• 치위생과학회지
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• 제11권1호
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• pp.31-35
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• 2011

본 연구는 치과 의료기관의 건강보험 청구실태를 파악하여 향후 효율적인 치과 건강보험 청구관리를 위한 기초자료를 제공하고자 2010년 4월 20일부터 6월 20일까지 서울, 인천 경기, 부산 울산 및 일부 지역에 소재한 치과 의료기관을 대상으로 설문조사를 실시한 결과 다음과 같은 결론을 얻었다. 1. 치과 건강보험 청구형태는 병원 내 인력을 활용하여 청구하는 단독청구가 45.4% 응답하였으며, 대행청구 54.6%이었다. 청구자의 직종은 치과위생사 78.2%, 일반사무원 7.2%, 간호조무사 6.5%, 치과의사 4.5%, 기타 3.5%로 조사되었다. 청구건수는 200건 이하가 23.9%, 201건-400건이 40.3%, 401건 이상이 35.8% 이었다. 2. 청구건수에 의한 분석에서 청구 건수가 적은 경우일수록 대행청구는 하는 의료기관이 76.3%로 많았고 청구건수가 많을수록 단독청구의 비율이 높아졌으며, 개원기간에 따른 분석에서는 단독청구를 하는 의료 기관은 개원기간이 5년 이하인 경우 82.7%, 개원기간이 16년 이상인 경우 31.3%로 개원기간이 짧을수록 단독청구를 하는 의료기관이 많았다(p<0.000). 3. 병원 인력 수에 따른 분석에서 4인 이하인 경우는 단독청구가 25.4%, 대행청구가 74.6%로 대행청구가 많았으나 9인 이상인 경우에는 단독청구가 71.1%, 대행청구가 32.6%이었다(p<0.000). 4. 치과위생사 수에 따라 청구방식의 차이를 분석한 결과 치과위생사가 없는 경우는 86.5%가 대행청구를하고 있었으며 치과위생사 수가 많아질수록 단독청구 방식을 선택하고 있었으며 통계적으로 유의한 차이가 있는 것으로 분석되었다(p<0.000). 5. 치과 의료기관에서 대행청구를 하는 이유를 분석한 결과 복잡한 청구절차가 28.0%로 가장 많았으며 다음으로 청구업무의 실력부족 22.6%, 청구업무인력의 인재부재가 20.8%이었다.

• 치위생과학회지
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• 제15권6호
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• pp.815-824
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• 2015

이번 연구는 임상에 근무하고 있는 치과의사와 보험청구 담당자들의 건강보험관련 교육의 참여 실태를 파악하고, 교육경험이 그들의 요양급여비용의 산정기준에 대한 지식과 건강보험 실무 적용수준에 미치는 영향을 파악하고자 전국에 소재한 치과 병 의원에 근무하는 치과의사와 보험청구 담당자를 대상으로 설문 후 분석한 결과 다음과 같은 결론을 얻었다. 요양급여비용 산정기준에 관한 지식수준은 보험청구 담당자가 치과의사보다 높은 것으로 나타났다(p<0.01). 교육참여 횟수가 많을수록 보험청구 담당자의 요양급여비용 산정기준 지식수준이 통계적으로도 유의하게 높은 것으로 나타났고(p<0.001), 평균교육시간이 3시간 미만인 경우보다 3시간 이상인 경우 요양급여비용 산정기준에 대한 지식수준이 높게 나타났고, 통계적으로 유의한 차이를 보였다(p<0.05). 보험청구 담당자가 치과의사보다 건강보험 실무적용수준이 높은 것으로 나타났고, 통계적으로 유의한 차이를 보였다(p<0.001). 치과의사는 보험청구 경력이 많을수록 건강보험 실무 적용수준이 높은 것으로 나타났고(p<0.01), 보험청구 담당자는 연령이 적을수록, 교육 참여 횟수가 많을수록, 평균교육 시간이 길수록 건강보험 실무 적용수준이 높은 것으로 나타났다(p<0.05) 최근 3년간 건강보험관련 교육의 참여경험이 보험청구 담당자의 요양급여비용 산정기준 지식수준에 유의한 영향을 미치는 요인으로 나타났고(p<0.001), 보험청구 경력과 요양급여비용 산정기준 지식수준은 그들의 건강보험 실무 적용수준에 유의한 영향을 미치는 것으로 나타났다(p<0.01) 이러한 결과로 미루어볼 때 치과의사 및 보험청구 담당자의 건강보험에 관한 지식수준과 건강보험 실무적용 수준을 유지하기 위해서는 관련된 교육 관련된 교육을 지속적으로 받는 것이 필요할 것으로 판단된다.

• 보건행정학회지
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• 제14권4호
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• pp.88-113
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• 2004

Starting from April, 2003, new pre-review system has been introduced and implemented to reduce unnecessary conflict with medical care organizations caused by current retrospective claim review system and to enhance efficiency of review system. The main purpose of pre-review system is to educate doctors to contrive adequacy of medical services. This research mainly focuses on effectiveness of pre-review system's influence on physicians' behavior changes. The analysis-participants were drawn from 1,449 clinics which implemented pre-review system, since April of 2003. The research results are as followings. First, the amount per claim has reduced by $\\3,154$, days of visit per claim by 0.1 day, and amount per visit by $\\412$, which were statistically significant. Second, anesthesiologists have decreased in three indicators the most, and the internists had least of changes. Third, the amount per claim and days of visit per claims has dropped significantly on physicians with less periods of practice and physicians with more ages. Fourth, the clinics without the expensive medical equipments, the city clinics showed significant decrease on days of visit per claim. Fifth, in intervention methods, the one-to-one education showed more significant decrease on amount per visit rather than information feedback by paper. In conclusion, the pre-review system have an impact on self-imposed physician behavioral change. The outcome of this research may be utilized for future extension implementation of pre-review system. Furthermore, it is showed that ability of transitions in medical services review system according to the future transition of payment system and context of health service policy.

• 한국병원경영학회지
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• 제10권2호
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• pp.45-63
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• 2005

The purposes of this study are to understand the doctors' attitude and satisfaction about the review system of national health insurance claim in Korea and to suggest the way to improve this system This study conducted a survey of the doctors registered in the medical association in Seoul city. The survey was performed as a form of self-administered questionnaire from January 2004 to February 2004. The contents of questionnaire dealt with doctors' attitude and satisfaction about the review system of medical service claim. Totally, 1,037 members replied to our survey and we analysed 981 doctors' data, excluding incomplete responses. As a result, 89.7% of repliers showed a negative attitude about the influences of the review system on improvement of medical service quality, 98.0% of repliers have had experiences that they have given distorted insufficient medical services in order to evade the curtailment of service claim. Also, 91.6% of repliers stated that they have had experiences of intentional modification or alteration of diagnostic code to shun the curtailment. Most of the doctors showed negative attitude to the curtailment procedure and the review system of service claim originally intended to be one of the quality control methods of medical service in Korea also, the development of both scientific and reasonable parameters and criteria for claim is needed. 'Through the improvement of review system for appropriate medical service, there is a need of a way to increase the satisfaction of medical service providers, and to encourage the motivation for quality control. Also, education is strongly needed to provide doctors with sufficient information about review criteria and curtailment cases.

• Journal of Preventive Medicine and Public Health
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• 제57권1호
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• pp.1-7
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• 2024

Objectives: Adjusting for potential confounders is crucial for producing valuable evidence in outcome studies. Although numerous studies have been published using the Korea National Health Insurance Claim Database, no study has critically reviewed the methods used to adjust for confounders. This study aimed to review these studies and suggest methods and applications to adjust for confounders. Methods: We conducted a literature search of electronic databases, including PubMed and Embase, from January 1, 2021 to December 31, 2022. In total, 278 studies were retrieved. Eligibility criteria were published in English and outcome studies. A literature search and article screening were independently performed by 2 authors and finally, 173 of 278 studies were included. Results: Thirty-nine studies used matching at the study design stage, and 171 adjusted for confounders using regression analysis or propensity scores at the analysis stage. Of these, 125 conducted regression analyses based on the study questions. Propensity score matching was the most common method involving propensity scores. A total of 171 studies included age and/or sex as confounders. Comorbidities and healthcare utilization, including medications and procedures, were used as confounders in 146 and 82 studies, respectively. Conclusions: This is the first review to address the methods and applications used to adjust for confounders in recently published studies. Our results indicate that all studies adjusted for confounders with appropriate study designs and statistical methodologies; however, a thorough understanding and careful application of confounding variables are required to avoid erroneous results.

• 융합정보논문지
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• 제9권9호
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• pp.195-200
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• 2019

국민건강보험 청구자료는 급여 지급을 위한 자료로 질환에 대한 유병 및 발생자료는 아니므로 보건학적 연구 자료로 활용하기 위해서는 진료에피소드개념을 적용하여 재가공이 필요하다. 따라서 건강보험 청구자료의 보건학적 연구 자료로 활용하기 위한 시범적 진료에피소드 자료를 구축하는 것이 목적이다. 본 연구에서는 무진료기간을 퇴원한 당일 입원한 경우 월 단위 분리청구를 보정하기 위해 0으로 정의하였다. 서울지역에 한하여 호흡기계 질환(ICD10: J00-J99)및 심혈관계 질환(ICD10: I00-I99) 발생의 진료개시일부터 입원 이후 재입원까지 경향을 확인하였다. 무진료기간이 0일 일 때 자료 감소율은 건강보험청구자료의 월 단위 분리청구건으로 인한 것으로 판단된다. 또한 의료기간 종별에 따라 월 단위 분리청구 경향 차이가 있는 것으로 확인 하였다. 본 연구를 통해 구축된 시범적 진료에피소드자료는 기초적 역학정보를 산출하는 자료처리 기법으로 이용될 수 있을 것이다.

• 보건행정학회지
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• 제26권1호
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• pp.63-70
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• 2016

Background: Selective health benefit was introduced for decreasing economic burden of patients. Medical devices with economic uncertainty have been covered as selective health benefit by National Health Insurance since December 2013. We aimed to analyze impact of selective health benefit to medical expenditure and provider behavior focused on electrosurgery (ultrasonic shears, electrothermal bipolar vessel sealers) for gastric cancer patients covered since December 2014. Methods: We used the National Health Insurance claims data of 2,698 patients underwent gastric cancer surgery between August 2014 and March 2015. Medical cost and patient sharing per inpatient day were analyzed to verify that covering electrosurgery increased medical expenditure and changed provider behavior from open surgery to endoscopic or laparoscopic surgery. Additionally, we analyzed the claim rate of medical device or goods relating gastric endoscopic and laparoscopic surgery. Results: Medical cost and patient sharing per inpatient day were increased after covering electosurgery as selective health benefit (39,724/1,421 won). However, there were no medical expenditure increases after adjusting claim of electosurgery and patient sharing was decreased 1,057 won especially. The coverage of selective health benefit did not increase the claim rate of medical device or goods related endoscopic or laparoscopic surgery, either. Conclusion: Covering electosurgery decreased patient economic burden and did not change of provider behavior. Expanding selective health benefit is needed to decrease economic burden of severe patients. Further study should evaluate the long term effect with accumulated data.

• Journal of Acupuncture Research
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• 제27권3호
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• pp.137-146
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• 2010

Objectives : While there are many studies about treatments of facial palsy, no study has been performed on general population of Korea, especially concerning about comparison between western medicine and oriental medicine. This study aimed to investigate magnitude of health visits and treatment patterns for Korean patients with facial palsy through the computerized database of Health Insurance Review and Assessment Service(HIRAS). Methods : According to the HIRAS database over 5 years' period from 2004 to 2008, the medical records of patients with facial palsy as a main diagnosis were extracted. Inclusion criteria of facial palsy are Bell's palsy(G510), Geniculate ganglionitis(G511), Melkersson's syndrome(G512), Other disorders of facial nerve(G518), Disorder of facial nerve, unspecified(G519) in western medicine. And Paralytic face(G016), Deviated eye and mouth(J01), The other facial palsy(J013) were included in oriental medicine. We compared the claim number of western medical care with that of oriental medicine treatment by year and month. Results : The total claim number of facial palsy was increasing on both western medicine and oriental medicine from 2004 to 2008. In western medicine, the claim number of Bell's palsy(G510) is the most. In oriental medicine the inpatients claim number of Deviated eye and mouth(J01) is the most, while outpatients claim number of the other facial palsy(J013) is the most. Conclusions : Medical database of HIRAS provided comprehensive and vast information on epidemiologic characteristics and treatment, which can be more reliable data to expect medical demand for facial palsy in condition that accurate diagnosis and standardized treatment is delivered in clinical settings.

• Journal of Preventive Medicine and Public Health
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• 제54권1호
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• pp.8-16
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• 2021

This article aims to introduce the inception and operation of the COVID-19 International Collaborative Research Project, the world's first coronavirus disease 2019 (COVID-19) open data project for research, along with its dataset and research method, and to discuss relevant considerations for collaborative research using nationwide real-world data (RWD). COVID-19 has spread across the world since early 2020, becoming a serious global health threat to life, safety, and social and economic activities. However, insufficient RWD from patients was available to help clinicians efficiently diagnose and treat patients with COVID-19, or to provide necessary information to the government for policy-making. Countries that saw a rapid surge of infections had to focus on leveraging medical professionals to treat patients, and the circumstances made it even more difficult to promptly use COVID-19 RWD. Against this backdrop, the Health Insurance Review and Assessment Service (HIRA) of Korea decided to open its COVID-19 RWD collected through Korea's universal health insurance program, under the title of the COVID-19 International Collaborative Research Project. The dataset, consisting of 476 508 claim statements from 234 427 patients (7590 confirmed cases) and 18 691 318 claim statements of the same patients for the previous 3 years, was established and hosted on HIRA's in-house server. Researchers who applied to participate in the project uploaded analysis code on the platform prepared by HIRA, and HIRA conducted the analysis and provided outcome values. As of November 2020, analyses have been completed for 129 research projects, which have been published or are in the process of being published in prestigious journals.

• 한국축산식품학회지
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• 제29권5호
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• pp.599-611
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• 2009

This article concerns the labeling guideline for health benefits of livestock products. In recent years, livestock products with health benefits have emerged as a key market for livestock product industries. However, the current labeling regulation for functional foods severely prohibits livestock product industries from attaching most of the health benefits claims to the products. Also, manufacturers have some difficulties in labeling the health benefits of certain livestock products because of a lack of guidelines on health benefit claims for livestock products. Therefore, some livestock product industries and scientists have strongly demanded a revision of labeling regulation, Appended Chart No. 14 provided by Article 52 (2) of Enforcement Regulation of the Processing of Livestock Products Act, so they could mark the health benefits on their products. To support the 'revision of labeling regulation', the goals of this article were as follows; 1) to assess the current situation on nutrition labeling and nutrition claims on foods, 2) to determine the current situation on health claim regulatory systems used in foreign countries (CODEX, USA, Japan, EU, and Australia/New Zealand), 3) to assess the current situation on the health claim or health benefit claim regulations for functional foods, conventional foods, and livestock products in Korea, and 4) to determine the need for complement in health benefit claim for livestock products. In conclusion, guidelines for the use of health benefit claims on livestock products should be prepared as soon as possible and the guidelines should be viable and easy for manufacturers and control authorities to understand. Also, nutrient profiles should be developed to identify whether the livestock products are eligible to bear health benefit claims and to help consumers make the right choices.