• Journal of Korean Academy of Nursing Administration
• /
• v.9 no.2
• /
• pp.243-250
• /
• 2003

Purpose : The purpose of this study was to suggest the number about the projected workforce of Certified Insurance Reviewer Nurses(CIRN) in Korea. Method : The following methods were used for this study: 1) national and international internet data were collected. 2) demand model was used for the prediction of the projected workforce of CIRN. 3) experts in insurance reviewing were contacted to get an opinion and information about the criteria of distribution and scope of CIRNs, 4) we figured out the maximum and minimum number of CIRN Korea needed as followed method, the maximum number was estimated that one CIRN would review 150 cases of Detailed Accounts for Examination and Treatment and the minimum was estimated 200 cases of it. 5) time series regression equation analysis was used for the prediction of number of CIRNs for the year 2003 to 2010. Result: 1) The prediction of CIRNs is as follows, there will be 2,313$\sim$2,827 of CIRN demanded in 2002, 2,500$\sim$3,069 in 2005 and 2,806$\sim$3,466 in 2010. 2) It is really desirable that CIRNs not only work for reviewing the detailed accounts for examination and treatment in hospital but also for inspecting allowance in individual insurance company. Conclusion : It is very desirable that the CIRN advocate the clients' rights because they will work for them satisfactory rather than other hospital experts group. But before settling the system of the CIRN in Korea, there would be its own professional role identity and a code of conduct.

• Journal of Korean Academy of Nursing Administration
• /
• v.15 no.2
• /
• pp.264-274
• /
• 2009

Purpose: This study is to develop job standards in order to propose proper job level of the advanced nurse practitioners and apply the results to the work and enhance the expertism. Method: This study is a methodical study. The validity was examined by using the content validity index(CVI). Result: The pre-items of job standards for advanced health insurance review nurses were established and the final job standards comprising of 12 standards, 46 criteria, 92 indicators, 418 activities were determined after the examination by the advisory group. The validity of the job standards were examined for two times by the seven professionals. The relevance of the modified job standards was examined by the working level employees above the assistant manager position working in the general hospitals and the result was 93.14% relevance. The job standards comprising of 12 standards, 46 criteria, 89 indicator and 409 activities were developed. Conclusions: By the development of the job standards, it is expected to prove that advanced health insurance review nurses are the most suitable professionals for dealing with medical affairs such as management and propriety evaluation of medical expenses while defining the roles of advanced health insurance review nurses.

• 한국노년학
• /
• v.31 no.2
• /
• pp.371-380
• /
• 2011

This study was to address changes on hospital-based home care utilization after long-term care insurance(LTCI) was launched. National electronic data information(EDI) on hospital-based home care from Health Insurance Review Agency in 2007.7~2008.6(prior to LTCI) and in 2009(posterior to LTCI) was analyzed. After the launch of long-term care insurance, 40 hospital-based home health care agencies(HHCA) were diminished and regions not having any HHCA were increased from 53% to 59%. Hospital-based home care utilization was decreased in the elderly(clients 13.4%, visits 20.9%) as well as non-elderly(clients 3.5%, visits 3.9%). It is presumed that diminished HHCAs result in decreased accessibility to hospital-based home health care for non-elderly. The clients, visits, and reimbursed cost per agency were not changed. It is presumed that small agencies were closed already. The total reimbursed cost per agency in 2009 was 121,850,000 won. Results suggest that the government has to give support to open more HHCA to increase the accessibility for non-elderly. Also, hospital-based home care services utilization has to be monitoring regularly.

• 한국노년학
• /
• v.30 no.1
• /
• pp.81-91
• /
• 2010

The purpose of this study was to test a validity and reliability of Cognitive Performance Scale(CPS), a cognitive measure generated from 5 items(comatose status, decision making, short-term memory, making self understood, and eating). Method: 393 patients in 2 hospitals for the elderly with dementia were measured with CPS by two nurses independently. The inter-rater agreement was tested by comparing two scores. The CPS score was compared with GDS, which was measured by doctors and nurses, and MMSE score which was drawn from the claim data of Health Insurance Review & Assessment Service. Result: The correlation coefficient between CPS and GDS was 0.742(p<0.0001), CPS and MMSE was -0.794(p<0.0001). The Cronbach's coefficient alpha of CPS was 0.742, Kappa value was 0.772~1.000. The CPS showed high validity and reliability in long term care hospitals of Korea.

• Health Policy and Management
• /
• v.34 no.1
• /
• pp.78-86
• /
• 2024

Background: The purpose of this study was to determine the effectiveness of the specialty hospital system by comparing the medical use of inpatients who had artificial joint replacement surgery in specialty hospitals and non-specialty hospitals. Methods: This study utilized 2021-2022 healthcare benefit claims data provided by the Health Insurance Review and Assessment Service. The dependent variable is inpatient medical use which is measured in terms of charges per case and length of stay. The independent variable was whether the hospital was designated as a specialty hospital, and the control variables were patient-level variables (age, gender, insurer type, surgery type, and Charlson comorbidity index) and medical institution-level variables (establishment type, classification, location, number of orthopedic surgeons, and number of nurses). Results: The results of the multiple regression analysis between charges per case and whether a hospital is designated as a specialty hospital showed a statistically significant negative relationship between charges per case and whether a hospital is designated as a specialty hospital. This suggests a significant low in charges per case when a hospital is designated as a specialty hospital compared to a non-specialty hospital, indicating that there is a difference in medical use outcomes between specialty hospitals and non-specialty hospitals inpatients. Conclusion: The practical implications of this study are as follows. First, the criteria for designating specialty hospitals should be alleviated. In our study, the results show that specialty hospitals have significantly lower per-case costs than non-specialty hospitals. Despite the cost-effectiveness of specialty hospitals, the high barriers to be designated for specialty hospitals have gathered the specialty hospitals in metropolitan and major cities. To address the regional imbalance of specialty hospitals, it is believed that ease the criteria for designating specialty hospitals in non-metropolitan areas, such as introducing "semi-specialty hospitals (tentative name)," will lead to a reduction in health disparities between regions and reduce medical costs. Second, it is necessary to determine the appropriateness of the size of hospitals' medical staff. The study found that the number of orthopedic surgeons and nurses varied in charges per case. Therefore, it is believed that appropriately allocating hospital medical staff can maximize the cost-effectiveness of medical services and ultimately reduce medical costs.