• 약학회지
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• 제59권4호
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• pp.190-200
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• 2015

Evaluation Project on Appropriate Prescribing (EPAP) which is analysing prescribing pattern and providing physicians feedback has begun in 2001. EPAP indicators are related to antibiotics for acute respiratory tract infections, overuse of injection, polypharmacy (no. of drugs prescribed together, no. of prescriptions with 6 or more drugs), prescribing of specific medication group (drugs for acid related disorders, NSAIDs, corticosteroids) and medication expenditure per prescription day. The aim of this study was to suggest a development plan for EPAP indicators suitable for domestic situation. A consensus group consisting of seventeen health care professionals evaluated significance of each therapeutic class for EPAP indicators expansion considering information such as magnitude of issue, prescribing indicators of foreign countries, reimbursement criteria by each therapeutic class. Based on the data and group survey, 5 classes were selected as candidates for prescribing indicators and we presented 24 indicators regarding 5 classes. The results suggested that we need to augment evaluation indicators of additional area.

• 의료법학
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• 제8권1호
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• pp.137-177
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• 2007

The medical expenses review system in Korea has developed under fee-for-service system with its own unique structure. The importance of reviewing medical expenses has been emphasized, as the size of medical expenditures moving through the health insurance legal context and its weight in the national economy have increased very rapidly. It is, however, analyzed that the feuds and arguments continue among the stakeholders for the lack of laws supporting the medical expenses review system. The medical expenses review is a series of administrative procedures, deciding whether claims from medical care institutions to the insurer are legal and valid or not. It mainly controls the increase of unnecessarily excessive health insurance claim and prevents fraudulent claim and abuse and checks the less use or unsuitable use of medical resources. It also works a function guarantees medical benefits for the appropriate treatment according to the object of health insurance system as a social insurance scheme. The dispute on legal base of the medical expenses review is about the source of law in the medical expenses review. There are the Health Insurance Act and administrative laws as jus scriptum and the guidelines of review as administrative orders. The medical expenses review should reflect various factors, such as the development of medical healthcare technologies, the health expenditures distribution, the financial situation of the health insurance, and the evaluation on the level of appropriate benefits. It is also likely to adapt to the traits of characters of medicine, and trends and transition, Besides it should judge the legality and the validity of medical benefits expenditures by synthesizing these all factors. And the evaluation system of appropriateness of medical benefits was administrative procedure which was consecutive with reviewing the medical expenses system and it was intended to make up for the result of reviewing the medical expenses in more comprehensive levels.

• 사회복지연구
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• 제41권2호
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• pp.35-65
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• 2010

본 연구는 최근에 이루어진 '건강보험 보장성 확대' 정책의 효과를 개인의 의료이용 및 건강수준을 중심으로 평가하였다. 2005년부터 시행된 건강보험 보장성 확대 정책은 암 등의 중증질환자에 대한 본인부담 경감, 입원환자 식대의 급여전환, 비급여항목의 급여전환, 본인부담상한제 시행 등을 주요 내용으로 한다. 이러한 정책 변화에 대해 만성질환을 보유하고 있어 의료욕구가 일반적으로 높은 제도의 주요 수혜집단에 비해 급성질환 등으로 의료서비스를 이용한 집단의 입원이용이 상대적으로 증가한 것과 제도의 직접적인 수혜집단인 중증질환자 집단의 입원이용이 상당 정도 증가한 것을 확인하였다. 또한 이러한 건강보험제도의 변화가 입원이용에서 혜택을 누린 중증질환자의 단기간의 건강평가지표인 2주간 이환경험 면에서 긍정적인 개선을 이끌어내고 있음을 확인하였다. 본 연구는 건강보험제도가 의료이용 및 건강수준에 인과적인 효과를 나타내고 있음을 확인하였고, 이후 건강보험 보장성 확대의 정책설계에 대한 정책적 함의를 제공한다.

• 한국사회정책
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• 제25권3호
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• pp.103-130
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• 2018

본 연구에서는 노인 돌봄을 돌봄 논의와 지원정책에 통합해야 함을 전제로 노인장기요양보험제도를 돌봄정의의 관점에서 분석하였다. 돌봄 정의는 돌봄에 대한 책임과 권리를 모든 사회구성원이 동등하게 분담하는 이상을 의미하며, 돌봄 정의의 실현을 위해 탈상품화, 탈가족화, 탈젠더화, 노인의 참여와 권한의 네 가지 차원이 설정되었다. 노인장기요양보험제도를 네 가지 차원에서 분석한 결과 시장 위주의 상품화와 젠더화 된 돌봄 서비스를 통해 노인을 배제한 돌봄의 탈가족화를 추구함으로써 돌봄 정의가 실현되지 못하고 있는 것으로 나타났다. 노인장기요양보험제도에서 나타난 노인 돌봄의 상품화, 가족화, 젠더화, 노인 배제를 극복하기 위한 방안으로 돌봄 서비스 비용의 적정화와 공공화를 통한 돌봄 노동의 사회적 위상 제고, 생애주기적 차원에서 아동, 성인, 노인을 통합적으로 포괄하는 돌봄 방식의 재조직화, 노인과 돌봄 관계 당사자들이 돌봄의 조직화와 결정 과정에 참여하고 결정권과 선택권을 행사할 수 있는 제도적 변화를 제시하였다.

• 한국산학기술학회논문지
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• 제12권2호
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• pp.795-804
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• 2011

본 연구는 장기요양보험급여를 받고 있는 노인들의 인구사회학적 특성, 건강상태 및 건강관련행위 특성에 따른 삶의 질 수준을 파악해 보고, 이들의 삶의 질에 영향을 미치는 관련요인을 규명해 보고자 시도하였다. 조사대상은 장기요양보험급여를 받고 있는 충청남도 9개 군(郡)의 농촌지역 노인 410명으로 하였으며, 조사는 2009년 3월 1일부터 5월 31일까지의 기간 동안에 표준화된 무기명식 면접조사용 설문지를 사용하여 면접조사를 실시하였다. 연구결과 조상대상자의 삶의 질은 장기요양등급이 높을수록 유의하게 낮은 것으로 나타났다. 위계적 다중회귀분석을 실시한 결과, 연령, 거주상태, 주관적인 건강상태, 와병유무, 신체의 부자유 유무, 요실금유무, 건망증유무, 외출 빈도가 삶의 질에 유의하게 영향을 미치는 것으로 나타났으며, 특히 건강상태를 나타내는 변수들이 삶의 질과 높은 관련성이 있는 것으로 나타났다.

• Journal of Preventive Medicine and Public Health
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• 제56권6호
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• pp.563-572
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• 2023

Objectives: The high readmission rate of patients with chronic obstructive pulmonary disease (COPD) has led to the worldwide establishment of proactive measures for identifying and mitigating readmissions. This study aimed to identify factors associated with readmission, as well as groups particularly vulnerable to readmission that require transitional care services. Methods: To apply transitional care services that are compatible with Korea's circumstances, targeted groups that are particularly vulnerable to readmission should be identified. Therefore, using the National Health Insurance Service's Senior Cohort database, we analyzed data from 4874 patients who were first hospitalized with COPD from 2009 to 2019 to define and analyze readmissions within 30 days after discharge. Logistic regression analysis was performed to determine factors correlated with readmission within 30 days. Results: The likelihood of readmission was associated with older age (for individuals in their 80s vs. those in their 50s: odds ratio [OR], 1.59; 95% confidence interval [CI], 1.19 to 2.12), medical insurance type (for workplace subscribers vs. local subscribers: OR, 0.84; 95% CI, 0.72 to 0.99), type of hospital (those with 300 beds or more vs. fewer beds: OR, 0.77; 95% CI, 0.66 to 0.90), and healthcare organization location (provincial areas vs. the capital area: OR, 1.66; 95% CI, 1.14 to 2.41). Conclusions: Older patients, patients holding a local subscriber insurance qualification, individuals admitted to hospitals with fewer than 300 beds, and those admitted to provincial hospitals are suggested to be higher-priority for transitional care services.

• 한국의료질향상학회지
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• 제17권1호
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• pp.69-78
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• 2011

Objectives : The purpose of this study was to determine whether the published AMI report card could reduce in-patient mortality, 7-day after discharge mortality, and length of stay (LOS). Methods : Interrupted time-series intervention analysis was used to evaluate the impact of the report card for AMI care quality in November 2005 in terms of risk-adjusted in-patient mortality, risk-adjusted 7-day after discharge mortality, and DRGs case-mix LOS using the claim data of Health Insurance Review and Assessment Service. Results : Public disclosure of AMI care quality decreased risk-adjusted in-patient mortality and DRGs case-mix LOS by 0.00050% per month and 0.042 days per month respectively, however there was no effect on risk-adjusted 7-day after discharge mortality. Patterns of effect of public disclosure on AMI outcomes were a fluctuating pattern on risk-adjusted mortalities and a pulse impact for 1 month on DRGs case-mix LOS. Conclusions : We found the public disclosure of AMI care quality had decreasing effects on risk-adjusted in-patient mortality and DRGs case-mix LOS, but the size of the effect was marginal.

• 한국병원경영학회지
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• 제12권3호
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• pp.1-19
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• 2007

This study focused on finding the variation of medical service utilization and medical payments of the patients died by three, cancers, stomach, breast, and colon cancer. For this study, data of the one-year episodes of the health insurance subscribers died in 2004 were selected. The frequency of medical visits, the lengths of slays, the days of outpatient visits, the total period of medical services and the total medical payments were compared by the characteristics of the suppliers and utilizers. The data of the patients died by cerebrovascular diseases and cancer in 2004 were selected. To select the dead by cerebrovascular diseases and cancer in 2004, were matched the 2004 reimbursement data of all medical institutions to the data of funeral fee payment by the National Health Insurance Corporation from January 2004 to May 2005 for the death in 2004. The results of the analysis were as follow. The variation of medical service utilization of the dead by cancers were not small in Korea. The current study found that the variation of medical care utilization was influenced by the factors of suppliers, such as types and locations of medical institutions and the factors of users, such as sex and age. It was suspected that the reimbursement by fee-for-service contributed to the variation quite a lot, but we could not compare the variation between the different reimbursement systems in Korea. The results of the study suggested that tile factors of suppliers and utilizers should he reviewed to reduce the under use and over use expressed by variations of medical service utilization. The processes of care, effective communication and management system should be investigated for the equity of medical service utilization. Additionally, prospective payment could he recommended to reduce the high variation of medical service Use. To find the variation caused by under use and over use, further study need to control the severity of diseases, socio-economic status of the users and the system factors.

• 보건의료산업학회지
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• 제10권4호
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• pp.1-11
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• 2016

Objectives : The aim of this study is to investigate the actual condition of the occurrence and recovery of medical expenses through seafarers insurance and to provide basic data that will be helpful in the establishment of efficient hospital management strategies for medical expenses of insurance companies depending on the type of seafarers insurance. Methods : Three general hospitals located in Busan, Korea, were selected, and seafarers insurance claim data was collected from January 1, 2012 to December 31, 2013(24 months) and analyzed. There were 5,490 cases in total. Results : There was a significant difference in the distribution of disease incidence, accrued medical expenses, reimbursement of medical expenses, and the actual condition of medical receivables depending on the insurance company. Conclusions : Therefore, differentiated payback strategies for medical expenses are needed that consider the various seafarers insurance companies and their treatment characteristics.

• 보건행정학회지
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• 제20권1호
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• pp.19-36
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• 2010

Fee for long-term care insurance in Korea are determined in proportion to resources utilized according to severity rather than based on categorization of beneficiaries in consideration of the characteristics of resource utilization. This adoption is based on the assumption that as beneficiaries of long-term care insurance, characteristically, demands social services rather than needs medical treatments, the characteristics of beneficiaries and the quality of utilized resources are comparatively homogenous. Therefore, the proposition is that the size of resource consumed by beneficiaries in the same grade is identical. However, even in the same grade, the level of utilized resources is different depending on the characteristic of beneficiaries. In this regard, this study is to examine whether there are differences in the volumes of utilized resources depending on the characteristics of beneficiaries even in the same grade. We analyzed time study data for 2003, 2005, 2006 which conducted by the Korea Institute for Health and Social Affairs. To look at differences in the volumes of utilized resources, we identified characteristics of beneficiaries that influence utilized resource volumes and categorized services provided by facilities into the rehabilitation treatment category, the problematic behavior category, and the physical malfunction category. Then, we examined each service in consideration of service difficulty levels and wage weights. The result of examination showed that differences in utilized resource volumes exist in all three grades depending on the characteristics of beneficiaries. Especially, in the first grade with a high level of seriousness, utilized resource volumes were different for those three service categories and the problematic behaviour category considered dementia was found to consume the largest volume of resources. Moreover, there was the inversion phenomenon of utilized resources volumes between the grades. This result indicates that utilized resource volumes are different even in the same grade depending on the characteristics of beneficiaries and it is required to consider case-mix for reflection of the volumes of utilized resources depending on the characteristics of beneficiaries.