• Title/Summary/Keyword: Claims analysis

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Diagnosis-Specific Analysis of Small Area Variations in Hospital Services (일부 다빈도 진단명들의 지역간 의료이용 변이)

  • 이선희;조우현;남정모;김석일
    • Health Policy and Management
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    • v.4 no.1
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    • pp.49-76
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    • 1994
  • Small area variations in health care utilization have long been studied as an important issue related to boto cost containment and quality assurance. This study was conducted to investigate if variations in hospital services across small geographic areas in Korea existed. The claims data of the fiscal year 1992 obtained from the regional health insurance societies were used for the study. Main findings of the research can be summarized as follows : 1. Extremal Quotients(EQ) of hospital expenditure per capita and hospital days per capita varied among diagnosis types. The EQ ranged from 2.05(cataract) to 41.67(pneumonia) in hospital expenditure per capita and from 1.86(cataract) to 45.89(pneumonia) in hospital days per capita. The diagnosis groups which showed high variation were pneumonia, cephalo-pelvic disproportion, gastritis and duodenitis, fracture of rib, and acute bronchitis. Those which showed low variation were acute appendicitis and cataract. 2. The EQ level of admission rate was different in terms of diagnosis types, ranging from 2.57(catarct) to 44.45(pneumonia). The variations were high in medical disorders such as pneumonia, oephalo-pelvic disproportion, gastritis and duodenitis and acute bronchitis, while relatively low in surgical conditions such as acute appendicitis and cataract. 3. As an indicator of service intensity, the EQ of expenditure per admission ranged from 1.67(acute appendicitis) to 31.27(essential hypertension). The diagnoses which had high variation were essential hypertension, gastric ulcer, whereas those which had low variation were cephalopelvic disproportion and acute appendicitis. With regard to hospital days per admission, the EQ ranged from 1.55(acute appendicitis) to 28.13(gastric ulcer) by diagnosis types. The diagnosis groups with showed high variation were gastric ulcer, essential hypertension, and acute bronchitis, whereas those with low variation were cephalo-pelvic disproportion, intervertebral disc disorders, and acute appendicitis. Both the expenditure and hospital days per admission showed lewwer variations than the expenditure per capita, hospital days per capita and admission rate. 4. Comparing patterns of variation in utilization indices, diagnoses such as essential hypertension, gastric ulcer, fracture of rib showed higher variations in expenditure per admission than in admission rates, whereas diagnoses such as pneumonia, cephalo-pelvic disproportion and gastric ulcer showed higher variations in admission rate than expenditure per admission. These findings suggest that wide variations existed in several diagnoses groups across small areas in Korea. Further research should be performed to investigate factors related to small area variations including provider behavior.

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Association Between Lifestyle and Medical Expenses of Older Adults With Mental Illness: Using Korea Older Adults' Cohort Database (노인 코호트 DB를 이용한 정신과 질환 동반 노인의 생활 습관과 의료비 지출 크기의 연관성 분석 연구)

  • Jeong, Jiin;Bae, Suyeong;Yoo, Eun-Young;Hong, Ickpyo
    • Therapeutic Science for Rehabilitation
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    • v.12 no.1
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    • pp.51-63
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    • 2023
  • Objective : This study aimed to analyze the association between lifestyle and medical expenses of older adults with mental illness using claims data. Methods : We conducted secondary data analysis using the older adult cohort database provided by the Korea National Health Insurance Service. The lifestyle and medical expense variables were extracted from the cohort database. We used a generalized linear model to examine the association between lifestyle and medical expenses. Results : In total, 32,853 records were extracted. The results showed that smokers had medical expenses (estimate = -218,255, p = .037). As the number of days of walking increased, medical expenses significantly decreased (estimate = -58,843, p < .0001). Furthermore, as the number of days of drinking decreased, medical expenses increased (estimate = 692,289, p < .0001). Conclusion : This study analyzed the estimates of medical expenses according to lifestyle among older adults with mental illness. Smoking and exercise were negatively associated with medical expenses. These results suggest the importance of a healthy lifestyle for older adults with mental illness. In addition, this study can be used as clinical evidence for lifestyle management programs to improve physical and mental health.

The Influence of Loyalty Program on the Effect of Customer Retention: Focused on Education Service Industry (고객보상 프로그램이 고객 유지에 미치는 효과: 교육 서비스 산업을 중심으로)

  • Jeon, Hoseong
    • Asia Marketing Journal
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    • v.13 no.3
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    • pp.25-53
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    • 2011
  • This study probes the effect of loyalty program on the customer retention based on the real transaction data(n=2,892) acquired from education service industry. We try to figure out the outcomes of reward program through more than 1 year-long data gathered and analyzed according to quasi-experimental design(i.e., before and after design). We adopt this kinds of research scheme in regard that previous studies measured the effect of loyalty program by dividing the customers into two group(i.e., members vs. non-members) after the firms or stores had started the program. We believe that it might not avoid the self-selection bias. The research questions of this study could be explained such as: First, most research said that the loyalty programs could increase the customer loyalty and contribute to the sustainable growth of company. But there are little confirmation that this promotional tool could be justified in terms of financial perspective. Thus, we are interested in both the retention rate and financial outcomes caused by the introduction of loyalty programs. Second, reward programs target mainly current customer. Especially CRM(customer relationship management) said that it is more profitable for company to build positive relationship with current customer instead of pursuing new customer. And it claims that reward program is excellent means to achieve this goal. For this purpose, we check in this study whether there is a interaction effect between loyalty program and customer type in retaining customer. Third, it is said that dis-satisfied customers are more likely to leave the company than satisfied customers. While, Bolton, Kannan and Bramlett(2000) claimed that reward program could contribute to minimize the effect of negative service by building emotional link with customer, it is not empirically confirmed. This point of view explained that the loyalty programs might work as exit barrier to current customer. Thus, this study tries to identify whether there is a interaction effect between loyalty program and service experience in keeping customer. To achieve this purpose, this study adopt both Kaplan-Meier survival analysis and Cox proportional hazard model. The research outcomes show that the average retention period is 179 days before introducing loyalty program but it is increased to 227 days after reward is given to the customers. Since this difference is statistically significant, it could be said that H1 is supported. In addition, the contribution margin coming from increased transaction period is bigger than the cost for administering loyalty programs. To address other research questions, we probe the interaction effect between loyalty program and other factors(i.e., customer type and service experience) affecting it. The analysis of Cox proportional hazard model said that the current customer is more likely to engage in building relationship with company compared to new customer. In addition, retention rate of satisfied customer is significantly increased in relation to dis-satisfied customer. Interestingly, the transaction period of dis-satisfied customer is notably increased after introducing loyalty programs. Thus, it could be said that H2, H3, and H4 are also supported. In summary, we found that the loyalty programs have values as a promotional tool in forming positive relationship with customer and building exit barrier.

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Incidence and magnitude of out-of-pocket payment and factors influencing them in Industrial Accident Compensation Insurance (산재환자의 진료비 본인부담 발생 및 크기와 이에 영향을 미치는 요인)

  • Park, Bo-Hyun;Lee, Tae-Jin;Lim, Wha-Young
    • Health Policy and Management
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    • v.20 no.1
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    • pp.103-124
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    • 2010
  • Objectives: The out-of-pocket payment (OOP) of the Industrial Accident Compensation Insurance (IACI) in Korea was investigated empirically in terms of its incidence, magnitude and factors influencing them. Methods: The subjects were sampled with stratified, randomized methods among medical institutions of which the number of monthly IACI claims exceeded its median as of May 2008. Out of 204 institutions selected, 118 institutions (57.8%) responded to this survey. A total of 24,826 episodes(2,457 inpatient and 22,369 outpatient episodes) were included in this analysis. The incidence and magnitude of OOP of IACI were calculated by characteristics of institution as well as patient. Factors that affected the incidence and magnitude of OOP were investigated through multi-level analysis. Results: The overall incidence of OOP of IACI was 9.9% (25.6% for inpatient and 8.2% for outpatient) and the percentage of OOP among total expenditures was 8.3% on average (7.6% for inpatient and 26.8% for outpatient); 25.2% at traditional oriental medicine hospitals, 9.5% at general hospitals and 2.5% at the industrial-accident-designated medical institutions. The incidence of OOP of IACI was influenced by hospital size, ownership, longer duration of designation (over 5 years) and length of stay. On the other hand, its magnitude was influenced by medium-sized hospital, public hospital, location of large city and length of stay. Extra charges for upper grade room which accommodates less than 4 patients and treatment by specialists were the leading contributors to the magnitude of OOP of IACI. Conclusion: The incidence and magnitude OOP of IACI varied in institution type and were influenced by both institutional and patient's factors. In order to achieve the goal of Industrial Accident Compensation Insurance, appropriate level of compensation, that is, no incidence of OOP, for accident and disease of workers, it is necessary to take measures to reduce incidence and magnitude of OOP.

Social Learning Values in the Justification Discourses for One Million-pyeong Park, Busan, South Korea (담론분석을 통한 100만평공원운동의 사회학습적 가치)

  • Lee, Sungkyung;Kim, Seung-Hwan
    • Journal of the Korean Institute of Landscape Architecture
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    • v.41 no.5
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    • pp.19-27
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    • 2013
  • This paper claims that the One Million-peyong Park(hereafter abbreviated as OMP) project is different from a typical citizen participatory park project by recognizing the exceptional leadership of the Civic Committee for the One Million-pyeong Park Construction(CCOMPC) in promoting and developing the OMP project. Since 2001 the CCOMPC has published a variety of written promotional materials to inform and educate the public about the project. In terms of approaching the promotional materials, this research focuses on the use of language on how the CCOMPC justifies the OMP project, namely the OMP justification discourse, and considers the discourse as a unique form of social document that represents the perspective of the CCOMPC in explaining the local environmental issues and values of urban parks to the public. Using a discourse analysis method, this research analyzes the justification discourses and investigates how they changed over the three main development phases of the OMP: the initiation and preliminary development phase(1999-2001.2), the development phase (2001.2-2008), and the time period after the greenbelt policy release on Dunchi Island(2008-present). In each discourse, the OMP project is rationalized as a citizen participation park project that (1) aims to enhance the quality of public green space in Busan, (2) is accompanied by various community engagement programs that emphasize the value of urban nature and environmental education to expand citizen participation, and (3) has contributed to the National Urban Park Bill. This research emphasizes the role of the discourses in helping the public gain a critical understanding about the local environment and values of urban parks. By analyzing the contents of the discourses, it explains the social learning values of the OMP expressed in the discourses.

Korean Family Business Research : A Review and Agenda for Future Research (우리나라 가족기업의 연구동향과 과제)

  • Nam, YoungHo
    • Korean small business review
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    • v.42 no.2
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    • pp.69-92
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    • 2020
  • This study is aimed at the growth and development of family businesses that greatly contribute to Korea's economic development, but the specific research purpose is to firstly examine the research trends and current status of Korean family businesses and compare them with those of developed countries such as the United States. Second, I would like to look at the future research for revitalizing Korean family business research. In addition, we intend to contribute to increasing the interest in this field and the number of researchers involved. The research target of this paper is 212 papers published in professional academic journals for 13 years from 2006 to 2018 when family businesses began to be fully researched in Korea, 112 master's and doctoral dissertations (graduate schools), and 324 totals. As a result of empirical analysis, the number of published papers is increasing more than the initial ones, but it has been on the decline recently. In addition, 57.5% of the journals are papers that do not have specific definitions or simply list the claims of several scholars by analyzing content. Thesis was 33.9%. As for the type of research, qualitative research, which is a conceptual research, is a small number, and empirical research occupies most of the research topics. Research topics and academic dissertations also have a large proportion of management, management strategy, succession, financial accounting, and business performance. In other words, it can be said that the research on family business in Korea corresponds to the early childhood of the United States. First of all, in the future, we need to put more effort into increasing the qualitative research, starting with the definition of a family business, which is an essential problem, in addition to the theory building of family business. Second, as an analysis level of research, we should make family an important level of analysis for existing individuals, groups, and organizations. Third, the research subject and research area should be expanded. It is desperately necessary to study large companies including chaebols, mainly from small and medium-sized companies, which are the existing research areas of family business. In addition, it is considered that it is necessary to appropriately introduce various theories suitable for the interdisciplinary study, which is the characteristic of the family business, for example, theories of family science, psychology, and sociology. Fourth, it should build the research infrastructure.

Associations between Socioeconomic Factors and Healthy Life Expectancy at Regional Level in Korea (대한민국 지역단위 건강수명과 사회경제적 요인 간의 연관성 분석)

  • Chung-Nyun Kim;Yoon-Sun Jung;Young-Eun Kim;Minsu Ock;Dal-Lae Jin;Seok-Jun Yoon
    • Health Policy and Management
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    • v.34 no.3
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    • pp.261-270
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    • 2024
  • Background: Various researchers are calculating the health adjusted life expectancy (HALE) at the regional level in South Korea using several methods, most studies merely enumerate the differences in healthy life expectancy based on social characteristics. This study aims to analyze the association between various sociodemographic factors and HALE at the regional level. Methods: To calculate HALE, we utilized the various data sources, including National Health Insurance claims data, and applied the Sullivan's method. We conducted multiple linear regression with regional socioeconomic variables from Korean Statistical Information Service. For the multiple linear regression analysis, we designed three regression models. Model 1 comprised solely socioeconomic variables, model 2 involved both socioeconomic variables and individual health behaviors, and model 3 integrated model 2 with healthcare utilization. Results: The analysis shows that an increase in financial independence (p<0.05), population density (p<0.1), and the number of doctors (p<0.05) associated with an increase in HALE, whereas an increase in the number of beds (p<0.01) was associated with a decrease in HALE. In case of the obesity rate, in model 2 (p<0.1) and model 3 (p<0.05), there was a negative association between HALE and obesity rate. Conclusion: Amidst various variables, it was observed that increased financial independence in specific regions had association with an increase in HALE, highlighting the need for stronger local governance in South Korea. Additionally, the inverse association between hospital beds and HALE suggests several implications, such as the appropriate deployment of healthcare resources. To gain a deeper understanding of the relationship between hospital beds and HALE, further analysis distinguishing different types of hospital beds across healthcare institutions seems necessary.

Analysis of Success Cases of InsurTech and Digital Insurance Platform Based on Artificial Intelligence Technologies: Focused on Ping An Insurance Group Ltd. in China (인공지능 기술 기반 인슈어테크와 디지털보험플랫폼 성공사례 분석: 중국 평안보험그룹을 중심으로)

  • Lee, JaeWon;Oh, SangJin
    • Journal of Intelligence and Information Systems
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    • v.26 no.3
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    • pp.71-90
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    • 2020
  • Recently, the global insurance industry is rapidly developing digital transformation through the use of artificial intelligence technologies such as machine learning, natural language processing, and deep learning. As a result, more and more foreign insurers have achieved the success of artificial intelligence technology-based InsurTech and platform business, and Ping An Insurance Group Ltd., China's largest private company, is leading China's global fourth industrial revolution with remarkable achievements in InsurTech and Digital Platform as a result of its constant innovation, using 'finance and technology' and 'finance and ecosystem' as keywords for companies. In response, this study analyzed the InsurTech and platform business activities of Ping An Insurance Group Ltd. through the ser-M analysis model to provide strategic implications for revitalizing AI technology-based businesses of domestic insurers. The ser-M analysis model has been studied so that the vision and leadership of the CEO, the historical environment of the enterprise, the utilization of various resources, and the unique mechanism relationships can be interpreted in an integrated manner as a frame that can be interpreted in terms of the subject, environment, resource and mechanism. As a result of the case analysis, Ping An Insurance Group Ltd. has achieved cost reduction and customer service development by digitally innovating its entire business area such as sales, underwriting, claims, and loan service by utilizing core artificial intelligence technologies such as facial, voice, and facial expression recognition. In addition, "online data in China" and "the vast offline data and insights accumulated by the company" were combined with new technologies such as artificial intelligence and big data analysis to build a digital platform that integrates financial services and digital service businesses. Ping An Insurance Group Ltd. challenged constant innovation, and as of 2019, sales reached $155 billion, ranking seventh among all companies in the Global 2000 rankings selected by Forbes Magazine. Analyzing the background of the success of Ping An Insurance Group Ltd. from the perspective of ser-M, founder Mammingz quickly captured the development of digital technology, market competition and changes in population structure in the era of the fourth industrial revolution, and established a new vision and displayed an agile leadership of digital technology-focused. Based on the strong leadership led by the founder in response to environmental changes, the company has successfully led InsurTech and Platform Business through innovation of internal resources such as investment in artificial intelligence technology, securing excellent professionals, and strengthening big data capabilities, combining external absorption capabilities, and strategic alliances among various industries. Through this success story analysis of Ping An Insurance Group Ltd., the following implications can be given to domestic insurance companies that are preparing for digital transformation. First, CEOs of domestic companies also need to recognize the paradigm shift in industry due to the change in digital technology and quickly arm themselves with digital technology-oriented leadership to spearhead the digital transformation of enterprises. Second, the Korean government should urgently overhaul related laws and systems to further promote the use of data between different industries and provide drastic support such as deregulation, tax benefits and platform provision to help the domestic insurance industry secure global competitiveness. Third, Korean companies also need to make bolder investments in the development of artificial intelligence technology so that systematic securing of internal and external data, training of technical personnel, and patent applications can be expanded, and digital platforms should be quickly established so that diverse customer experiences can be integrated through learned artificial intelligence technology. Finally, since there may be limitations to generalization through a single case of an overseas insurance company, I hope that in the future, more extensive research will be conducted on various management strategies related to artificial intelligence technology by analyzing cases of multiple industries or multiple companies or conducting empirical research.

A Study on Legal Issues with Airline Over-booking Practice (항공권 초과예약의 법률적 문제에 관한 연구)

  • Jeong, Jun-Sik;Hwang, Ho-Won
    • The Korean Journal of Air & Space Law and Policy
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    • v.27 no.2
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    • pp.143-166
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    • 2012
  • This paper deals in depth with airline over-booking practices and legal questions therefrom in the light of public interests. Chapter I as an introduction gives clear ideas of what are the over-booking, fact-revealing current state of denied boarding and nature of the problems inherent but veiled in those practices. In Chapter II, it is reviewed whether legal instruments for DBC(Denied Boarding Compensation) are adequately equipped for airline passengers in R. O. K. Upon the results of the review that international law to which Korea is a party, domestic law and administrative preparedness for the DBC are either null or virtually ineffective, the Chapter by contrast illustrates how well the U. S. and the E. U. safeguard civil rights of their passengers from such an 'institutionalized fraud' as the over-booking. In Chapter III on which a main emphasis lies, it is examined whether the over-booking practice constitutes a criminal offense: Fraud. In section 1, the author identifies actus reus and mens rea required for fraud then compares those with every aspect of the over-booking. In conjunction with the structural element analysis, he reviews the Supreme Court's precedents that lead the section into a partial conclusion that the act of over-booking judicially constitutes a crime of fraud. Despite the fulfillment of drawing up an intended answer, the author furthers the topic in section 2 by arguing a dominant view from Korean academia taking opposite stance to the Supreme Court. The commentators assert, "To consummate a crime of fraud, there must be property damage of the victim." For this notion correlates with a debate on legally protected interest in criminalization of fraud, the section 2 shows an argument over 'Rechtgut' matters specific to fraud. The view claims that the Rechtgut comes down rather to 'right to property' than 'transactional integrity' or 'fair and equitable principles'. However, the section concludes that the later values shall be deemed as 'freedom in economic decision-making' which are the benefit and protection of the penal law about fraud. Section 3 demonstrates the self-contradiction of the view as it is proved by a conceptual analysis that the infringement on freedom in economic decision-making boils down to the 'property damage'. Such a notion is better grounded in section 4 by foreign court decisions and legislation in its favour. Therefore, this paper concludes that the airline's act of over-booking is very likely to constitute fraud in both theory and practice.

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Analysis of Lumbar Herniated Intervertebral Disc Patients' Healthcare Utilization of Western-Korean Collaborative Treatment: Using Health Insurance Review & Assessment Service's Patients Sample Data (요추 추간판 탈출증 환자의 의·한의 협진 의료이용 현황 분석: 건강보험심사평가원 환자표본 데이터를 이용하여)

  • Ko, Jun-Hyuk;Yu, Ji-Woong;Seo, Sang-Woo;Seo, Joon-Won;Kang, Jun-Hyuk;Kim, Tae-Oh;Cho, Whi-Sung;Seo, Yeon-Ho;Ahn, Jong-Hyun;Lee, Woo-Joo;Kim, Bo-Hyung;Choi, Man-Khu;Kim, Sung-Bum;Kim, Hyung-Suk;Kim, Koh-Woon;Cho, Jae-Heung;Song, Mi-Yeon;Chung, Won-Seok
    • Journal of Korean Medicine Rehabilitation
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    • v.31 no.4
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    • pp.105-116
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    • 2021
  • Objectives Lumbar herniated intervertebral disc (L-HIVD) is common disease in which Western-Korean collaborative treatment is performed in Korea. This study aimed to analyze Western-Korean collaborative treatment utilization of Korean patients with L-HIVD using Health Insurance Review & Assessment Service's Patients Sample Data. Methods This study used the Health Insurance Review & Assessment Service-National Patient Sample (HIRA-NPS) in 2018. Claim data of L-HIVD patients were extracted. The claim data were rebuilt with the operational concept of 'episode of care' and divided into Korean medicine episode group (KM), Western medicine episode group (WM) and collaborative treatment episode group (CT). General characteristics, medical expenses and healthcare utilization were analyzed. In addition, the difference of average visit day and average medical expenses between non-collaborative group (KM plus WM) and CT were analyzed by the propensity score matching method. Results A Total of 64,333 patients and 365,745 claims were extracted. The number of episodes of WM, KM and CT was 69,383 (92.97%), 3,903 (5.23%), and 1,341 (1.80%) respectively. The frequency of collaborative treatment episode was higher in women and the age of 50s. The most frequently described treatment in CT was acupuncture therapy. As a result of the propensity score matching, the number of visit days and medical expenses in the collaborative treatment group was higher than in the non-collaborative group. Conclusions The analysis of healthcare utilization of Korean-Western collaborative treatment may be used as basic data for establishing medical policies and systematic collaborative treatment model in the future.