• 보건행정학회지
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• 제30권4호
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• pp.460-466
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• 2020

Background: The purpose of this study is to analyze whether there is a change in patterns of medical use among those likely to be converted their health insurance qualifications when the family support rule is alleviated. There is no empirical analysis that converting health insurance qualification will affect the increase in medical use. Methods: For analysis, data were extracted from the national health insurance eligibility and medical care database. To identify analysis targets similar to that of medical aids' characteristics among health insurance coverage, we compared income, property level, and medical use patterns through basic statistical analysis and used a difference-in-difference (DID) analysis to estimate the net effect of changes in medical use following the change of qualifications. Results: The main results are as follows. The results show that those who are under the 5% income group (1st income group) of health insurance coverage are the most similar to the medical aids group. DID analysis shows that changes in the medical use of people who maintain their national insurance qualification and who are not. As a results, the number of hospitalized days of converting group was reduced by 3.5 days while outpatient days were increased by 1.8 days. Conclusion: As a result, there was not much difference in the patterns of medical use for the under 5% income group who are likely to be eligible for expanded medical aids when the family support rule is alleviated. In addition, more than 30% of them are in arrears with their health insurance premiums, causing inconvenience in using medical services. These findings suggest the need of abolishing the criteria obligated to support family, and great efforts should be made to contribute to non-paid poor and remove their medical blind spot.

• 대한예방한의학회지
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• 제28권1호
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• pp.69-87
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• 2024

Objectives : This study is to investigate the current National Health Insurance Database cohort studies related to complications of Parkinson's Disease (PD) and suggest the design of Korean medical epidemiological studies of PD. Methods : Nationwide longitudinal studies of PD patients in South Korea were collected through Pubmed and the Korea Citation Index (KCI). We selected cohort studies that used the National Health Insurance Database in Korea and targeted Parkinson's disease patients. Studies published before February 2024 were categorized according to study designs. We examined variables and covariates, enroll dates and matching methods. Results : Of a total of 536 studies, 18 studies met the inclusion criteria. All studies used the National Health Insurance (NHI) Research Database and among them, 5 used sample data and one senior database. Studies can be classified into two types. 11 cohort studies were comparing PD patients and non-PD patients. Another type was 4 PD patients cohort studies. Most studies used two diagnostic codes (G20 and V124) for inclusion criteria. Enroll periods were from 2002 to 2017, and follow-up periods were from 7 to 14 years. 16 studies considered age and sex as covariates. 15 studies used the propensity score matching method to increase the level of causality. There was only one study related to the Korean medical treatment. Conclusion : In future cohort studies on Korean medical treatment, more attempts should be made to reveal the effect of the treatments on PD patients by defining inclusion criteria for patient groups, covariates, exposure variables, and assessment indicators more operatively.

• 간호행정학회지
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• 제15권2호
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• pp.264-274
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• 2009

Purpose: This study is to develop job standards in order to propose proper job level of the advanced nurse practitioners and apply the results to the work and enhance the expertism. Method: This study is a methodical study. The validity was examined by using the content validity index(CVI). Result: The pre-items of job standards for advanced health insurance review nurses were established and the final job standards comprising of 12 standards, 46 criteria, 92 indicators, 418 activities were determined after the examination by the advisory group. The validity of the job standards were examined for two times by the seven professionals. The relevance of the modified job standards was examined by the working level employees above the assistant manager position working in the general hospitals and the result was 93.14% relevance. The job standards comprising of 12 standards, 46 criteria, 89 indicator and 409 activities were developed. Conclusions: By the development of the job standards, it is expected to prove that advanced health insurance review nurses are the most suitable professionals for dealing with medical affairs such as management and propriety evaluation of medical expenses while defining the roles of advanced health insurance review nurses.

• 대한예방한의학회지
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• 제11권1호
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• pp.139-151
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• 2007

This paper evaluated the benefits of the National Health Insurance(NHI) and suggested the necessity of extending some oriental medical services into the benefits schedule in the NHI. Comparing the rate of public financing in national health expenditure in OECD countries and measuring out-of-pocket payments in total medical cost showed the level of insurance payments to total medical cost is approximately $50%{\sim}60%$ in Korea, which is quite insufficient to pay household medical expenses, although the NHI covers the whole population. A few of consumers' priority surveys for medical needs suggested herb medicine, muscle treatment, and manufactured herb medicine be included in the list of the NHI benefits, based on efficiency and equity criteria. It was estimated that the NHI can afford to cover these three items of oriental medical services.

• Journal of Preventive Medicine and Public Health
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• 제33권1호
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• pp.76-82
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• 2000

Objectives : We attempted to assess He accuracy of ICD codes for cerebrovascular diseases in medical insurance claims (ICMIC) and to investigate the reasons for error. This study was designed as a preliminary study to establish a nationwide surveillance system. Methods : A total of 626 patients with medical insurance claims who indicated a diagnosis of cerebrovascular diseases during the period from 1993 to 1997 was selected from the Korea Medical Insurance Corporation cohort (KMIC cohort: 115,600 persons). The KMIC cohort was 10% of those insured who had taken health examinations in 1990 and 1992 consecutively. The registered medical record administrators were trained in the survey technique and gathered data from March to May 1999. The definition of cerebrovascular diseases in this study included cases which met ore of two criteria (Minnesota, WHO) or 'definite stroke' in CT/MRI finding. We questioned the medical record administrators to explain the error if the final diagnoses were not coded as stroke. Results : The accuracy rate of the ICMIC was 83.0% (425 cases) Medical records were not available for 8.2% (51 cases) due to the closing of hospitals, the absence of a computer system or omission of medical record, etc. Sixty-three cases (10.0%) were classified as impossible to interpret due to insufficient records in 'major clinical symptoms' or 'neurological deficits'. The most common reason was 'to meet review criteria of medical insurance benefits (52.9%)'. The department where errors in the ICMIC occurred most frequently was the department for medical insurance claims in the hospital. Conclusion : The accuracy rate of the ICMIC was 83.0%.

• 의료법학
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• 제14권2호
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• pp.173-214
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• 2013

Traditionally, the Supreme Court has held that medical treatment agreements covered by national health insurance should be distinguished from other medical treatment agreements which are viewed as a consummation of the autonomous free will between doctor and patient. Namely, the Supreme Court views medical treatment agreements covered by national health insurance to be bound by the National Health Insurance Law with the intent to promote the applicability and comprehensiveness of the national health insurance scheme. Yet, issues of voluntary non-reimbursable treatments are triggered not only by the mistakes or moral hazard of medical care institutions but also by systemic limitations of national health insurance coverage criteria. Thus, there is a need for legislative measures that allow certain medical treatments to be included or reflected in the national health insurance coverage system so that patients may receive prompt and flexible medical treatments. To reflect such concerns, the Supreme Court made an exception for voluntary non-reimbursable treatments and developed a strict test to be applied in such cases in Supreme Court Judgment 2010 Doo 27639, 27646 (ruled on June 8, 2012 by the Grand Bench). Such judgment, however, is not a fundamental overturn of the Supreme Court's prior rulings that voluntary non-reimbursable treatments are not allowed under the law. It is only a slight revision of its previous stance for cases in which there is a lack of legislative measures to make coverage of a new yet valid medical treatment possible under the current national health insurance coverage system.

• 보험의학회지
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• 제27권2호
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• pp.68-74
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• 2008

Medical verification of cancer diagnosis in insurance claims is a very important procedure in insurance administrations. Claims staffs are in need of medical experts' opinions about claim administration. This procedure is called medical claim review (MCR) and is composed of verification and advice. MCR verification evaluates the insured’s physical condition by medical records and compares it with product coverage. It is divided into assessment of living assurance benefit, verification of cancer, and assessment of the cause of death. Actually cancer verification of MCR is applicable to coding because the risk ratio in product development is usually coded data. There are some confusing neoplastic diseases in assessing the verification of cancer. This article reviews gastrointestinal stromal tumors (GIST) and mucosa-associated lymphoid tissue tumors (MALToma) of the stomach. The second most common group of stromal or mesenchymal neoplasms affecting the gastrointestinal tract is GIST. Nowadays there are many articles about the pathophysiology of GIST. However there are few confirmative theories except molecular cell biology of KIT mutation and some tyrosine kinase. Therefore, coding the GIST, which has previously been classified as an intermediate risk group according to NIH2001 criteria, for cancer verification of MCR is suitable for D37.1; neoplasm of uncertain or unknown behavior of digestive organs and the stomach. The gastrointestinal tract is the predominant site of extranodal non-Hodgkin's lymphomas. B-cell lymphomas of the MALT type, now called extranodal marginal zone B-cell lymphoma of MALT type in the REAL/WHO classification, are the most common primary gastric lymphomas worldwide. Its characteristics are as follows. First, it is different from traditional stomach cancers such as gastric adenocarcinoma. Second, the primary therapy of MALToma is the eradication of H. pylori by antibiotics and the remission rate is over 80%. Third, it has a different clinical course compared to traditional malignant lymphoma. Someone insisted that cancer verification is not possible for the above reasons. However, there have been findings on pathologic mechanism, and according to WHO classification, MALToma is classified into malignant B-cell lymphoma and it must be verified as malignancy in MCR.

• Journal of Korean Neurosurgical Society
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• 제65권2호
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• pp.173-179
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• 2022

Disabilities can emerge due to traumatic spinal fractures. In terms of sacrococcygeal spine, because of its unique anatomic structure with minimal movement, the possibility for it to have a disability is relatively low. In Korea, unlike most disability criteria, private insurance companies acknowledge angular deformities caused by vertebral fractures as disabilities according to their degree, so there were several cases where patients required compensation, arguing angular deformity caused by sacrococcygeal fracture, which in some cases led to legal conflicts. Except the Act Welfare of Persons with Disabilities which recognizes only severe angular deformity affecting internal organs as disability and the industrial accident disability evaluation which does not recognize coccygeal fracture as disability but rarely recognizes sacral vertebra deformity equivalent to compressive deformation, there is little or no case where angular deformity is recognized as disability. Given the impairment evaluation standards in social insurance, McBride system, American Medical Association (AMA) guides, and newly proposed standards by the Korean Academy of Medical Sciences (KAMS), the most contentious point in the general terms and conditions of private insurance is spinal deformity. To overcome controversy over disability evaluation, the private insurance sector is now applying criteria for axial skeleton to sacrococcygeal vertebrae through revision of standards. Under these circumstances, it is fair to recognize sacrococcygeal fracture as impairment in terms of the pelvis only when the fracture leaves serious deformity and neurological symptoms with clear relevancy. Though it may not be easy to develop accurate disability evaluation standards, improvement is necessary to remove any irrationalities and make the standards as objective as possible.

• 보건행정학회지
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• 제11권1호
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• pp.107-130
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• 2001

During the last year, we had a very severe situation with the strike of physicians working in medical facilities. From that time, many politicians and scholars insisted on the expansion of public hospitals to enhance the public role in the medical care sector. They think that private medical facilities work for profit motivation and that the high proportion of private to whole facilities is an obstacle to the public function of medical care under social insurance system. They found that one of the reasons for failing to prevent the physicians' strike was the high proportion of private facilities. Others insisted that the strike was not a good reason for the expansion of public hospitals. The physicians' strike was a very rare case, and it is not a good basis for generalization of the discussion of public hospitals. Last year almost all apprentice physicians in public facilities took part in the strike, and consequently the public hospitals also lost the role of public function. They view this increasing involvement of government in the medical sector as improper and the cause of inefficiencies. In this paper we review the debate over the expansion of public facilities. To clarify the debate, we review traditional criteria for the role of government in a market system and to apply these criteria to medical care. There are two traditional areas where government Is acknowledged to have a role in a market system: market imperfections and market failure. Where market imperfections and market failure exist, there may be a role for government. The justifications for government intervention are consumer protection and the existence of externalities. One of externalities is to provide medical care for the poor. The appropriate measures to provide medical owe to the poor can be sought in both demand and supply side subsidies. National health insurance is a method of demand subsidies and establishment of public hospitals is a method of supply side subsidies. Under the National Health Insurance System, the expansion of public hospitals is not an appropriate subsidy policy.

• 보건행정학회지
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• 제16권4호
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• pp.128-146
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• 2006

The objective of this paper is to examine the proportion and characteristics of non-emergent patients at emergency departments. The observational survey was conducted using a structured form used by emergency medicine specialists or senior residents on June 7-20, 2005. 1,526 patients at ten emergency centers took part in this study. The structural form contained type of insurance, route and means of emergency department (ED) visit, triage based on the Manchester Triage Scale(MTS)-modified criteria, emergency level based on the government defined rule, type of emergency centers (Regional Emergency Medical Center; REMC, Local Emergency Medical Center; LEMC, Local Emergency Agency; LEA), as well as patient's general information. Data were analyzed using SAS statistical program(V.8.2). Descriptive analysis was performed to describe the magnitude of non-emergent patients. ${\chi}^2-analysis$ and logistic regression analysis was performed to identify the nonurgent patients' characteristics. In the MTS-modified criteria, we found a 15.3% rate of non-emergent patients. This rate differed from that of non-emergent patients obtained using government's rule. In particular, there were inaccuracies in the definition of government rule on non-emergent patients, so it is necessary to apply the new government rule regarding classification of non-emergent patients. There were significant differences in the rate of non-emergent patients according to type of ED, means of ED visit, time to visit, and insurance. Non-emergent patients are more likely to visit a D-type ED(LEA having less than 20,000 patients annually), not to use ambulance, to have 'Automobile Insurance, Industrial Accident Compensation Insurance, or pay out-of-pocket'. Non-emergent patients tend to visit ED due to illness rather than injury. Further studies on the development' of triage scale and reexamination of the government's rule on emergency visits are required for future policy in this area.