Health Policy and Management (보건행정학회지)

Korean Academy of Health Policy and Management (한국보건행정학회)
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Refinement and Evaluation of Korean Outpatient Groups for Visits with Multiple Procedures and Chemotherapy, and Medical Visit Indicators

한국형 외래환자분류체계의 개선과 평가: 복수시술 및 항암제 진료와 내과적 방문지표를 중심으로

  • Park, Hayoung (Technology Management, Economics, and Policy Graduate Program, Seoul National University) ;
  • Kang, Gil-Won (Department of Health Informatics & Management, Chungbuk National University College of Medicine) ;
  • Yoon, Sungroh (Department of Electrical and Computer Engineering, Seoul National University College of Engineering) ;
  • Park, Eun-Ju (Classification System Development Division, Health Insurance Review and Assessment Service) ;
  • Choi, Sungwoon (Department of Electrical and Computer Engineering, Seoul National University College of Engineering) ;
  • Yu, Seunghak (Department of Electrical and Computer Engineering, Seoul National University College of Engineering) ;
  • Yang, Eun-Ju (Classification System Development Division, Health Insurance Review and Assessment Service)
  • 박하영 (서울대학교 협동과정 기술경영경제정책 전공) ;
  • 강길원 (충북대학교 의과대학 의료정보학및관리학교실) ;
  • 윤성로 (서울대학교 공과대학 전기정보공학부) ;
  • 박은주 (건강보험심사평가원 분류개발부) ;
  • 최성운 (서울대학교 공과대학 전기정보공학부) ;
  • 유승학 (서울대학교 공과대학 전기정보공학부) ;
  • 양은주 (건강보험심사평가원 분류개발부)
  • Received : 2015.06.26
  • Accepted : 2015.09.14
  • Published : 2015.09.30
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Abstract

Background: Issues concerning with the classification accuracy of Korean Outpatient Groups (KOPGs) have been raised by providers and researchers. The KOPG is an outpatient classification system used to measure casemix of outpatient visits and to adjust provider risk in charges by the Health Insurance Review & Assessment Service in managing insurance payments. The objective of this study were to refine KOPGs to improve the classification accuracy and to evaluate the refinement. Methods: We refined the rules used to classify visits with multiple procedures, newly defined chemotherapy drug groups, and modified the medical visit indicators through reviews of other classification systems, data analyses, and consultations with experts. We assessed the improvement by measuring % of variation in case charges reduced by KOPGs and the refined system, Enhanced KOPGs (EKOPGs). We used claims data submitted by providers to the HIRA during the year 2012 in both refinement and evaluation. Results: EKOPGs explicitly allowed additional payments for multiple procedures with exceptions of packaging of routine ancillary services and consolidation of related significant procedures, and discounts ranging from 30% to 70% were defined in additional payments. Thirteen chemotherapy drug KOPGs were added and medical visit indicators were streamlined to include codes for consultation fees for outpatient visits. The % of variance reduction achieved by EKOPGs was 48% for all patients whereas the figure was 40% for KOPGs, and the improvement was larger in data from tertiary and general hospitals than in data from clinics. Conclusion: A significant improvement in the performance of the KOPG was achieved by refining payments for visits with multiple procedures, defining groups for visits with chemotherapy, and revising medical visit indicators.

Keywords

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