• Safety and Health at Work
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• v.11 no.2
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• pp.165-172
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• 2020

Background: To gain a better understanding of nonfatal injuries in Alaska, underutilized data sources such as workers' compensation claims must be analyzed. The purpose of the current study was to utilize workers' compensation claims data to estimate the risk of nonfatal, work-related injuries among occupations in Alaska, characterize injury patterns, and prioritize future research. Methods: A dataset with information on all submitted claims during 2014-2015 was provided for analysis. Claims were manually reviewed and coded. For inclusion in this study, claims had to represent incidents that resulted in a nonfatal acute traumatic injury, occurred in Alaska during 2014-2015, and were approved for compensation. Results: Construction workers had the highest number of injuries (2,220), but a rate lower than the overall rate (34 per 1,000 construction workers, compared to 40 per 1,000 workers overall). Fire fighters had the highest rate of injuries on the job, with 162 injuries per 1,000 workers, followed by law enforcement officers with 121 injuries per 1,000 workers. The most common types of injuries across all occupations were sprains/strains/tears, contusions, and lacerations. Conclusion: The successful use of Alaska workers' compensation data demonstrates that the information provided in the claims dataset is meaningful for epidemiologic research. The predominance of sprains, strains, and tears among all occupations in Alaska indicates that ergonomic interventions to prevent overexertion are needed. These findings will be used to promote and guide future injury prevention research and interventions.

• Strategy21
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• s.45
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• pp.91-115
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• 2019

When compared to land territorial claims, maritime claims have not attracted as much attention from the public as well as the academia. However, after the ICOW (Issue Correlates of War) data was published and was expanded to include maritime and river claims, there have been many quantitative studies that analyze maritime claims or separate different types of territorial claims to explain various mechanisms over different types of territorial claims. These quantitative studies have provided valuable explanations about the onset and the management of maritime claims. This research tries to review these quantitative research. Most studies about maritime claims, especially regarding the management of claims, analyze maritime claims based on two different levels of factors. First, from the perspective of systemic level, several studies focus on the role of international institutions and systemic level of democracy to explain the management of maritime claims. Second, at the dyadic level, many studies explain how the issue salience, past experience, the presence of resources, joint democracy, and relative power influence the occurrence of peaceful settlement attempts or conflictual behaviors over maritime claims. Based on the review of these literature, this research tries to identify several factors to explain the Dokdo issue and to encourage peaceful settlement attempts over the Dokdo issue.

• Journal of Preventive Medicine and Public Health
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• v.38 no.2
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• pp.132-140
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• 2005

Objectives: To propose a risk-adjustment model from insurance claims data, and analyze the changes in cesarean section rates of healthcare organizations after adjusting for risk distribution. Methods: The study sample included delivery claims data from January to September, 2003. A risk-adjustment model was built using the 1st quarter data, and the 2nd and 3rd quarter data were used for a validation test. Patients' risk factors were adjusted using a logistic regression analysis. The c-statistic and Hosmer-Lemeshow test were used to evaluate the performance of the risk-adjustment model. Crude, predicted and risk-adjusted rates were calculated, and compared to analyze the effects of the adjustment. Results: Nine risk factors (malpresentation, eclampsia, malignancy, multiple pregnancies, problems in the placenta, previous Cesarean section, older mothers, bleeding and diabetes) were included in the final risk-adjustment model, and were found to have statistically significant effects on the mode of delivery. The c-statistic (0.78) and Hosmer-Lemeshow test ($x^2$=0.60, p=0.439) indicated a good model performance. After applying the 2nd and 3rd quarter data to the model, there were no differences in the c-statistic and Hosmer-Lemeshow $x^2$. Also, risk factor adjustment led to changes in the ranking of hospital Cesarean section rates, especially in tertiary and general hospitals. Conclusion: This study showed a model performance, using medical record abstracted data, was comparable to the results of previous studies. Insurance claims data can be used for identifying areas where risk factors should be adjusted. The changes in the ranking of hospital Cesarean section rates implied that crude rates can mislead people and therefore, the risk should be adjusted before the rates are released to the public. The proposed risk-adjustment model can be applied for the fair comparisons of the rates between hospitals.

• The Korean Journal of Health Service Management
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• v.11 no.1
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• pp.27-42
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• 2017

Objectives : This study analyzes the characteristics of hospital organization structures, insurance claims reviews and assessment tasks and their effects on hospitals in Pusan. Methods : The data for this study were collected through interview and self-administered surveys in 109 hospitals. The study included only - hospitals with a minimum of 50beds and excluded those providing only dental, psychiatric, or long-term care. Results : The findings of this study state that the number of beds has an influence on the organizitional structure. Conclusions : Hospital managements should seek human resources management(the insurance claims reviewer and evaluator) schemes that take into account the characteristics of the medical institution. In addition, insurance claims review and assessment tasks in hospitals require considerable knowledge and experience, and hospitals should be equipped with staff that have the relevant expertise. Therefore, to further deepen knowledge, comprehensive training should be continuously carried out in order to produce specialists in claims review and assessment.

• Journal of Korean Society for Quality Management
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• v.31 no.4
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• pp.219-225
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• 2003

Two­dimensional warranty data can be modelled using two different approaches： two­dimensional point process and one­dimensional point process with usage as a function of age. The first approach has three different models. First of all, bivariate model is appealing but is not appropriate for explaining warranty claims. Next, the rest of the two models (marked point process, and counting and matching on both directions independently) are more appropriate for explaining warranty claims. However, the second one (counting and matching on both directions independently) assumes that the two variables (variables representing the two­dimensions) are independent. Last of all, one­dimensional point process with usage as a function of age is also promising to explain the two­dimensional warranty claims. But the models or variations of them need more investigation to be applicable to real warranty claim data.

• International Journal of Computer Science & Network Security
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• v.22 no.2
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• pp.413-423
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• 2022

The NHIS provides free or highly subsidized healthcare to all people by providing financial fortification. However, the financial sustainability of the scheme is threatened by numerous factors. Therefore, this work sought to provide a solution to process claims intelligently. The provided Petri net model demonstrated successful data flow among the various participant. For efficiency, scalability, and performance two main subsystems were modelled and integrated - data input and claims processing subsystems. We provided smart claims processing algorithm that has a simple and efficient error detection method. The complexity of the main algorithm is good but that of the error detection is excellent when compared to literature. Performance indicates that the model output is reachable from input and the token delivery rate is promising.

• Korean Journal of Clinical Pharmacy
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• v.24 no.4
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• pp.255-264
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• 2014

Objective: The aims of this study are to investigate the total volume of prescribed medicines against Alzheimer's disease (AD) and the trends of usage by analyzing the claims-data from the Korea National Health Insurance Service. Method: The demographic and claims-data were included the major AD treating medicines such as donepezil, galantamine, rivastigmine and memantine, and analyzed during the period of 2010~2012. The assessing criteria were gender, age, habitation, types of medical institution, code of ingredients, outcomes of treatment, volume and amount of claims, and the numbers of patients with dementias. After trimming the data, it were analyzed by the market size, demographic traits, characteristics of medical service, characteristics of each anti-AD medicine, etc. Results: Among the chosen 4 medicines, donepezil had the top prescription volumes. Most prevalent prescribing preparations of donepezil were conventional types. However, among the non-conventional types, oro-dispersible formulation is the fast increasing one in both volume and growth rate. This specialized preparations to improve both toleration and adherence, tend to being prescribed generally at the tertiary medical institutions. While the younger patients with mild-to-moderate AD mostly treated by expensive medicines in resident at the tertiary hospitals, the rest older patients with severe AD have been treated non-expensive one at long-term care facilities. Conclusion: AD is a chronic illness therefore, long-term use of therapeutic medications are highly important. If an anti-AD treatment was applied steadily in the earlier stages, it would be achieved not only improving the quality of life of patient but also reducing the expenses in the medical and nursing cares. As the socioeconomical impacts of AD is expanding, healthcare professionals need to aware the importance of pharmacotherapy and to improve sociopolitical fundamentals.

• Journal of Preventive Medicine and Public Health
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• v.34 no.1
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• pp.28-34
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• 2001

Objectives : To investigate the changing pattern of medical utilization claims following the economic crisis in Korea. Methods : The original data consisted of the claims of the 'Medical insurance program of self-employees' between 1997 and 1998. The data was selected by medical treatment day ranging between 8 January and 30 June. Medical utilizations were calculated each year by the frequency of claims, visit days for outpatients, length of stay for inpatients, total days of medication, and the sum of expenses. Results : The length of stay as an inpatient in 1998 was decreased 4.7 percent in comparison to 1997. However, inpatient expenses in 1998 increased 10.8 percent as compared to 1997. Inpatient hospital claims in 1998 increased 6.2 percent over 1997, although general hospital inpatient claims in 1998 decreased 3.3 percent in comparison to 1997. The outpatient claim frequency decreased 7.3 in 1998 percent as compared to 1997 Outpatient visit days of in 1998 were decreased 8.5 percent in comparison to that recorded in 1997. Outpatient claim frequencies of 'gu region' in 1998 decreased 10.5 percent comparison to that in 1997, but 'city and gun region' decreased less than 'gu region'. Conclusions : Medical utilization in 1998 deceased in relation to 1997 Medical utilization by outpatients decreased more than that of inpatients. Medical utilization by 'gu region' decreased mere than the other regions.

• Health Policy and Management
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• v.16 no.2
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• pp.49-76
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• 2006

The aim of this study was to explore the effects of a computerized review program which was introduced in August 1, 2003, using claims data for acute respiratory infection related diseases. National Health Insurance (NHI) claims data on respiratory infection related diseases before and after the introduction, with six month intervals respectively, were used for the analysis. Clinic was the unit of observation, and clinics with only one physician whose specialty was internal medicine, pediatrics, otorhinolaryngology and family medicine and clinics with a general practitioner were selected. The final sample had 7,637 clinics in total. Indices used to measure practice pattern was prescription rates of antibiotics, prescription rates of injection drug per visit, treatment costs per claim, and total costs per claim. Changes in the number of claims for major disease categories and upcoding index for disease categories were used to measure claiming behavior. Data were analysed using descriptive analysis, t-test for indices changes before and after the introduction, analysis of variance (ANOVA) for practice pattern change for major disease categories, and multiple regression analysis to identify whether new system influenced on provider' practice patterns or not. Prescription of antibiotics, prescription rates of injection drug, treatment costs per claim, and total costs per claim decreased significantly. Results from multiple regression analysis showed that a computerized review system had effects on all the indices measuring behavior. Introduction of the new system had the spillover effects on the provider's behavior in the related disease categories in addition to the effects in the target diseases, but the magnitude of the effects were bigger among the target diseases. Rates of claims for computerized review over total claims for respiratory diseases significantly decreased after the introduction of a computerized review system and rates of claims for non target diseases increased, which was also statistically significant. Distribution of the number of claims by disease categories after the introduction of a computerized review system changed so as to increase the costs per claims. Analysis of upcoding index showed index for 'other acute lower respiratory infection (J20-22)', which was included in the review target, decreased and 'otitis media (H65, H66)', which was not included in the review target, increase. Factors affecting provider's practice patterns should be taken into consideration when policies on claims review method and behavior changes. It is critical to include strategies to decrease the variations among providers.

• Health Policy and Management
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• v.13 no.1
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• pp.98-115
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• 2003

Concerns about growing health insurance expenditures became a national Issue in 2001 when the National Health Insurance went into a deficit. Increases in spending for ambulatory care shared the largest portion of the problem. Methods and systems to control the spending should be developed and a system to measure case mix of providers is one of core components of the control system. The objectives of this article is to examine the feasibility of applying Korean Diagnosis Related Groups (KDRGs) to classify health insurance claims for ambulatory care and to identify problem areas of the classification. A database of 11,586,270 claims for ambulatory care delivered during January 2002 was obtained for the study, and the final number of claims analyzed was 8,319,494 after KDRG numbers were assigned to the data and records with an error KDRG were excluded from the study. The unit of analysis was a claim and resource use was measured by the sum of charges incurred during a month at a department of a hospital of at a clinic. Within group variance was assessed by th coefficient of variation (CV), and the classification accuracy was evaluated by the variance reduction achieved by the KDRG classification. The analyses were performed on both all and non-outlier data, and on a subset of the database to examine the validity of study results. Data were assigned to 787 KDRGs among 1,244 KDRGs defined in the classification system. For non-outlier data, 77.4％ of KDRGs had a CV of charges from tertiary care hospitals less than 100％ and 95.43％ of KDRGs for data from clinics. The variance reduction achieved by the KDRG classification was 40.80％ for non-outlier claims from tertiary care hospitals, 51.98％ for general hospitals, 40.89% for hospitals, and 54.99% for clinics. Similar results were obtained from the analyses performed on a subset of the study database. The study results indicated that KDRGs developed for a classification of inpatient care could be used for ambulatory care, although there were areas where the classification should be refined. Its power to predict tile resource utilization showed a potential for its application to measure case mix of providers for monitoring and managing delivery of ambulatory care. The issue concerning the quality of diagnostic information contained in insurance claims remains to be improved, and significance of future studies for other classification systems based on visits or episodes is guaranteed.