• Safety and Health at Work
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• v.11 no.3
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• pp.301-306
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• 2020

Background: The Functional Movement Screen (FMS^TM) is a screening tool used to assess an individual's ability to perform fundamental movements that are necessary to do physically active tasks. The purpose of this study was to assess the ability of FMS to predict occupational injury among Denver Fire Department firefighters. Method: FMS tests were administered from 2012 to 2016. Claim status was defined as any claim occurrence vs. no claim and an overexertion vs. no claim/other claim within 1 year of the FMS. To assess associations between FMS score and claim status, FMS scores were dichotomized into ≤ 14 and > 14. Age-adjusted odds ratios were calculated using logistic regression. Sensitivities and specificities of FMS predicting claims at various FMS score cut points, ranging from 10 to 20 were tested. Results: Of 581 firefighters (mean ± SD, age 38 ± 9.8 y) who completed FMS between February 2015 and March 2018, 188 (32.4%) filed a WC claim in the study time frame. Seventy-two of those (38.3%) were categorized as overexertion claims. There was no association between FMS score and claim status [odds ratio (OR) = 1.27, 95% confidence interval (CI): 0.88 - 1.83] and overexertion claim vs. no claim/other claim (OR = 1.33, 95% CI: 0.81 - 2.21). There was no optimal cutoff for FMS in predicting a WC claim. Conclusions: Although the FMS has been predictive of injuries in other populations, among this sample of firefighters, it was not predictive of a future WC claim.

• Health Policy and Management
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• v.21 no.1
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• pp.77-92
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• 2011

Objectives : This study examined the health policy researchers' needs and their accessibility towards health insurance claim datasets according to their academic capacity. Methods : An online questionnaire to capture relevant proxy variables for academic needs, accessibility, and research capacity was constructed based on previous studies. The survey was delivered to active health policy researchers through three major scholarly associations in South Korea. Seven-hundred and one scholars responded while the survey as open for 12 days (starting on December 20th, 2010). Descriptive statistics and logistic regression analysis were carried out. Results : Regardless of the definition for operational needs, the prevalent needs of survey respondents were not met with the current provision of claim data. Greater research capacity was shown to be correlated with increased demand for claim data along with a positive correlation between attempts to obtain claim datasets and research capacity. A greater research capacity, however, was not necessarily correlated with better accessibility to the claim data. Conclusions : The substantial unmet need for claim data among the healthcare policy research community calls for establishing proactive institutions which could systematically prepare and make available public datasets and provide call-in services to facilitate proper handling of data.

• Journal of Preventive Medicine and Public Health
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• v.27 no.2 s.46
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• pp.242-257
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• 1994

In Korea, female workforce has reached more than 40% of total working population, but the effects of work on spontaneous abortion are yet to be examined. This study as conducted to investigate the occupational effects on spontaneous abortion. Medical insurance claim data were used to examine the effects of the employment status and industry of employment on spontaneous abortion. The study population was composed of females, aged $15{\sim}44$, who were the beneficiary of medical insurance in the month of June, 1993. The working females covered by medical insurance for industrial workers, had the highest age-adjusted Spontaneous Abortion rate (SAB rate=claim frequency of spontaneous abortion/claim frequency of complication of pregnancy, childbirth and the puerperium), 6.65% whereas female dependants of medical insurance for industrial workers had the lowest age-adjusted SAB rate, 4.54%. Among industrial workers, the workers in manufacturing industry had the highest age-adjusted Spontaneous Abortion ratio(SAB ratio=claim frequency of spontaneous abortion/claim frequency of completly normal delivery), 43.2/100 whereas those in financing and service industry had age-adjusted SAB ratio, 16.2/100 and 20.5/100, respectively. The results of the study suggest the adverse effect of manufacturing Industry on reproduction. Work environments such as chemical exposures, overwork, awkard posture, and job stress should be further studied for their effects on reproductive functions of female.

• Korea Journal of Hospital Management
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• v.9 no.3
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• pp.71-97
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• 2004

This study conducted a comparative analysis of awareness level of review standards, continuing education, and awareness about the need for speciality and educational courses in order to improve quality of Korean health insurance review work and to present directions for policies of personnel development and continuing education to smoothly perform hospital's insurance claim work and Agency's review work. The analysis unit of the study is individuals, and survey was conducted among hospital's claim officers and Agency' review officers by distributing questionnaires. The major results of the study are as follows: First, it is found that hospital's claim officers and Agency's review officers have conflicting awareness about review standards; more Agency's review officers think that current review standards are universal and reasonable, while more hospital's claim officers believe that they need to be revised. Especially, hospital's claim officers replied that it is possible that review results can differ according to government's policies. Second, there is no significant difference between the two groups in the opinion that there are individual differences in awareness level of review standard. In particular, both groups share the opinion that review results can differ according to officer's interpretation of review standards. Third, Both review officer groups feel the need for further training and continuing education. Fourth, there is no difference between the two groups in the opinion that both groups members should be educated in review related educational institutions. However, while 81.5% of Agency's review officers the education should be offered at the Agency, only 45.2% of hospital's claim officers agreed to it. Fifth, both review personnel do not show any difference in awareness of needed experience to successfully perform review work; both groups replied that three to four years experience is necessary to smoothly perform claim work and review work. This study was tried in order to search for directions to improve Korean insurance review work in quality rather than to explore characteristics themselves of individual factors. In this sense, this study presupposed an intention that the educational subjects for further training and continuing education for the two groups should be the same in order to narrow the awareness gap between hospital's claim officers and Agency's review officers. Thus, this study suggests that it is desirable to offer beginner courses at junior colleges or in undergraduate courses and advanced courses in professional graduate school for six to twelve months. In that a comparison of awareness level of hospital's claim officers and Agency's review officers who are actually in practice should precede appropriate presentation of directions for the qualitative improvement of insurance review work in Korea, the significance of this study lies in comparatively analyzing the awareness level of hospital's claim officers and Agency's review officers and in presenting the establishment of future further training and continuing education.

• Journal of Preventive Medicine and Public Health
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• v.33 no.4
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• pp.393-401
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• 2000

Objectives : To evaluate the impacts of the DRG payment system on the behavior of medical insurance claimants. Specifically, we evaluated the case-mix index, the numbers of diagnosis and procedure codes utilized, and the corresponding rate of diagnosis codes before, during and after implementation of the DRG payment system. Methods : In order to evaluate the case-mix index, the number of diagnosis and procedure codes utilized, we used medical insurance claim data from all medical facilities that participated in the DRG-based Prospective Payment Demonstration Program. This medical insurance claim data consisted of both pre-demonstration program data (fee-for-service, from November, 1998 to January, 1999) and post-demonstration program data (DRG-based Prospective Payment, from February, 1999 to April, 1999). And in order to evaluate the corresponding rate of diagnosis codes utilized, we reviewed 820 medical records from 20 medical institutes that were selected by random sampling methods. Results : The case-mix index rate decreased after the DRG-based Prospective Payment Demonstration Program was introduced. The average numbers of different claim diagnosis codes used decreased (new DRGs from 2.22 to 1.24, and previous DRGs from 1.69 to 1.21), as did the average number of claim procedure codes used (new DRGs from 3.02 to 2.16, and previous DRGs from 2.97 to 2.43). With respect to the time of participation in the program, the change in number of claim procedure codes was significant, but the change in number of claim diagnosis codes was not. The corresponding rate of claim diagnosis codes increased (from 57.5% to 82.6%), as did the exclusion rate of claim diagnosis codes (from 16.5% to 25.1%). Conclusions : After the implementation of the DRG payment system, the corresponding rate of insurance claim codes and the corresponding exclusion rate of claim diagnosis codes both increased, because the inducement system for entering the codes for claim review was changed.

• Journal of Preventive Medicine and Public Health
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• v.39 no.5
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• pp.433-437
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• 2006

Objectives: The aim of this study is to develop a methodology for estimating a nationwide statistic for hernia operations with using the claim database of the Korea Health Insurance Cooperation (KHIC). Methods: According to the insurance claim procedures, the claim database was divided into the electronic data interchange database (EDI_DB) and the sheet database (Paper_DB). Although the EDI_DB has operation and management codes showing the facts and kinds of operations, the Paper_DB doesn't. Using the hernia matched management code in the EDI_DB, the cases of hernia surgery were extracted. For drawing the potential cases from the Paper_DB, which doesn't have the code, the predictive model was developed using the data mining technique called SEMMA. The claim sheets of the cases that showed a predictive probability of an operation over the threshold, as was decided by the ROC curve, were identified in order to get the positive predictive value as an index of usefulness for the predictive model. Results: Of the claim databases in 2004, 14,386 cases had hernia related management codes with using the EDI system. For fitting the models with applying the data mining technique, logistic regression was chosen rather than the neural network method or the decision tree method. From the Paper_DB, 1,019 cases were extracted as potential cases. Direct review of the sheets of the extracted cases showed that the positive predictive value was 95.3%. Conclusions: The results suggested that applying the data mining technique to the claim database in the KHIC for estimating the nationwide surgical statistics would be useful from the aspect of execution and cost-effectiveness.

• Health Policy and Management
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• v.26 no.1
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• pp.71-78
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• 2016

The value of using health insurance claim database is continuously rising in healthcare research. In studies where comorbidities act as a confounder, comorbidity adjustment holds importance. Yet researchers are faced with a myriad of options without sufficient information on how to appropriately adjust comorbidity. The purpose of this study is to assist in selecting an appropriate index, look back period, and data range for comorbidity adjustment. No consensus has been formed regarding the appropriate index, look back period and data range in comorbidity adjustment. This study recommends the Charlson comorbidity index be selected when predicting the outcome such as mortality, and the Elixhauser's comorbidity measures be selected when analyzing the relations between various comorbidities and outcomes. A longer look back period and inclusion of all diagnoses of both inpatient and outpatient data led to increased prevalence of comorbidities, but contributed little to model performance. Limited data range, such as the inclusion of primary diagnoses only, may complement limitations of the health insurance claim database, but could miss important comorbidities. This study suggests that all diagnoses of both inpatients and outpatients data, excluding rule-out diagnosis, be observed for at least 1 year look back period prior to the index date. The comorbidity index, look back period, and data range must be considered for comorbidity adjustment. To provide better guidance to researchers, follow-up studies should be conducted using the three factors based on specific diseases and surgeries.

• Journal of Korean Medical Science
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• v.33 no.53
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• pp.343.1-343.8
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• 2018

Background: Linkage of public healthcare data is useful in stroke research because patients may visit different sectors of the health system before, during, and after stroke. Therefore, we aimed to establish high-quality big data on stroke in Korea by linking acute stroke registry and national health claim databases. Methods: Acute stroke patients (n = 65,311) with claim data suitable for linkage were included in the Clinical Research Center for Stroke (CRCS) registry during 2006-2014. We linked the CRCS registry with national health claim databases in the Health Insurance Review and Assessment Service (HIRA). Linkage was performed using 6 common variables: birth date, gender, provider identification, receiving year and number, and statement serial number in the benefit claim statement. For matched records, linkage accuracy was evaluated using differences between hospital visiting date in the CRCS registry and the commencement date for health insurance care in HIRA. Results: Of 65,311 CRCS cases, 64,634 were matched to HIRA cases (match rate, 99.0%). The proportion of true matches was 94.4% (n = 61,017) in the matched data. Among true matches (mean age 66.4 years; men 58.4%), the median National Institutes of Health Stroke Scale score was 3 (interquartile range 1-7). When comparing baseline characteristics between true matches and false matches, no substantial difference was observed for any variable. Conclusion: We could establish big data on stroke by linking CRCS registry and HIRA records, using claims data without personal identifiers. We plan to conduct national stroke research and improve stroke care using the linked big database.

• Safety and Health at Work
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• v.14 no.4
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• pp.406-414
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• 2023

Background: This study examined age-group differences in the rate, severity, and cost of injuries among construction workers to support evidence-based worker safety and health interventions in the construction industry. Methods: Ohio workers' compensation claims for construction workers were used to estimate claim rates and costs by age group. We analyzed claims data auto-coded into five event/exposure categories: transportation incidents; slips, trips, and falls (STFs); exposure to harmful substances and environments; contact with objects and equipment (COB); overexertion and bodily reaction. American Community Survey data were used to determine the percentage of workers in each age group. Results: From 2007-2017, among 72,416 accepted injury claims for ~166,000 construction full-time equivalent (FTE) per year, nearly half were caused by COB, followed by STFs (20%) and overexertion (20%). Claim rates related to COB and exposure to harmful substances and environments were highest among those 18-24 years old, with claim rates of 313.5 and 25.9 per 10,000 FTE, respectively. STFs increased with age, with the highest claim rates for those 55-64 years old (94.2 claims per 10,000 FTE). Overexertion claim rates increased and then declined with age, with the highest claim rate for those 35-44 years old (87.3 per 10,000 FTE). While younger workers had higher injury rates, older workers had higher proportions of lost-time claims and higher costs per claim. The total cost per FTE was highest for those 45-54 years old ($1,122 per FTE). Conclusion: The variation in rates of injury types by age suggests that age-specific prevention strategies may be useful.

• Journal of Korean society of Dental Hygiene
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• v.11 no.2
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• pp.275-289
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• 2011

Objectives : The recognition rate for issues and improving resolution for the recuperation income expense claim policy was examined. Methods : 1,135 copies of survey have been sent to the group of people who have claimed the dental recuperation income expense to dental recuperation institutions in Daejeon, Chungcheong Do that are registered to the health insurance evaluation and estimation office as of the May 2010 and 207 surveys that were regarded to be sincere for answering were analyzed. Results : Majority of respondence were belonged to the dentist institutions with more than 5 years of claim experiences as well as 10~50% of claim rate. The recognition of medical fee evaluation guideline was normal level, and negative recognition was higher to the health center with daily charge policy compare to the dental hospital and university affiliated dental center with treatment charge policy, Highest opinion for inappropriateness of dentist with significance was found (p<0.05). The openness of evaluation cases are regarded to be discharged through the transparent evaluation and most of the opinions for insurance claim evaluation adjustment are within the both 'Do not understand the evaluation guideline and program error of disease category, code and program' with significance(p<0.05). The reaction after the evaluation adjustment was high in reflection on the claim process after examining the reason for the evaluation adjustment through the evaluation and estimation office and university affiliated dental institution and dental center was regarded to be most active and deputy reclaimment was seemed to be most actively discharge the objection registration task (p<0.05). The claim error improving resolution recognition was highly prioritized to the accurate charting for the disease title and treatment description, improving the setting of claim program, and most highly recognized by the university affiliated dental hospital/dental center and comparably low by health center(p<0.05). and although the most of the responds of treatment description and browsing the medical fee was positive, 50% of dentists disagreed the idea so that this was creating a significant discrepancy with other groups(p<0.05). Conclusions : From this research, the recognition of medical fee evaluation guideline for dental (university) hospital and dentists were negative and high adjustment experience was examined as lacking of evaluation guideline understanding and error of disease name, code and programs and deputy reclaimment, university affiliated dental hospital/dental center were most actively handle the objection registration tasks and dentists have objection on the treatment description and browsing the treatment fee so that if these indexes can be referred to implement into the recuperation income claim process, this can be regarded to be a opportunity to create mutual credibility between recuperation institution, treatment pensioner and the evaluation institutions.