• Korea Journal of Hospital Management
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• v.10 no.2
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• pp.45-63
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• 2005

The purposes of this study are to understand the doctors' attitude and satisfaction about the review system of national health insurance claim in Korea and to suggest the way to improve this system This study conducted a survey of the doctors registered in the medical association in Seoul city. The survey was performed as a form of self-administered questionnaire from January 2004 to February 2004. The contents of questionnaire dealt with doctors' attitude and satisfaction about the review system of medical service claim. Totally, 1,037 members replied to our survey and we analysed 981 doctors' data, excluding incomplete responses. As a result, 89.7% of repliers showed a negative attitude about the influences of the review system on improvement of medical service quality, 98.0% of repliers have had experiences that they have given distorted insufficient medical services in order to evade the curtailment of service claim. Also, 91.6% of repliers stated that they have had experiences of intentional modification or alteration of diagnostic code to shun the curtailment. Most of the doctors showed negative attitude to the curtailment procedure and the review system of service claim originally intended to be one of the quality control methods of medical service in Korea also, the development of both scientific and reasonable parameters and criteria for claim is needed. 'Through the improvement of review system for appropriate medical service, there is a need of a way to increase the satisfaction of medical service providers, and to encourage the motivation for quality control. Also, education is strongly needed to provide doctors with sufficient information about review criteria and curtailment cases.

• Health Policy and Management
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• v.32 no.2
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• pp.154-163
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• 2022

Background: The costliness index (CI) is an index that is used in various ways to improve the quality of medical care and the management of appropriate treatment in medical institutions. However, the current calculation method for CI has a limitation in reflecting the actual medical cost of the patient unit because the outpatient and inpatient costs are evaluated separately. It is desirable to calculate the CI by integrating the medical cost into the episode unit. Methods: We developed an episode-based CI method using the episode classification system of the Centers for Medicare and Medicaid Services to the National Inpatient Sample data in Korea, which can integrate the admission and ambulatory care cost to episode unit. Additionally, we compared our new method with the previous method. Results: In some episodes, the correlation between previous and episode-based CI was low, and the proportion of outpatient treatment costs in total cost and readmission rates are high. As a result of regression analysis, it is possible that the level of total medical costs of the patient unit in low volume medical institute and rural area has been underestimated. Conclusion: High proportion of outpatient treatment cost in total medical cost means that some medical institutions may have provided medical services in the ambulatory care that are ancillary to inpatient treatment. In addition, a high readmission rate indicates insufficient treatment service for inpatients, which means that previous CI may not accurately reflect actual patient-based treatment costs. Therefore, an integrated patient-unit classification system which can be used as a more effective CI indicator is needed.

• Health Policy and Management
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• v.31 no.4
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• pp.508-517
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• 2021

Background: After the first case of coronavirus disease 2019 (COVID-19) in January 2020, Korea has experienced three waves in 2020. This study aimed to analyze changes in health care utilization according to the period of the 1st to 3rd waves of the COVID-19 pandemic. Methods: We analyzed 3,354,469,401 national health insurance claims from 59,104 medical facilities between 2017 and 2020. Observed-to-expected ratios (O:E ratio) with data from 2017 to 2019 as expected values and data from 2020 as observed values were obtained to analyze changes in medical utilization. T-test was used to test whether the difference of observed and expected values was statistically significant. Results: In 2020, the O:E ratio was 0.894, indicating a decrease in health care utilization overall during the pandemic. The O:E ratio of the 1st wave was 0.832, which was lower than those of the second (0.886) and third (0.873) waves. Health care utilization decreased relatively more among outpatient, women, children and adolescents, and health insurance patients. And health care utilization decreased more in small medical facilities and in Daegu and Gyeongbuk during the first wave. During the pandemic, the O:E ratios of respiratory diseases were 0.486-0.694, while chronic diseases and mental diseases were more than 1.0. Conclusion: Health care utilization decreased during the COVID-19 pandemic overall, and there were differences by COVID-19 waves, and by the characteristics of patients and medical facilities. It is necessary to understand the cause of changes in health care utilization in order to cope with the prolonged COVID-19 pandemic.

• Journal of Acupuncture Research
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• v.26 no.3
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• pp.1-10
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• 2009

Objectives : The main purpose of this Survey is to make a research on the actual condition of Automobile insurance system in oriental medical care. Methods : In this research, we surveyed 544 patients of traffic accident who were visited oriental medical clinic or hospital in Daegu, Korea from January, 1, 2008 to December, 31, 2008 according to medical chart. They made up Questionnaire about sex, age, pattern of accidents, days to visit oriental medical clinic, motivation to visiting clinic, damaged part of the body, chief complaint, treatment given to them, medication, tests, days of treatment and the effect. Results : The patients visited oriental medical clinic or hospital were fewer numbers from most of traffic accident patients. And most of their symptoms were light and the treatment and test of oriental medicine was limited for them because of automobile insurance limitation. Conclusions : For this study, we confirmed a possibility for the treatment of traffic accident patients in oriental medical treatment. Still, we needs to expend the boundary of treatment and to come into application of insurance.

• Health Policy and Management
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• v.32 no.3
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• pp.323-329
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• 2022

Background: This study aimed to identify the characteristics of the referral and return of patients to clinics in the endocrinology and cardiology departments at the National Health Insurance Service Ilsan Hospital to evaluate the "referral and return of patients to clinics" program and reduce the rate of returning patients. Methods: From May 2018 to December 2020, we identified the number of visits to referral hospitals and hospital usage status at Ilsan Hospital after returning to clinics. We also identified the patients who returned to Ilsan Hospital within 6 months, defined as "failure to transport," among those recommended to be transported to clinics of the Medical Cooperation Center. Additionally, we evaluated the characteristics of the "failure to transport" patients. Results: Among the returning patients, the rate of visiting Ilsan Hospital within 6 months was higher in cardiology than in endocrinology (25.1% vs. 16.7%). Older age, more severe disease, and more number of visits to the department were associated with a high rate of failure to transport. The rate of failure to return was low in cases diagnosed with hyperlipidemia/lipoprotein metabolism disorder. With respect to diabetes, the rate of failure to transport differed according to each type of diagnosis of diabetes. Conclusion: The success rate of the "referral and return of patient to clinics" program differed based on each patient's characteristics, department of visit, and diagnosis. Individualizing according to the visit department and diagnosis is required to ensure successful transfers, and infrastructure expansion and institutional arrangements must be facilitated.

• The Journal of Korean Physical Therapy
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• v.10 no.1
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• pp.105-125
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• 1998

We are confronted by increase in old people due to the improvement in medical science, public hygiene and socioeconimic status in 20th century. But our medical security system for old people dees not meet the need for medical service of old people. Current medical insurance system restricts term and extent in allowance although the characteristics of the disease of the aged people need medical care of Bong duration and high cost. And in the medicaid system the speciality of the aged people is not recognized and the budget of the government is scanty. In addition many old people to our country are in economic distress due to low income. But the government authority does not give sufficient consideration for eld people in law, policy and budget. To improve social security system for old people it is necessary to increase the budget for the security of old people, to enhance the traditional respect for the aged, to improve medical security system by improving the accessibility to medical service and by expanding the allowance of medical insurance, and to expand the public welfare institutions. And these are roles for all the family. the society and the nation as well as the aged people themselves.

• Health Policy and Management
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• v.11 no.1
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• pp.107-130
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• 2001

During the last year, we had a very severe situation with the strike of physicians working in medical facilities. From that time, many politicians and scholars insisted on the expansion of public hospitals to enhance the public role in the medical care sector. They think that private medical facilities work for profit motivation and that the high proportion of private to whole facilities is an obstacle to the public function of medical care under social insurance system. They found that one of the reasons for failing to prevent the physicians' strike was the high proportion of private facilities. Others insisted that the strike was not a good reason for the expansion of public hospitals. The physicians' strike was a very rare case, and it is not a good basis for generalization of the discussion of public hospitals. Last year almost all apprentice physicians in public facilities took part in the strike, and consequently the public hospitals also lost the role of public function. They view this increasing involvement of government in the medical sector as improper and the cause of inefficiencies. In this paper we review the debate over the expansion of public facilities. To clarify the debate, we review traditional criteria for the role of government in a market system and to apply these criteria to medical care. There are two traditional areas where government Is acknowledged to have a role in a market system: market imperfections and market failure. Where market imperfections and market failure exist, there may be a role for government. The justifications for government intervention are consumer protection and the existence of externalities. One of externalities is to provide medical care for the poor. The appropriate measures to provide medical owe to the poor can be sought in both demand and supply side subsidies. National health insurance is a method of demand subsidies and establishment of public hospitals is a method of supply side subsidies. Under the National Health Insurance System, the expansion of public hospitals is not an appropriate subsidy policy.

• Journal of Service Research and Studies
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• v.11 no.1
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• pp.31-44
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• 2021

The net function of the domestic medical insurance system is highly regarded, but due to the problem of incomplete coverage, the public wants to secure coverage through private medical insurance subscription. As a result, the subscription rate of private medical insurance has recently increased, and the billing rate has also increased. As the number of people seeking private medical insurance increased, workers at private medical insurance companies are experiencing increased job stress and side effects, especially for insurance reviewers who are in charge of paying insurance, such as communicating with customers who claimed insurance and contributing to the company's profit. In response, this study analyzed the effects of job stress on mental health of insurance reviewers and conducted a descriptive survey study to reduce job stress of insurance reviewers and promote mental health. The analysis shows that job stress for insurance reviewers has a significant impact on mental health (+). In detail, job stress has a significant impact on all four factors: social performance and self-confidence, depression, sleeping disturbance and anxiety, and general well-being and vitality. This study showed that job stress in insurance reviewers has a significant (+) impact on mental health. Job stress can cause side effects in organizational aspects, such as reducing enthusiasm for job performance and increasing turnover and resignation rates, but it can also worsen individual physical health and cause diseases such as depression and anxiety, causing mental health to be impoverished. Therefore, in order to prevent this, appropriate work stress prevention methods and countermeasures should be provided to help reduce work stress and improve mental health.

• Journal of Preventive Medicine and Public Health
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• v.22 no.3 s.27
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• pp.398-405
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• 1989

A change in the consumer's surplus was measured in order to evaluate the social benefit to be derived from expanding health insurance to the entire population. The most refined and correct way to measure a project's net benefit to society is to determine a change in the consumer's surplus. Benefits from introducing the health insurance program to the uninsured people can be classified into two elements. The first is the pricing-down effect(E1) which results from applying the insurance price system, which is lower than the actual price, to the uninsured patients. The second effect(E2) is a decrease in actual payment because an insured patient pays only a portion of the total medical bill(copayment). We collected medical price information from the data banks of 93 hospitals, and obtained information of medical utilization by referring to the results of other research and from data published by the Korean Medical Insurance Societies. The total net benefit was estimated as \214 billion, comprising the first effect(E1) of \57 billion and the second effect(E2) of \157 billion. The price elasticity of physician visits is less than that of hospital admissions: however, benefits from the increase in physician visits are greater than those from hospital admissions because there are considerably more of physician visits than hospital admissions. The sensitivity analysis also shows the conclusion that expansion of the health insurance program to the entire population would result in a positive net benefit. Therfore, we conclude that the National Health Insurance Program is socially desirable.

• Health Policy and Management
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• v.20 no.4
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• pp.45-57
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• 2010

Background : If different cost efficiency indexes were informed to the same clinic depending on the inclusion or exclusion of pharmacy cost, it may impair the reliability of provider-profiling system. This study aimed to investigate whether the omission of pharmacy cost affects cost-efficiency rankings in medical clinics. Methods : Data for ambulatory care cost at 23,112 medical clinics were collected from the claims database, which was constructed after review by the Health Insurance Review and Assessment Service (HIRA) of Korea in April 2007. We calculated two types of cost efficiency indexes by inclusion or exclusion of pharmacy cost for a medical clinic. The agreement between the decile rankings of the two indexes was also assessed using the weighted kappa statistic of Landis and Koch. Results : When the cost efficiency index for total cost including pharmacy cost was compared with the index for total cost excluding it, the agreement between the two indexes was only 55%. The agreements between the two indexes were relatively low within specialties which have larger pharmacy volume of total cost and lower correlation between total cost with or without pharmacy cost included than the average level of all the specialties. Conclusion : These results suggest that the omission of pharmacy cost may result in contradictory outcomes that may be confusing to a medical institution and may impair the reliability of provider-profiling systems. It is very important to standardize profiling criteria for the reliability of provider profiling system.