• Title/Summary/Keyword: Health Insurance Reimbursement

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Demand-supply of Advanced Practice Nurse (APN) and Alternative Benefit Strategies in the National Health Insurance (전문간호사의 수급 현황과 건강보험 급여화 방안)

  • Kim, Jin-Hyun
    • Perspectives in Nursing Science
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    • v.7 no.1
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    • pp.23-35
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    • 2010
  • Purpose: The purpose of this paper is to analyze the demand and supply of advanced practice nurses and suggest alternative benefit strategies in the Korean national health insurance. Methods: A revised demand & supply model was used to estimate the excess supply of APNs, and policy making process and key actors in the Korean health insurance were considered to develop a political approach to the APN issue. Results: The social demand for APNs is currently estimated to be less than 50% of its supply and the APN education program fell into difficulties in recruits. No reimbursement mechanism for APN's services in the national health insurance has given no economic incentive to hospital managers who have monopsony power in nursing labor market, which has caused the demand shortage of APNs in hospital industry. Payment for APN's services recognized as one of the most significant strategies to booster the social demand for APN's services should be carefully designed and implemented in the national health insurance. In line with this, key actors in health insurance policy decision-making include government, national assembly, labor unions, NGOs, civic groups, medical associations, and academia. Conclusion: The basic researches for APN's activities and cost-effectiveness analysis in clinical settings are required to support the strategies aforementioned. Constructing a policy network among key actors is able to make the payment strategy feasible, which will increase the socal demand for APNs.

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New Drug Listing Process and Reimbursement Standard Management (약제의 신규등재 절차와 급여기준 관리)

  • Yoon Kyeong Bai;Mi-Young You
    • Journal of Digestive Cancer Research
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    • v.11 no.2
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    • pp.104-107
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    • 2023
  • The Ministry of Health and Welfare of Korea has implemented various social security programs to ensure a basic standard of living and raise overall quality of life for all citizens. The Korean social security system provides social insurance, public assistance, and social welfare services. To achieve adequate drug benefits, the Drug Management Department of Health Insurance Review and Assessment Service (HIRA) implement drug management duties including drug listing, upper price limit setting, scope of benefits, and post-factum management. When a manufacturer or an importer wants to apply for National Health Insurance (NHI) coverage of the drug that has obtained safety and efficacy approval, the pharmaceutical benefit assessment committee of HIRA evaluates the drug's clinical efficacy and cost-effectiveness to determine whether or not to include the drug into the benefit package. The benefit standards for a listed drug (ingredient) are set either for the whole permitted range or a part of range with conditions. To increase the coverage rate for new drugs, the listed drugs are regularly reviewed for their value. The status of listed drugs can be adjusted or eliminated from the benefit package if the clinical efficacy turns out to be insignificant. Therefore, through these pharmaceutical management procedures, high-quality drugs are provided at reasonable prices, which save healthcare expenditure by price determination and selective coverage in consideration of economic evaluation.

Research on Reimbursement of Therapeutic Medical Device through Delphi Method and Analytic Hierarchy Process (치료재료 별도산정 기준 개선을 위한 델파이 및 계층분석과정 조사)

  • Noh, Jin-Won;Lee, Yejin;Jang, Suk Yong;Kim, Mi Kyung;Cho, Kyoung Hee;Kim, Jae-Hyun;Yoo, Ki-Bong
    • Korea Journal of Hospital Management
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    • v.23 no.4
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    • pp.15-25
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    • 2018
  • Purposes: The objectives of this study present the direction of the criteria for the separately reimbursement of therapeutic medical device. Methodology: We summarized experts' opinion using Delphi survey and Analytic Hierarchy Process(AHP). 48 experts were gathered from Medical Insurance Review Nurses Association, medical device industry, academy and association, Medical Device Expert Evaluation Committee. Descriptive statistics, consistency index, content validity ratio were analyzed. Findings: Clinical utility, patient safety, infection control, cost-homogeneity, cost-effectiveness showed high feasibility and importance, but market contribution and functional utility showed low feasibility and importance in a relative sense. The results of functional utility differed between clinical and non-clinical experts. Measurability was low across the whole area. Among the criteria for the separately reimbursement of therapeutic medical device. Patient safety/infection control and clinical utility showed the highest relative importance values, analyzed using AHP. Practical Implications: Patient safety and infection control are needed to be considered as one of Value Assessment Criteria. It is important to find out how to improve the measurability of therapeutic medical device.

What Can Koreans Learn from the Dutch Experiences in Reforming the Health Insurance System? (한국의료보험제도(韓國醫療保險制度)의 개혁필요성(改革必要性)과 네덜란드의 경험(經驗)이 주는 교훈(敎訓))

  • Kwon, Soon-won;Sunwoo, Duk
    • KDI Journal of Economic Policy
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    • v.12 no.3
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    • pp.47-69
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    • 1990
  • The measures taken to reform the Dutch health insurance system hold valuable lessons for countries such as Korea, where there has been increased concern regarding the efficiency and effectiveness of the health services provided. The growing literature on comparative health insurance policies suggests that nations can learn from each other. In addition, Korean policymakers have shown great interest in the health insurance systems of foreign countries, particularly in Japan. The development of Korea's health insurance scheme during the past 12 years has made a significant contribution to the increased accessibility of health care services. Although the insurance coverage is universal, the health insurance system today in Korea is by no means a product of systematic and planned efforts. Moreover, it lacks due considerations of insured's needs as well as the long-term objectives of the social security health care system. There are growing gaps in premium burdens and benefits between the rural health insurance program and the employee's health insurance programs. Furthermore, the regional health insurance program is experiencing financial difficulties in spite of the fact that the amount of the government subsidy has been sharply increased in recent years. Under the present payment method solely based on the fee-for-service schedule, both consumers and providers are encouraged to utilize and prescribe more services. The combination of the utilization-inducing reimbursement system and continuous pushes for expanding health insurance has played a crucial role in raising the country's medical bills. Current trends in Korea's health care sector and those anticipated in the near future necessitate changes in the structure and funding of health care. As indicated in the above, there are various shortcomings in this context, the health policy authority in Korea can draw valuable lessons from the Dutch experiences in reforming their health insurance system. The main elements of the Dutch reform measures are a restructuring of the insurance system and a greater role for market forces in the health care system. On this basis a new system will be created which reflects the social nature of health care while at the same time containing sufficient mechanisms to allow the health care sector to operate in a cost-effective and efficient manner.

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Impact of Adjusted Out-of-Pocket Maximum Rules of Long-stay Admissions in Long-Term Care Hospitals (요양병원 장기입원에 대한 본인부담상한제 개편 영향 분석)

  • Yeojeong Gu;Seungji Lim
    • Korea Journal of Hospital Management
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    • v.29 no.2
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    • pp.37-47
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    • 2024
  • Purpose: This study aimed to determine the effect of adjusted out-of-pocket maximum rules in the 'differential co-payment ceiling', which means having a higher burden of co-payment, that expanded to the entire ceiling level in long-stay admission patients in long-term care hospitals(LTCH). Methodology: We used health insurance claim data between January 1, 2022, and December 31, 2022 received from the National Health Insurance Service. The study populations were inpatients in long-term care hospitals more than 1 days during the study period. We performed the difference in characteristics of the LTCH patient of the differential and general ceiling by the chi-square test. We estimated the change of the population, cost, and co-payments per person under the assumption of restructuring. Finding: Based on adjusted out-of-pocket maximum rules in 2023, it was expected that the number of benefits decreases at the high-income level while increasing at the low-income level. The burden of health expenditure after reimbursement of co-payment ceiling, is expected to increase by 65.1% in the highest medical necessity, whereas the low medical necessity would decreases compared to 2022. Practical Implications: The results demonstrate that the current out-of-pocket maximum rules do not reflect the needs of medical necessity. This study suggested the need to reflect the medical necessity in LTCH on the out-of-pocket maximum rules in the future.

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Pitfalls in Reimbursement Decisions for Oncology Drugs in South Korea: Need for Addressing the Ethical Dimensions in Technology Assessment

  • Cho, Eun;Park, Eun-Cheol;Kang, Myoung Sheen
    • Asian Pacific Journal of Cancer Prevention
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    • v.14 no.6
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    • pp.3785-3792
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    • 2013
  • This study aimed to discover to what extent ethical issues are considered in the reimbursement decision process based on health technology assessment (HTA) in Korea, especially for oncology medications. Public summary documents (PSDs) published by the Health Insurance Review and Assessment Service (HIRA) were analyzed for empirical and normative factors. For external comparison, PSDs presented by corresponding institutions of Australia and the United Kingdom were employed. Furthermore, the opinions of eight expert oncologists were obtained regarding the accountability of the evidence in PSDs. Among 7 oncology drugs, there were differences in the final decisions and empirical factors considered, such as selected comparators and interpretation of evidence between the PSDs from the three institutions. From an ethical viewpoint, the following matters were deficient in the HTA decision-making process for oncology drugs: clear and reasonable standards; identifying and evaluating ethical values; and public accountability for reasonableness about decisions and due process.

Priority Therapeutic Groups to Expand Development of Prescribing Indicators using a Consensus Group of Health Care Professionals (전문가 조사를 활용한 약제급여 적정성 평가 항목 및 지표 확대방안 도출)

  • Jeon, Ha-Lim;Kim, Dong-Sook;Kim, Bo-Yun
    • YAKHAK HOEJI
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    • v.59 no.4
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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.

Analysis of Frequent Therapeutic Duplication Drug Classes Based on National Health Insurance Claimed Data in Korea (국내 건강보험심사청구자료에 근거한 다빈도 치료중복 의약품 약효군 분석)

  • Sohn, Hyun-Soon;Lee, Young-Sook;Choi, Kyung-Eob;Shin, Hyun-Taek
    • Korean Journal of Clinical Pharmacy
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    • v.20 no.3
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    • pp.262-267
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    • 2010
  • Therapeutic duplication of prescriptions is the most frequently reported inappropriate drug use in Korea. To prevent significant problems during drug prescribing and dispensing, prospectively, development of standard including drug lists considered as therapeutic duplications for the prioritized drug classes first would be necessary. This study was aimed to analyze frequent drug classes of therapeutic duplications by healthcare providers in clinical practice settings. National health claims data for drug review and reimbursement (1,426,065 prescriptions dated March 19, 2008) were analyzed. Therapeutic duplication was defined as the prescription including more than 2 ingredients belonging to the same KFDA drug classification numbers that considered to have therapeutic similarities. The following 3 drug classes were mostly frequent therapeutic duplication classes: 114 anti-pyretics, analgesics and anti-inflammatory drugs; 117 drugs for psycho-nervous system; 141 Antihistamines. About 3.5% of overall prescriptions analyzed showed therapeutic duplications. This result might be starting step to develop DUR therapeutic duplication standard.

Economic Value of the Sirolimus Eluting Stent($CYPHER^{TM}$) in Treating Acute Coronary Heart Disease (관상동맥질환 치료를 위한 시롤리무스 방출 스텐트 ($CYPHER^{TM}$)의 경제성 분석)

  • Lee, Hoo-Yeon;Park, Eun-Cheol;Park, Ki-Dong;Park, Ji-Eun;Kim, Young;Lee, Sang-Soo;Kang, Hye-Young
    • Journal of Preventive Medicine and Public Health
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    • v.36 no.4
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    • pp.339-348
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    • 2003
  • Objective : To quantify the economic value of the Sirolimus fluting Stent ($CYPHER^{TM}$) in treating acute coronary heart disease (CMD), and to assist in determining an adequate level of reimbursement for $CYPHER^{TM}$ in Korea. Methods : A decision-analytical model, developed by the Belgium Health Economics Disease Management group, was used to investigate the incremental cost-effectiveness of $CYPHER^{TM}$ versus conventional stenting. The time horizon was five years. The probabilities for clinical events at each node of the decision model were obtained from the results of large, randomized, controlled clinical trials. The initial care and follow-up direct medical costs were analyzed. The initial costs consisted of those for the initial procedure and hospitalization, The follow-vp costs included those for routine follow-up treatments, adverse reactions, revascularization and death. Defending on the perspective of the analysis, the costs were defined as insurance covered or total medical costs (=sum of insurance covered and uncovered medical costs). The cost data were obtained from the administrative data of 449 patients that received conventional stenting from five participating Korean hospitals during June 2002. Sensitivity analyses were peformed for discount rates of 3, 5 and 7%. Since the major clinical advantage of $CYPHER^{TM}$ over conventional stenting was the reduction in the revascularization rates, the economic value of $CYPHER^{TM}$, in relation to the direct medical costs of revascularization, were evaluated. If the incremental cost of $CYPHER^{TM}$ per revascularization avoided, compared to conventional stenting, was no higher than that of a revascularization itself, $CYPHER^{TM}$ would be considered as being cost-effective. Therefore, the maximum acceptable level for the reimbursement price of $CYPHER^{TM}$ making the incremental cost-effectiveness ratio equal to the cost of a revascularization was identified. Results : The average weighted initial insurance covered and total medical costs of conventional stenting were about 6,275,000 and 8,058,000 Won, respectively. The average weighted sum of the initial and 5-year follow-up insurance covered and total medical costs of conventional stenting were about 13,659,000 and 17,353,000 Won, respectively. The estimated maximum level of reimbursement price of $CYPHER^{TM}$ from the perspectives of the insurer and society were $4,126,897{\sim}4,325,161$ and $4,939,939{\sim}5,078,181$ Won, respectively. Conclusion : By evaluating the economic value of $CYPHER^{TM}$, as an alternative to conventional stenting, the results of this study are expected to provide a scientific basis for determining the acceptable level of reimbursement for $CYPHER^{TM}$.

Review of 2021 Major Medical Decisions (2021년 주요 의료판결 분석)

  • Park, Taeshin;Yoo, Hyunjung;Lee, Jeongmin;Cho, Woosun;Jeong, Heyseung
    • The Korean Society of Law and Medicine
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    • v.23 no.2
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    • pp.171-209
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    • 2022
  • There were also many medical-related rulings in 2021, among which the rulings reviewed in this paper are as follows. The first relates to a case in which the medical record, which is the primary judgment data regarding the presence or absence of medical negligence, has been modified. The court judged whether there was negligence on the basis of the first written medical record without considering the contents of the medical record that was later modified. Next, the ruling on the case of asking for liability for damages for prescription of anti-obesity drugs recognized negligence related to prescription, but denied liability for property damage by denying a causal relationship, and recognized only alimony for violation of the duty of explanation. The a full-bench ruling on the scope of subrogation of the National Health Insurance Corporation, which subrogates the claims for compensation for medical expenses against the perpetrator of the patient, changed the existing precedent that had taken the 'deduction method after offsetting negligence' and judged it as 'the method of offsetting negligence after deduction'. In addition, in the ruling on whether or not there was negligence, the court was not bound by the medical record appraisal result. Lastly, in relation to the National Health Insurance Service's disposition of reimbursement for medical care benefit costs, we reviewed the ruling that discretion should be exercised even when a non-medical person makes a refund to a medical institution opened by a non-medical person. And we also reviewed the ruling that the scope of reimbursement for medical institutions jointly using facilities and manpower specifically should be determined.