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http://dx.doi.org/10.4332/KJHPA.2020.30.1.72

An Aanalysis of Predictive Factors of Medical Service Overuse for Inpatients Applied Out-of-Pocket Maximum in Long-Term Care Hospitals in South Korea  

Lim, Seungji (Health Insurance Policy Research Institute, National Health Insurance Service)
Shin, Hannah (Health Insurance Policy Research Institute, National Health Insurance Service)
Publication Information
Health Policy and Management / v.30, no.1, 2020 , pp. 72-81 More about this Journal
Abstract
Background: The out-of-pocket maximum is one of the distinctive healthcare systems which sets a ceiling on co-payment in order to reduce the burden of households from the unpredictable medical expenditure. However, this leads to an increase in the demand for healthcare services especially in long-term care hospitals (LTCHs) in Korea. Methods: This study analyzed the influence factor of medical service overuse of 165,592 inpatients in LTCHs which out-of-pocket maximum is applied, by utilizing data from the National Health Insurance Service (2016). Based on Anderson Model, the medical service overuse, as a dependent variable, was defined as long-stay admission more than 180 days at the LTCHs. Independent variable was comprised of predisposing factors (gender, age), enabling factors (income level, types of out-of-pocket maximum) and need factors (illness level, patient use of tertiary hospital). Results: The most powerful factor of medical service overuse in LTCHs was availability of pre-payment for the out-of-maximum (odds ratio [OR], 191.66; p<0.001). This tendency was found in high income level status (p<0.001). Furthermore, mild inpatients (OR, 1.50; p<0.001) which had no experience with the tertiary hospitals (OR, 2.06; p<0.001) were more relevant to the medical service overuse in LTCHs, compared to the severe inpatients. Conclusion: It is suggested that a separate standard of out-of pocket maximum with regards to LTCHs is required to secure the beneficial functions of long-term hospitals and prevent unnecessary financial leakage to achieve sustainable and financially sound National Health Insurance.
Keywords
Out-of-pocket maximum; Long-term care hospitals; Medical service overuse; Long-stay admissions; Mild inpatients;
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