• Health Policy and Management
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• v.25 no.3
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• pp.185-196
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• 2015

Background: Issues concerning with the classification accuracy of Korean Outpatient Groups (KOPGs) have been raised by providers and researchers. The KOPG is an outpatient classification system used to measure casemix of outpatient visits and to adjust provider risk in charges by the Health Insurance Review & Assessment Service in managing insurance payments. The objective of this study were to refine KOPGs to improve the classification accuracy and to evaluate the refinement. Methods: We refined the rules used to classify visits with multiple procedures, newly defined chemotherapy drug groups, and modified the medical visit indicators through reviews of other classification systems, data analyses, and consultations with experts. We assessed the improvement by measuring % of variation in case charges reduced by KOPGs and the refined system, Enhanced KOPGs (EKOPGs). We used claims data submitted by providers to the HIRA during the year 2012 in both refinement and evaluation. Results: EKOPGs explicitly allowed additional payments for multiple procedures with exceptions of packaging of routine ancillary services and consolidation of related significant procedures, and discounts ranging from 30% to 70% were defined in additional payments. Thirteen chemotherapy drug KOPGs were added and medical visit indicators were streamlined to include codes for consultation fees for outpatient visits. The % of variance reduction achieved by EKOPGs was 48% for all patients whereas the figure was 40% for KOPGs, and the improvement was larger in data from tertiary and general hospitals than in data from clinics. Conclusion: A significant improvement in the performance of the KOPG was achieved by refining payments for visits with multiple procedures, defining groups for visits with chemotherapy, and revising medical visit indicators.

• Journal of the Korea Academia-Industrial cooperation Society
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• v.14 no.7
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• pp.3390-3399
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• 2013

The purpose of this study was to examine the incidence rates of pressure ulcers depending on the types of healthcare organizations and to determine whether the characteristics of patients and facilities influence on the incidence of pressure ulcers in long term facilities. We analyzed data on 796,857 patients of the 2009 National Patient Sample which was extracted from to claims for medical fees to Health Insurance Review & Assesment Service(HIRA). A total of 3.2% of patients(n=25,339) had at least 1 pressure ulcer during their hospitalization. The pressure ulcer rates were highest in long term care facilities(8.2%, n=11,895) following general hospital(2.7%, n=8,052), hospital(1.7%, n= 5,059). According to logistic regression analysis, urinary incontinence (Odds ratio(OR)=2.462, 95% confidence interval(CI)=2.038-2.974), hypertension(OR=1.456, CI=1.400-1.515), peripheral vessel diseases (OR=1.357, CI=1.200-1.534) were significant predictors of pressure ulcers. As the number of diagnoses, age, and the number of doctors per 100 beds increased, the incidence of pressure ulcers increased. In addition, more number of beds was associated with fewer pressure ulcers.

• Quality Improvement in Health Care
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• v.27 no.2
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• pp.73-82
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• 2021

Purpose: This study aims to examine the quality of tuberculosis (TB) care after the 1st to 3rd national quality assessment (QA) program for TB healthcare service in Korea was conducted. Methods: We analyzed Health Insurance Review & Assessment Service (HIRA) claims data of new TB patients during the period of January to June from 2018-2020. The new TB patients were defined as TB patients reported to Korea Centers for Disease Control and Prevention Agency (KCDA). The unit of analysis was the patient. Chi-square tests were used to analyze the differences in indicator value according to the types of medical facilities. The QA indicators of TB care were divided into 3 areas consisting of the following 7 quality indicators: 4 indicators of diagnosis test (the rate of acid-fast bacilli smear, the rate of acid-fast bacilli culture, the rate of Mycobacterium tuberculosis-polymerase chain reaction, drug susceptibility test), 1 compliance of treatment guideline, and 2 indicators of care management of TB patients (encounter rate, day of therapy). Results: The QA program for TB care was conducted among 8,246 patients from 534 facilities in 2020. The value of the 7 quality indicators was shown to increase as a result of the QA program. The indicators of the diagnostic test were all higher than 95%, with the exception of the drug susceptibility test which was 84.8%. Both indicators for care management of TB patients were 88.5%. Conclusion: The quality of TB care has been improving with the implementation of the QA program. In order to continue to improve the quality of TB care, it will be necessary to disclose the results of the QA program in medical facilities in the future.

• 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.