• Health Policy and Management
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• v.3 no.1
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• pp.84-101
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• 1993

The current method of rate adjustment is based on the evaluation of the financial performance of hospitals. The method has the disadvantages such as too complicated, expensive process as well as low reliability due to small sample size. This study, therefore, develops a new model for the rate adjustment with the use of the composite index. In addition to that, it examines the validity of the model by comparing the result of the new method with that of the conventional method. The idea of the new model comes from the Medicare Economic Index(MEI) on which physician fees for the Medicare patients are adjusted periodically in the United States. Medical costs are classified into three groups : labor costs, materials and other expenses. Labor costs are subdivided into physicians and other personnels. Materials are subdivided into drugs and others. Other expenses are subdivided into 5 items. Macro economic indices are selected for each cost item in order to reflect the cost inflation during the specific period. Then the composite index which integrate all items according to the ration of each item in the total costs is calculated. The result from the application of empirical data to the new model is very similar to that of the current method. Furthermore, this method is very simple and also to easy to get social concensus. This model can be replaced the current method based on the analysis of the financial performance for the adjustment of medical fees.

• The Korean Society of Law and Medicine
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• v.15 no.1
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• pp.335-373
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• 2014

According to one Medicare report, in the US, total federal spending on health care expends almost 18 percent of the nation's GDP, about double what most industrialized nations spend on health care. And in 2011, Medicare spending reached close to $554 billion, which amounted to 21 percent of the total spent on U.S. health care in that year. Of that $554 billion, Medicare spent 28 percent, or about $170 billion, on patients' last six months of life. So what are the reasons of this high cost in EOL care and its possible solutions? Much spendings of Medicare on End-of-Life care for the terminally ill/chronically ill in the US has led health economics experts to assess the characteristics of the care. Decades of study shows that EOL care is usually supply-sensitive and poor in cost-effectiveness. The volume of care is sensitively depending on the supply of resources, rather than the severity of illness or preferences of patients. This means at the End-of-Life care, the medical resources are being overused. On the other hand, opposed to the common assumption, "The more care the better utility", the study shows that the outcome is very poor. Actually the patient preference and concerns are quite the opposite from what intense EOL care would bring about. This study analyzes the reasons for the supply-sensitiveness of EOL care. It can be resulted from the common misconception about the intense care and the outcome, physicians' mission for patients, lack of End-of-Life Care Decision which helps the patients choose their own preferred treatment intensity. It also could be resulted from physicians' fear of legal liabilities, and the management strategy since the hospitals are also seeking for financial benefits. This study suggests the possible solutions for over-treatment at the End-of-Life resulting from supply-sensitiveness. Solutions can be sought in two aspects, legal implementation and management strategy. In order to implement advance directive properly, active ethics education for physicians to change their attitude toward EOL care and more conversations about end-of-life care between physicians and patients is crucial, and incentive system for the physicians who actively have the conversations with patients will also help. Also, the general education towards the public is also important in the long run, and easy and official advance directive registry system-such as online registry-has to be built and utilized more widely. Alternative strategies in management are also needed. For example, the new strategic cost management and management education, such as cutting unnecessary costs and resetting values as medical providers have to be considered. In order to effectively resolve the problem in EOL care for the terminally ill/chronically ill and provide better experience to the patients, first of all, the misconception and the wrong conventional wisdom among doctors, patients, and the government have to be overcome. And then there should be improvements in systems and cultures of the EOL care.

• Health Policy and Management
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• v.18 no.4
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• pp.148-169
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• 2008

As the Korean Government began to perceive healthcare as one of foundational industries for national dynamics, there has been mounting advocacy for the introduction of for-profit hospitals with a view to bringing efficiency in healthcare services industries and improvement of their international competitiveness. The Government is now considering the issue from all angles in favor of permitting for-profit hospitals. However, There have been few precedent studies on this subject to provide helpful data for the discussion and in the health policy making. This study used private hospitals - for-profit and nonprofit - in Florida, USA as study subjects to accumulate basic data that may be utilized for those involved in debates and health policy making relating to the introduction of for-profit hospitals in Korea. Among all the private general hospitals in Florida, those surveyed by AHA(American Hospital Association) for four consecutive years from 2001 and 2004 and others reported about to MCR(Medicare Cost Report) included in the collected data for analysis. In total 139 private general hospitals consisting of 73 for-profit hospitals and 66 nonprofit hospitals were included in the collected analysis data. Results of analysis revealed no significant difference between for-profit hospitals and nonprofit hospitals in the usage aspects of healthcare services including the average length of stay and the ratio of Medicare vs Medicaid patients. However, financial performances indicated by such factors. as the pre-tax return on assets and the pre-tax operating margin showed to be significantly higher in for-profit hospitals compared with nonprofit hospitals. And the ratio of personnel expenses and the turn period of total assets showed to be significantly lower in for-profit hospitals. Based on the hypothesis that arguments about the introduction of for-profit hospitals have considerably different viewpoints depending on the size of hospital represented by the number of bed, these two hospital types were compared again using the number of beds as a controlled factor, but the results were similar. We, therefore, could conclude that the for-profit hospitals in Florida included in this study could, in their for-profit operation, improve their financial performance by pursuing cost reduction and effectively utilizing their assets without limiting the amount and the range of their services or avoiding less medically protected groups such as Medicare and Medicaid patients.

• Health Policy and Management
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• v.27 no.2
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• pp.149-156
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• 2017

Background: This study was conducted to evaluate the performance of the Hierarchical Condition Category (HCC) model, identify potentially high-cost patients, and examine the effects of adding prior utilization to the risk model using Korean claims data. Methods: We incorporated 2 years of data from the National Health Insurance Services-National Sample Cohort. Five risk models were used to predict health expenditures: model 1 (age/sex groups), model 2 (the Center for Medicare and Medicaid Services-HCC with age/sex groups), model 3 (selected 54 HCCs with age/sex groups), model 4 (bed-days of care plus model 3), and model 5 (medication-days plus model 3). We evaluated model performance using $R^2$ at individual level, predictive positive value (PPV) of the top 5% of high-cost patients, and predictive ratio (PR) within subgroups. Results: The suitability of the model, including prior use, bed-days, and medication-days, was better than other models. $R^2$ values were 8%, 39%, 37%, 43%, and 57% with model 1, 2, 3, 4, and 5, respectively. After being removed the extreme values, the corresponding $R^2$ values were slightly improved in all models. PPVs were 16.4%, 25.2%, 25.1%, 33.8%, and 53.8%. Total expenditure was underpredicted for the highest expenditure group and overpredicted for the four other groups. PR had a tendency to decrease from younger group to older group in both female and male. Conclusion: The risk adjustment models are important in plan payment, reimbursement, profiling, and research. Combined prior use and diagnostic data are more powerful to predict health costs and to identify high-cost patients.

• Health Policy and Management
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• v.14 no.2
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• pp.1-16
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• 2004

The study purpose was to find which factors affect selection of hospital network types. This study used the 1998 American Hospital Association Annual Survey Database from Health Forum. Among these U.S. hospitals, the researcher selected hospitals located in Metropolitan Statistical Areas. Therefore the final observation cases for analysis are 1,971 Metropolitan Statistical Area hospitals in the United States. To identify significant variables influencing hospital network types, the study used proportional odds logistics regression model on population size, Health Maintenance Organization penetration rate, and market competition rate of area including a hospital, types of hospital ownership, hospital bed size, proportion of Medicare patients and Medicaid patients in total hospital patients, and occupancy rate. Contrary to conventional wisdom, selection of hospital network types was influenced by population size of area which a hospital located, types of ownership, hospital bed size, and proportion of medicare patients rather than Health Maintenance Organization penetration. Population size 1,000,000-2,499,999 had the highest probability of selecting type IV (clinical-vertical integration) from an independent hospital, and a religious group owned hospitals and for-profit owned hospitals had the highest probability of selecting Type IV (clinical-vertical integration) from an independent hospital. A bed size had positive relation on selecting Type IV (clinical-vertical integration) from an independent hospital. Unlikely general belief that the selecting types of hospital network was determined by the change of health insurance policy such as Health Maintenance Organizations and Preferred Provider Organizations, the types of hospital network were influenced by community characteristics such as population size, and hospital characteristics.

• Quality Improvement in Health Care
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• v.7 no.2
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• pp.204-216
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• 2000

Background : There has been a concern that the quality of care provided to end-stage renal disease (ESRD) patients in the United States may not be as good as recommended. This paper illustrates a composite measure to assess, the quality of care received by ESRD patients undergoing in-center hemodialysis by incorporating outcomes for 4 major treatment areas. The 4 treatment areas are: dialysis treatments, anemia control, nutritional management, and blood pressure control. Methods : The major data source for the study was the United States Renal Data System (USRDS) Dialysis Morbidity and Mortality Study Wave 1 (DMMS-1) d Sixteen categories of a composite quality indicator were constructed by combining 4 dichotomous variables (16=2*2*2*2). representing the optimal vs. less than optimal level of outcome for each of the 4 treatment outcome measure respectively. Optimal outcome level for each treatment area was defined based on the recommendation from the National Kidney Foundation: (a) delivered dialysis doses (Kt/V) ${\geq}$ 1.2; (b) hematocrit level ${\geq}$ 30%; (c) serum albumin concentration ${\geq}$ 3.8g/dl ; and (d) blood pressure of <140 / <90mmHg. The 16 quality indicator were ranked according to their relative quality weights, which were estimated from its association with the relative risk of survival, adjusting for patient's baseline severity and dialysis facility characteristics. Results : Out of the entire sample of 2,179 patients, only 229 (10%) meet th recommended outcome levels for all 4 treatment areas. Overall, the study patients were distributed evenly over the 16 quality indicators, indicating a great variation in the quality of ESRD care. It appears that the rank of the 16 quality-indicators is driven by serum albumin concentration, suggesting that serum albumin concentration may be the most powerful predictor of ESRD patient survival among the 4 outcome measures. Conclusion : The developed quality indicator has the advantage of describin a range of care for dialysis patients and thus providing a more complete picture of care as compared to previous studies that have focused on only single or few components of the ESRD care.

• The Korean Journal of Health Service Management
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• v.5 no.1
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• pp.147-158
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• 2011

This study compares the degree of satisfaction and the causes of selecting facilities for stroke patients in the senior specialized hospitals and other senior care facilities. The research results are followed. First, The patients who held the level of senior long-term care used senior specialized hospitals, while the patients who had the level of 2 or 3 degree used senior care facilities. The patients helped by cooperative care service used senior care facilities, and the patients helped by private service or family service used senior specialized hospitals. Second, The patients in senior specialized hospitals had affirmative attitude for their service system, while the patients in senior care facilities preferred their various service systems. In the satisfaction of the facilities, the patients in senior care facilities felt more satisfaction to staff, environment, service, and other factors than the patients in hospitals did. Third, in the result of logistic analysis, the patients had an affirmative attitude in case that they had spouse, experience of senior specialized hospitals or senior care facilities, without senior long-term care insurance. They also valued the service standard and the staff quality. As this study points out, the overall preference is higher in the senior care facilities. So, the stroke patients recognized the new role between the hospitals and the facilities after the establishment of long-term senior medicare system. This research had some limitation for the research areas and numbers. So the data analysis for the types of facility and the responses may not be generalized. However, the standard of choosing facility and satisfaction will be a guideline for establishing a new future role between hospitals and facilities. This result will be used as a basic data for the renovation of long-term senior medicare insurance.

• Korea Journal of Hospital Management
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• v.7 no.1
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• pp.105-120
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• 2002

In the United States, the prospective payment system(PPS), under which diagnosis related groups (DRGs) are used to reimburse hospitals for the care of Medicare patients since 1983, Study results showed that the PPS is having a major impact on the quantity of services especially of hospital length of stay. The PPS has increased the likelihood that a patient will be discharged home in an unstable condition and the use of nursing homes or long term care facilities increased. Still, it is insufficient to conclude that the PPS has decreased the Medicare total expenditure, but relatively sufficient to conclude that the quality of care hasn't changed. The maintenance of the quality resulted from the systemic "check-and-balance" composed of three factors; (1) The doctors are reimbursed based on the fee-for-service system, (2) hospitals contact with doctors under the attending system, and (3) there are some public hospitals. In Korea, the reimbursement for hospitals and doctors are not divided, the hospitals have doctors as employees, and 90% of hospitals are private. These differences may weaken the "check-and-balance" existing in the U.S. system. And there are few long term care facilities and the diagnostic coding system using in pilot test are not suitable for Korean situation. In conclusion, for successful implementation of the DRG payment system in Korea, the government should establish the "check-and-balance" system in the health sector to make sure the quality of care before the implementation.

• Journal of The Korea Institute of Healthcare Architecture
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• v.4 no.7
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• pp.67-74
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• 1998

Although Medical Care System pays medical fee for each patients with the establishment of National Medicare System, patients cannot be equally benefited from hospitals. At present, the Korean government provides minimum requirements on medical facilities in enforcement of medical law, but it is not enough to guarantee the rights of patients. The purpose of this study is in search for the way to improve the minimum requirements of ward which will be needed to examine the present situation of general hospitals, to find out their problems, and to compare the law of medical facilities in korea.

• Nuclear Medicine and Molecular Imaging
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• v.42 no.sup1
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• pp.166-171
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• 2008

PET of the cerebral metabolic rate of glucose is increasingly used to support the clinical diagnosis in the examination of patients with suspected major neurodegenerative disorders, such as Alzheimer's disease. $^{18}F-FDG$ PET has been reported to have high diagnostic performance, especially, very high sensitivity in the diagnosis and clinical assessment of therapeutic efficacy. According to clinical research data hitherto, $^{18}F-FDG$ PET is expected to be an effective diagnostic tool in early and differential diagnosis of Alzheimer's disease. Since 2004, Medicare covers $^{18}F-FDG$ PET scans for the differential diagnosis of fronto-temporal dementia (FTD) and Alzheimer's disease (AD) under specific requirements; or, its use in a CMS approved practical clinical trial focused on the utility of $^{18}F-FDG$ PET in the diagnosis or treatment of dementing neurodegenerative diseases.