• Health Policy and Management
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• v.15 no.3
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• pp.40-59
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• 2005

The objective of this paper is to examine what impact the newly introduced Purchasing Price Reimbursement System, where insurance drugs are reimbursed at the prices as they were purchased by medical care providers under the maximum allowable cap, has upon the health insurer's financing situation. The impact of the Purchasing Price Reimbursement System is considered to be confined mainly to the inpatient department among three drug reimbursement fields such as inpatient department, out-patient department and pharmacy. Hypothesis was set and tested in this study for each of three components of inpatient drug reimbursement in health insurance, i.e. average price level, composition of drugs and their overall volume. Drug price level calculated in this study from 403 selected reimbursement drugs according to the Laspayres methodology revealed faster decline under the new Purchasing Price Reimbursement System than previously by $1.53\%$ on the annual average basis. However, additional 1.4 percent financial burden in the ratio of the total inpatient reimbursement was owed by the health insurer. This was analysed to be a combined result of both 2.0-3.1 percent of reduced reimbursement due to drug price decline and 3.4-4.5 percent of additional reimbursement due to drug volume increase. These results suggest that recalling the Purchasing Price Reimbursement System would not have so much impact upon the health insurer's financial situation given that the current compulsory separation between doctor's prescribing and pharmacist's dispensing is irrevocable.

• Korea Journal of Hospital Management
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• v.7 no.3
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• pp.121-136
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• 2002

The main purpose of this study is to examine the overall procedure of hospital's internal review of health insurance reimbursement, to present the case of protest against reimbursement cut, and hence to provide some information on hospital's management of medical revenue. The object of the case study is 'P' university medical center, possessing 5 different hospitals under its system. Presentation of the case of protest against reimbursement cut has following meanings: Firstly, to the hospitals that already have internal review departments, information on the details of the protest process and results can be exchanged. Secondly, to the Government and National Health Insurance Corporation, useful data are provided for the improvement of the rules and procedures of health insurance reimbursement. Thirdly, to the hospitals without internal review departments, fundamental materials on the internal review process are provided for the effective management of medical revenue.

• Health Policy and Management
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• v.10 no.4
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• pp.20-56
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• 2000

The purpose of this article was to evaluate the effects of reimbursement system on the basis of diagnosis-related groups(DRGs). We searched articles which was published from 1970 to 2000 using MEDLINE ； Key words "diagnosis-related groups, DRGs, prospective payment system, PPS. Then we reviewed 97 articles on classifying them into several categories of contents. It seems that the effects of DRGs in controlling hospitals cost in the U.S. was not clear cut. The U.S. Medicare PPS using DRGs remains vulnerable to compensatory increases in ambulatory care and long-term care facilities utilization despite cost per case and cost per admission being reduced. Also some research indicated the possibilities of deterioration in health care service quality. So putting theses results together, much more consideration is needed before the application of DRGs reimbursement system in Korea. Particularly there is the crucial difference between U.S. health care system and Korean, we must be aware of the limitations of DRGs and revise the DRG system to applicable in Korea.orea.

• Korea Journal of Hospital Management
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• v.8 no.1
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• pp.1-23
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• 2003

General drug prices involve three stages: shipment stage, wholesaler stage and retail stage. Policies on drug price differ from country to country. Shipment stage prices are tightly regulated in countries like France and Netherlands. They are free in only a minority of advanced countries, even if these include some major players such as the US, Germany and, in a very limited sense, Japan. The situation in the UK is very complex with a semi-free system, where drug companies are free to set their own prices but cannot exceed a predetermined profit ceiling. Mark-up at both wholesaler and retail stages is formally admitted in most countries observed. Apart from the general drug prices, reimbursement price of insured drugs has been major policy concerns. Most countries reviewed in this study has exerted some control over reimbursement prices, but differ both in the way how and in the extent to which prices are admitted or fixed. Price fixing has been used in France and Japan. Some countries have transformed their system over time, particularly to move to reference pricing in the last decade. This mechanism has empowered the customer, and improved price competition on the market. Referring to the drug price policies in the advanced countries, this study makes some suggestions for the redirection of Korean price policy for reimbursement drug in health insurance as follows: to match appropriate policy tools to each policy goal; to maximize market mechanism through effective reimbursement price fixing which admits mark-ups in wholesaler and retail prices; to introduce reference pricing system in order to redirect patient's demand with a financial incentive to choose the best-priced drugs and to save the finance of health insurance; and to strengthen surveillance and monitoring mechanism in the drug market.

• Journal of Korean society of Dental Hygiene
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• v.18 no.2
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• pp.177-189
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• 2018

Objectives: To provide necessary information for stable establishment of the national dental scaling reimbursement system. Methods: This study was conducted in 380 adults in their twenties or older for about one month from July 2017. The questionnaires were composed of general characteristics, recognition (awareness) of dental scaling, knowledge of the dental scaling reimbursement program, changes in perception before versus after introduction of the dental scaling reimbursement program, and interest in oral health. To investigate into any factors affecting changes of interest in oral health care after introduction of the dental scaling reimbursement program, a multiple regression analysis was performed. Results: The investigation into any factors affecting changes of interest in oral health care after introduction of the dental scaling reimbursement program showed that higher usual interest in oral health (p<0.001) and the consideration that the dental scaling charges have been affordable after introduction of the scaling reimbursement program (p<0.01) led to more changes in interest in oral health care. Conclusions: The above-mentioned results suggest that the dental scaling reimbursement program has brought favorable changes in the perception of dental scaling. It is expected that the said program will contribute significantly to the improved national oral health, and the Government should make constant efforts to develop it as a long-term policy for oral health improvement.

• The Journal of the Korean dental association
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• v.48 no.1
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• pp.6-11
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• 2010

Amid the rapid transitions in both local and international markets, the Korean dental industry is facing more challenges than at any time in its history. This paper tried to address some of the key issues faced by the industry as well as the policy issues and I direction of implementation that the Korean Dental Association (KDA) is expected to tackle. First, the direction of reforming the country's health insurance system was examined with emphasis on the expected changes in and improvement of the fee-for-service reimbursement system (FFSRS) and medical reimbursement system (MRS). With FFSRS, the most urgent issue would be ameliorating the current lop-sided, unreasonable reimbursement system that prevents suppliers from voicing their opinions. To help achieve that goal, the limited authority and responsibility of the president of National Health Insurance Corporation (NHIC) as one of the contract-making parties must be clarified. In addition, the functions of NHIC's Health Insurance Finance Committee must be restricted; at the same time, the panel organization of the Health Insurance Policy Review Committee needs to be reformed to embrace greater democracy. As with MRS, the government is considering a block budget bill to help promote efficiency in employing and managing the health insurance fund. Policymakers must understand that the implementation of such proposal could exacerbate an already dire situation. Improving MRS requires meeting the following preconditions: (a) the structurally vicious cycle of small charge-small salary needs to be resolved, and a certain percentage of fee raise must be guaranteed on a yearly basis to help adjust the fee system to a more realistic level; (b) the supply-and-demand balance in producing health care professionals must be improved including the prevention of oversupply of doctors, nurses, etc., and; (c) institutional strategies must be provided to enhance the quality of medical care and ensure academic advancement in health care disciplines.

• Korean Journal of Adult Nursing
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• v.24 no.4
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• pp.358-369
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• 2012

Purpose: This study was performed to compare the costs of nursing interventions implemented for the obstetrical and gynecological patients using Korean Reimbursement System and ABC codes system developed in the US for costing out interventions performed by health care professional. Methods: First, the narrative data on nursing interventions were extracted from electronic medical record system of a tertiary university and mapped with Nursing Intervention Classification (NIC) by two researchers until 100% consent was reached. Narrative nursing interventions mapped with NIC were then remapped with ABC codes system using the electronic program developed in the research. The mapping data were analyzed with real numbers, frequency, percentage, mean, and standard deviation. Results: More nursing interventions were mapped with ABC codes than Korean reimbursement system. Total of 97 different types of narrative interventions could be mapped with NIC, 43 NIC interventions could be reimbursed by ABC code but only 16 NIC interventions were reimbursed by Korea Reimbursement System. Conclusion: Korean medical insurance fee system needs amendment to include more comprehensively interventions performed by nurses which are very important to patient outcomes. Further study is needed to develop strategies to costing out nursing interventions.

• The Journal of the Korean dental association
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• v.48 no.6
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• pp.459-468
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• 2010

International Classification of Disease (ICD-10) is widely used as a crucial reference not only in the medical diagnosis of diseases but also within the health insurance system. It makes possible for medical personnel to make decisions systematically and for the people working in the health insurance or public health industries to better understand medical issues. However, this classification is often not enough or acceptable in a clinical setting. Many countries amend in their own way to make it more appropriate for their people. Korean Classification of Disease (KCD-5) was made by adding a 5 digit code for some diseases to clarify the conditions of the patients. The authors found problems of KCD-5 in temporomandibular disorders and several related medical problems. Medical treatment for these problems had not been covered even by public health insurance until 2000 in Korea. For the last decade, private insurance companies have introduced new items for reimbursement of the treatment fees the patients actually pay. The authors assumed that many patients with these medical problems encountered difficulties in the reimbursement from private insurance companies because KCD-5 did not classify these medical conditions appropriately. An overview of KCD-5 and suggestions for improvement are introduced in this study.

• Korea Journal of Hospital Management
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• v.5 no.2
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• pp.78-99
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• 2000

Objectives: The purpose of this study was to evaluate the opinions of hospital managers on DRG pilot study. Methods: Managers of 800 hospitals which had participated in DRG pilot study during the period 1997-1999, were requested to respond to structured self-administerd questionnaire. The questionnaire was composed with six categories: the motivation and satisfaction for the DRG pilot study, the opinions on the level of unit price, the appropriateness of DRG classification, the change of medical service quality during the pilot study, the patient's complains resulted from DRG system. and the opinions on the nation-wide application of DRG system. Results : Of the 800 subjects, 327(clinic, 210: 25 hospitals, 82 general hospitals, and 16 tertiary hospitals) completed the questionnaire, and the overall response rate was 41%, 121 hospitals(27%) answered that they participated in DRG pilot study because of convenience of claims and 118 hospitals(35%) dissatisfied with DRG system. 251 hospitals(85%) thought that the level of unit price under the DRG system was same as or lower than that of fee-for service. 297 hospitals(92%) responded that DRG classification should be modified and 137 hospitals(47%) experienced deterioration of medical service quality during the DRG pilot study. The 116 hospitals(35%) experienced the patient's complains resulted from DRG system. The 85 hospitals(88%) didn't want nation-wide application of DRG system. Conclusion: Most of the responded managers seemed to have negative opinions on DRG pilot study, even though they had been participated voluntarily. Further studies and extensive evaluations of DRG reimbursement system are needed before nation-wide application.

• Journal of Korean Academy of Nursing Administration
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• v.14 no.3
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• pp.229-240
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• 2008

Purpose: To develop the patient classification system based on the resource utilization for reimbursement of long-term care hospitals in Korea. Method: Health Insurance Review & Assessment Service (HIRA) conducted a survey in July 2006 that included 2,899 patients from 35 long-term care hospitals. To calculate resource utilization, we measured care time of direct care staff (physicians, nursing personnel, physical and occupational therapists, social workers). The survey of patient characteristics included ADL, cognitive and behavioral status, diseases and treatments. Major category criteria was developed by modified delphi method from 9 experts. Each category was divided into 2-3 groups by ADL using tree regression. Relative resource use was expressed as a case mix index (CMI) calculated as a proportion of mean resource use. Result: This patient classification system composed of 6 major categories (ultra high medical care, high medical care, medium medical care, behavioral problem, impaired cognition and reduced physical function) and 11 subgroups by ADL score. The differences of CMI between groups were statistically significant (p<.0001). Homogeneity of groups was examined by total coefficient of variation (CV) of CMI. The range of CV was 29.68-40.77%. Conclusions: This patient classification system is feasible for reimbursement of long-term care hospitals.