• 한국병원경영학회지
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• 제12권2호
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• pp.1-24
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• 2007

The medical fee reimbursement denied by HIRA(Health Insurance Review Agency) amounted to about 1.2% of the total medical fee claim to HIRA for reimbursement. Most of the denials stem from the inappropriate prescriptions of medical staff violating the medical fee review standards issued by HIRA. Considering the significant impacts of the standards observance behavior on the hospitals' financial viability, we attempted to analyze the predisposition factors of medical staffs' review standards observance behavior. The TPB(Theory of Planned Behavior) was adopted as the theoretical framework of the analysis. Data were collected by administrating a survey on the concepts included in TPB model to the 187 medical staff of a tertiary care hospital. Of the 187 questionaries distributed, 150 were responded resulting 80.2% of response rate. The mean differences among the groups classified by age group, years of experience, medical specialty and gender were analysis using ANOVA. The relationships among the TPB concepts were analysed by applying the Structural Equations Modeling method. The TPB model consists of three exogenous concepts (attitude toward the behavior, subjective norm, and perceived behavioral control) and two endogenous concepts (intention and the behavior). The results of ANOVA indicated significant mean differences among the groups classified by the medical staff's age, years of experience, and medical specialty. The older and the more experienced had the higher mean of observance behavior score. The results of Structural Equations analysis showed that the subjective norm and perceived behavioral control had statistically significant influences on intention, but the influence of attitude to intention was not statistically significant. The influences of perceived behavioral control and intention on behavior were significant. Based on these results the theoretical and practical implications were discussed.

• 의료법학
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• 제8권1호
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• pp.137-177
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• 2007

The medical expenses review system in Korea has developed under fee-for-service system with its own unique structure. The importance of reviewing medical expenses has been emphasized, as the size of medical expenditures moving through the health insurance legal context and its weight in the national economy have increased very rapidly. It is, however, analyzed that the feuds and arguments continue among the stakeholders for the lack of laws supporting the medical expenses review system. The medical expenses review is a series of administrative procedures, deciding whether claims from medical care institutions to the insurer are legal and valid or not. It mainly controls the increase of unnecessarily excessive health insurance claim and prevents fraudulent claim and abuse and checks the less use or unsuitable use of medical resources. It also works a function guarantees medical benefits for the appropriate treatment according to the object of health insurance system as a social insurance scheme. The dispute on legal base of the medical expenses review is about the source of law in the medical expenses review. There are the Health Insurance Act and administrative laws as jus scriptum and the guidelines of review as administrative orders. The medical expenses review should reflect various factors, such as the development of medical healthcare technologies, the health expenditures distribution, the financial situation of the health insurance, and the evaluation on the level of appropriate benefits. It is also likely to adapt to the traits of characters of medicine, and trends and transition, Besides it should judge the legality and the validity of medical benefits expenditures by synthesizing these all factors. And the evaluation system of appropriateness of medical benefits was administrative procedure which was consecutive with reviewing the medical expenses system and it was intended to make up for the result of reviewing the medical expenses in more comprehensive levels.

• The Journal of Korean Physical Therapy
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• 제34권1호
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• pp.26-37
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• 2022

Purpose: Japan established the convalescent rehabilitation wards, corresponding to Korea's rehabilitation medical institutions, in 2000 and developed it into the present system through continuous revisions. This study sought to analyze the issues and tasks faced by Japan segregated by the period of revision of convalescent rehabilitation ward-related medical fee regulations, through a literature review and further aimed to explore the direction of development of domestic rehabilitation medical institutions. Methods: Ten revisions of the medical fee regulations were classified into three stages based on quality evaluation: (1) the quantitative expansion stage (2000-2006); (2) quality evaluation introduction stage (2008-2014); and (3) quality evaluation maturity stage (2016-2020). Results: The following issues and tasks emerged: (1) For the quantitative expansion stage; insufficient rehabilitation within the ward, insufficient after-hour rehabilitation, insufficient connection with acute-stage hospitals and maintenance facilities, and the low ratio of specialists. (2) For the quality evaluation introduction stage; disparity in the manpower between institutions, the necessity of a 365-day rehabilitation system, avoidance of critical patients, and the problem that an increase in the amount of rehabilitation did not lead to a qualitative improvement. 3) For the quality evaluation maturity stage; cream-skimming issues in selecting patients, inappropriate evaluation of rehabilitation effects, and the necessity of follow-up measures after discharge. Conclusion: It is worth referring to the established regulations in Japan, and concurrently it is necessary to strengthen the evaluation of the structures, processes, and results when operating and evaluating rehabilitation medical institutions in Korea taking into account the side effects that could be identified in Japan.

• 의료법학
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• 제13권2호
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• pp.11-38
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• 2012

The Supreme Court stand in the position in specific lawsuit that it doesn't allow the discretionary not covered service, but recently in revocation suit of fine disposal that is imposed on medical fee of leukemia patient, it altered the existing adjudgement and admitted the discretionary not covered service exceptionally. It put forward the allowable condition roughly in that case. According as this alteration, it has become more important to embody the allowance conditions of exceptions. The Supreme Court presented three things, which are procedural condition, medical condition and subscriber's agreement. Concerning procedural condition, several present conciliation procedures are as follows: medical care benefit arret request, relative value conciliation etc, prior request on anti-cancer drug among chemicals which exceed acceptance criteria, request of non benefit object on common drugs. To be granted the existence of those system, there should be no obstacle to use that. Even if it were so, we should take circumstances into consideration; individual situation is unescapable concerning substance and urgency of the discretionary not covered service, process of the procedure, time required etc. Regarding medical condition, safety and effectiveness will be verified through evaluation procedures of new medical skill. About the necessity, the Supreme Court made clear through a sentence that it allow the discretionary not covered service, in case that needs to treat a patient out of the standard of medical benefit. Strict interpretation is right and it answer the purpose of the sentence that the supreme court permit the discretionary not covered service, exceptionally. We need to differentiate medical necessity and medical validity. Subscriber's agreement should holds true if it entails full explanation, and if it is preliminary, explicit and individual. On this account, it should be difficult to admit that someone agree effectively when he call for the affirmation that he is recipient of medical care. Reasonable expense needs to be a part of review whether the agreement is valid. Meanwhile If we adjust system of medical expense and eventually reorganize a fee for consultation payment system (Fee-for-service controlled by item to DRG (Diagnosis Related Groups)), controversial area of the discretionary not covered service will be decreased and that will guarantee the discretion of the doctor.

• 보건행정학회지
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• 제7권2호
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• pp.65-88
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• 1997

In Korea, telemedicine is still under the beginning stage, but we expect that the developing 'Information Highway' will make this technology more common place and more easily used in coming soon. Currently, three hospitals are providing telemedicine services with their subsidiary hospitals which are far away from their remote place. However, the fee schedule of telemedicine services are not well-settled down, of course not reimbursed through current health insurance system. This study aims to develop new payment system for medical services provided through telemedicaine system. To design appropriate fee schedule for telemedicine services, we, first, review the current insurance payment system and telemedicine system both in domestic and foreign countries focusing on its payment system. A framework of telemedicine payment system is proposed in following steps based on information we acquired from this stage. Second. We decide the span of cost items which should be covered by telemedicine payment scheme. In hear, we suggest payment method for telemedicine services should be designed as dual structure which are telemedicine fee that should be reimbursed through payment scheme and any costs related to capital investment that should not be covered by payment system. Which is, payment system for telemedicine services should cover only service-related costs and any costs related to capital investment should be generated through third party such as government, health insurance association, etc. Finally, we suggest new fee schedules for telemedicine services. The key issues on developing telemedicine fee schedules are related with the determination of appropriate additional rate($\alpha$). The reasonable additional rate($\alpha$) must determine through careful evaluation of any additional efforts(e. g. : additional work hours which are related to providing telemedicine services). This study shows the process of how to determine appropriate additional rate($\alpha$).

• 한국병원경영학회지
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• 제15권2호
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• pp.61-83
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• 2010

The purpose of this study is to analyze the effects of the introduction of 'business performance evaluation program' on the changes in organizational culture and employee commitment. The data for this study were collected three times, in 2006, 2008, and 2009 from the employees at a public hospital in Korea. The main findings of this study are as follows. 1. Organizational culture has gradually changed as the 'business performance evaluation program' was introduced and implemented. Regarding the changes in the different type of culture, we can see that group culture, developmental culture and rational culture has been stronger and, on the other hand, the introduction of 'the program' did not have as much impact on the hierarchical culture as on the other types of culture. 2. The group culture has have more impact on the organizational commitment than other types of culture. In case of the hierarchical culture, however, statistically significant relationships could not be found between the organizational commitment and the introduction of business performance evaluation program.

• 보건행정학회지
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• 제16권1호
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• pp.17-40
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• 2006

With the prospect of rapidly growing health insurance expenditures, particularly spending for ambulatory care, the introduction of a case-based payment method is discussed as an alternative to the current fee-for-service based method. A system to measure case mixes of providers is a core component of such payment systems. The objective of this study were to develop a classification system for ambulatory care, Korean Ambulatory Patient Group (KAPG) based on the U.S. APG version 2.0 and to evaluate the classification accuracy of the system. A database of 64,258,386 records was constructed from insurance claims submitted to the Health Insurance Review Agency (HIRA) during three months from August 2002. A total of 41,347,307 records with a single visit was used for the development and 7% random sample of the database was used for the evaluation. Additional groups were defined to include both physician and hospital fees in the classification, age splits were added to classify the entire population as well as the population older than 65, and the definition of medical groups used by the HIRA was adopted. The variance reduction in charges achieved by KAPGs was computed to evaluate the accuracy of classification. A total of 474 KAPGs was defined compare to 290 groups in the U.S. APG. The variance reduction for charges of all visits ranged from 20% to 37% depending on the type of provider, and ranged from 22% to 42% for non-outliers, that were better than those achieved by the system currently used by the .HIRA for its internal review purpose. Although further study is required to improve the classification for complicated care in larger hospitals, the results indicated that KAPGs could be used for better management of costs for ambulatory care.

• 보건행정학회지
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• 제25권3호
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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.

• 의료법학
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• 제17권1호
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• pp.299-346
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• 2016

2015년 한해에도 의료분야에서 다양한 판결이 선고되었다. 요양원 입소자에 대하여 요양원측 과실로 상해가 발생하여 요양원을 운영하는 사회복지법인이 환자의 진료를 의뢰한 사건에서 진료계약의 당사자 확정 기준이 제시되었고, 뇌사상태에 빠진 환자 가족의 무의미한 연명치료 중단 요구에 대하여 병원이 이를 거부하고 계속 진료한 경우 청구 가능한 진료비에 관한 판단이 이루어졌다. 안전성이 확인되지 아니하여 2011. 2. 보건복지부로부터 사상 초유의 시술중단조치를 받았던 눈미백수술에 관하여 법원은 시술 자체의 위법성을 인정하지는 아니하였으나 임상시험 단계에 있어 비용 대비 효과가 확립되어 있지 않다는 사실을 설명하지 아니한 설명의무 위반으로 전 손해의 배상을 명하였다. 의료과실을 적극적으로 인정한 판결로는 척추수술 후 마미증후군이 발생한 사건들에서 수술과정상 과실이 인정된 사례가 상당수 있었고, 병원감염 사건에서 감염을 유발한 과실을 인정한 판결이 선고되었다. 응급의료에 관한 법률상 응급장비 설치의무와 응급상황 발생시 조치의무를 구분하여 의료과실을 인정한 판결이 선고되었고, 극히 드문 희귀질환이라 하더라도 그에 대한 적절한 조치를 취하지 않은 의료기관에게 과실을 인정한 판결이 선고되었다. 손해배상의 범위와 관련하여 항소심 신체재감정 결과 노동능력상실률이 1심보다 작아지자 시간의 경과에 따라 노동능력상실률을 달리 적용하거나 환자의 상태에 따라 노동능력상실률을 신체감정 결과보다 낮게 인정하는 등 실체진실에 부합하는 판결이 선고되었다. 의료과실로 손해가 발생한 경우 의료사고 후 발생한 진료비에 책임제한이 적용되는지 여부와 관련하여 법원은 병원에서 환자 상태의 치유 또는 악화를 방지하는 정도의 치료만 계속되었다면 환자에게 진료비 지급을 청구할 수 없다는 이유로 병원 측의 상계주장을 배척하였다. 사전심의를 받지 않은 의료광고를 금지하고 그 위반시 처벌하는 의료법 규정에 대하여 사전심의기관인 대한의사협회 등의 행정기관성을 부인할 수 없어 사전검열에 해당한다는 이유로 위헌결정이 내려졌다. 임상에서 흔하게 시행되고 있는 PRP 치료가 법정비급여에 해당하는지 여부에 관하여 법원은 법정비급여 여부는 이론적인 가능성이나 실제 실시 여부 등에 따라 결정되는 것이 아니라 의학적 안전성 유효성을 인정받은 후 요양급여 또는 비급여대상으로의 편입절차를 거쳐야 함을 분명히 하였다. 또한 법원은 요양병원 적정성 평가에 관한 행정소송에서, 구조부문의 조사방식이나 절차상 위법을 인정하면서도 그 위법사유의 정도가 당연무효에까지는 이르지 아니하고 평가기관의 고의 과실이 없다는 이유로 건강보험심사평가원과 국민건강보험공단에 부당이득반환이나 손해배상의무가 없다는 판단을 하였다. 향후 더욱 다양하게 제기되는 쟁점들에 관하여 명쾌한 법리를 통해 실체진실에 다가가는 판결을 기대해본다.

• 보건행정학회지
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• 제28권3호
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• pp.195-196
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• 2018

The Korean Academy of Health Policy and Management (KAHPM) has shown remarkable achievements in the field of health policy and management in Korea for the last 30 years. The KAHPM consists of experts in various fields of health policy and management, and has been the leading academic discussion forum for health policy agendas of interest to the public. Health Policy and Management (HPM), the official journal of the KAHPM, published the first issue of volume 1 in October, 1991 and is publishing the second issue of volume 28 as of 2018. Currently, it is one of Korea' main journals in the field of health policy and management. HPM has published a special issue in commemoration of the 30th anniversary of the KAHPM. The HPM invited authors, including former presidents of the KAHPM and current board members, to write about main issues in health policy and management. Although the HPM tried to set up an invited author on all subjects in the health policy and management field, 19 papers are published, that completed the peer review process by August, 2018. The authors of the special issue of the 30th anniversary of the KAHPM include six former presidents, a senior professor, and 12 board members. The subjects of this issue are reform of the healthcare delivery system, health insurance and medical policy, reform of health system governance, the role of National Health Insurance Service (NHIS), the Korea Institute for Health and Social Affairs (KIHASA) and the National Evidence-based healthcare Collaborating Agency (NECA), ethical aspects of health policy change, regional disparities of healthcare, healthcare accreditation, new healthcare technology evaluation system, globalization of the healthcare industry, the epidemiological investigator system, the quarantine system, safety and disaster, and official development assistance. There are some remaining topics to deal with for the KAHPM: aged society, anti-smoking, non-infectious disease, suicide, healthcare resources, emergency medical care, out-of-pocket money, medical fee payment system, medical aid system, long-term care insurance, industrial accident compensation insurance, community-centered health welfare system, and central government and local government of health. The HPM will continue to publish review articles on the main topics in health policy and management. This is because the KAHPM, which has been the leading academic society of Korea's health policy and management for the last 30 years, feels responsible for continuing its mission for the next 30 years.