enhance people's awareness of oriental medicine in an attempt to diversify the brackets of clients and increase frequency of their utilization.

• The Korean Society of Law and Medicine
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• v.14 no.2
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• pp.11-41
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• 2013

Article 347 of criminal law provides the act of deceiving another, thereby taking property or obtaining pecuniary advantage from another. On the other hand, the concepts of fraud and abuse are confused upon interpretation since the definition in National Healthcare Insurance Law is unclear, and it affects closely to the administrative measures such as surcharge levy by the period of inspection, therefore, the disputes continue in the forms of formal objection, administrative ruling and administrative litigation. This study aims to look over the legal problems on application of criminal fraud toward the abuse of 'Paid Medical Expenses(Article 57, Sections 1 and 4 of the National Health Insurance Act)'. The main issues are concept of abuse(Article 57, Sections 1 and 4 of the National Health Insurance Act), the problems of Directions of Health-Welfare Ministry on aspect of 'Nullum crimen sine lege' Principles, the proper sentenc-ing guidelines of fraud.