보건행정학회지 (Health Policy and Management)

  • 제20권4호
  • /
  • Pages.45-57
  • /
  • 2010
  • /
  • 1225-4266(pISSN)
  • /
  • 2289-0149(eISSN)
한국보건행정학회 (Korean Academy of Health Policy and Management)
권호 표지
DOI QR코드

DOI QR Code

약제비 제외가 의원의 진료비 효율성 순위에 영향을 미치는가?

Does Omission of Pharmacy Cost Affect Cost-Efficiency Rankings in Medical Clinics?

  • 강희정 (건강보험심사평가원 심사평가정책연구소) ;
  • 홍재석 (건강보험심사평가원 심사평가정책연구소)
  • Kang, Hee-Chung (Health Insurance Review & Assessment Service, Health Insurance Review & Assessment Policy Institute) ;
  • Hong, Jae-Seok (Health Insurance Review & Assessment Service, Health Insurance Review & Assessment Policy Institute)
  • 투고 : 2010.05.19
  • 심사 : 2010.09.30
  • 발행 : 2010.12.31
PDF 다운로드
⟨ 이전 논문 다음 논문 ⟩

초록

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.

키워드

참고문헌

  1. Cave DG. Profiling Physician Practice Patterns Using Diagnostic Episode Clusters. Medical Care 1995;33(5):463-486. https://doi.org/10.1097/00005650-199505000-00003
  2. Green J, Wintfeld N. Report cards on cardiac surgeons: assessing New York State's approach. N Engl J Med. 1995;332:1229-1232. https://doi.org/10.1056/NEJM199505043321812
  3. Gwet K. Statistical Tables for Inter-Rater Agreement. Gaithersburg : StatAxis Publishing, 2001. http://www.stataxis.com/6statistical_tables .pdf (Accessed at May 10, 2009).
  4. Hofer TP, Hayward RA, Greenfield S, Wagner EH, Kaplan SH, Manning WG. The Unreliability of individual physician "Report Cards" for assessing the costs and quality of care of a chronic disease. JAMA 1999;281(22):2098-2105. https://doi.org/10.1001/jama.281.22.2098
  5. Kang H, Hong J, Lee K, Kim S. The effects of the fraud and abuse enforcement program under the National Health Insurance program in Korea. Health Policy 2010;95:41-49. https://doi.org/10.1016/j.healthpol.2009.10.003
  6. Kassirer JP. The use and abuse of practice profiles. N Engl J Med. 1994;330:634-636. https://doi.org/10.1056/NEJM199403033300910
  7. Kerr EA, Mittman BS, Hays RD, Siu AL, Leake B, Brook RH. Managed care and capitation in California: how do physicians at financial risk control their own utilization? Ann Intern Med. 1995 Oct 1;123(7): 500-4. https://doi.org/10.7326/0003-4819-123-7-199510010-00004
  8. Landis JR, Koch GG. The measurement of observer agreement for categorical data Biometrics 1977;33:159--174. https://doi.org/10.2307/2529310
  9. Medicare Payment Advisory Commission : Report to the Congress : Medicare Payment Policy. Washington, DC. 2005.
  10. Medicare Resource Use Measurement Plan. CMS http://www.cms.hhs.gov/ QualityInitiativesGenInfo/downloads/ResourceUse_Roadmap_OEA_1-15_ 508.pdf (accessed at May 10, 2009).
  11. National Health Insurance Corporation and Health Insurance Review & Assessment Service : National Health Insurance Statistical Yearbook. Seoul. 2007. Available at: http://www.hira.or.kr/common/dummy.jsp? pgmid=HIRAF010304010000 (accessed on Nov. 4, 2009).
  12. Newhous JP. Patients at risk : Health Reform and risk adjustment. Health Affairs 1994;1:132-146.
  13. Pope GC, Kautter J. Profiling efficiency and quality of physician organizations in Medicare. Health Care Financing Review 2007; 29(1):31-43.
  14. Sandy LG. The Future of Physician Profiling. Journal of Ambulatory Care Management 1999;22(3):116.
  15. Thomas JW, Grazier KL, Ward K. Comparing accuracy of risk-adjustment methodologies used in economic profiling of physicians. Inquiry 2004; 41(2):218-231. https://doi.org/10.5034/inquiryjrnl_41.2.218
  16. Thomas JW. Economic profiling of physicians: does omission of pharmacy claims bias performance measurements? Am J Manag Care. 2006; 12:341-351.
  17. Tucker AM, Weiner JP, Honigfeld S, Parton R. Profiling Primary Care Physician Resource Use : Examining the Application of Case Mix Adjustment. Journal of Ambulatory Care Management 1996;1991): 60-80.
  18. 건강보험심사평가원. KOPG분류집 version 1.1. 서울 ; 건강보험심사평가원:2008.
  19. 박하영, 강길원, 고영. 한국형 외래환자분류체계의 개발과 평가. 보건행정학회지 2006;16(1):17-40. https://doi.org/10.4332/KJHPA.2006.16.1.017