• 보건행정학회지
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• 제16권2호
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• pp.117-134
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• 2006

Korean health care system introduced the reform for separation between prescribing and dispensing of drugs (SPD reform) in the latter part of the year 2000. The objective of this paper is to look at what change this reform has brought about in the financial situation of Korean public health insurance scheme, particularly in terms of insurance benefit outlay. Since the inception of the reform is a development of more than five years ago, its impact on the finance situation would now start to become apparent. Hypothesis is set in this study for each of three components of drug reimbursement in health insurance, i.e. average price level, composition of drugs and their overall volume. In terms of the classification of health care services by mode of production, the impact of the SPD reform is confined mainly to the last two among three drug reimbursement fields including inpatient department, out-patient department and pharmacy. Pure impact of the SPD reform was estimated to be more or less than 1.7 trillion won, 13.1% of the total outlay of the Nation Health Insurance in 2001, and more than 2.0 trillion won, 14.9% of the total outlay of the Nation Health Insurance in 2003. Both dispensing fees for the pharmacists, which had been newly introduced on occasion of the SPD reform, and larger share of expensive drugs in the medicines prescribed by doctors were confirmed to be main drivers of the augmentation of drug reimbursement.

• 의료법학
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• 제8권2호
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• pp.37-68
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• 2007

Health insurance has gone far toward solving Korea's health related problems through thirty years. Health Insurance as social security system has a role of national system to secure national health. But there are many problems in health insurance. There is a dispute about many issues, coverage of health security, compulsory appointment of health insurance organization, coverage and level of health insurance benefit, decisionmaking right of health insurance price, examination of health insurance etc. Generally, the opinion for health insurance policy to be leaded by nation sets against the opinion to be leaded by private sector. It is necessary to study politics of law, constitute law and comparative law for rational solving these problems. If desirable setting of health law system can be made, legal system must be set during a long time and be discussed synthetically in different standpoint.

• 보건행정학회지
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• 제28권3호
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• pp.210-216
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• 2018

National Health Insurance Service (NHIS) has put a great effort on extending life expectancy, for last 40 years. The system has also made remarkable outcomes in achieving universal health coverage. However, it is facing challenges of low health insurance benefits and sustainability risk due to low birth rate and aging society at the same time. To overcome the difficulties and build a lifelong health security system for the nation, it is required for NHIS to make multilateral changes in its roles. Based on the quantitative growth achieved so far, NHIS needs to strive for the growth in quality by not only increasing coverage and reforming contribution imposition system, but also reorganizing the relevant systems such as lifelong health management support, rational adjustment to the medical fee, and benefit costs monitoring. In addition, it's important for NHIS to restructure the organizational culture by having specialty and communicating with people for high quality of administration and health insurance sustainability.

• 한국치위생학회지
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• 제6권3호
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• pp.243-261
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• 2006

Priority setting in national health insurances in major advanced countries and the nation was investigated to draw the criteria for priority setting and suggest the most rational criteria for dental insurance so as to help secure the efficiency of medicare financing and individual's health right and also elevate medical consumers' satisfaction with health insurance. 1. Priorities in national health insurance are different from country to country, depending on the medical security systems, priority introducing conditions, and social environment, but have many common factors. 2. The priority setting criteria for national health insurance in those countries include the following in common: the efficiency, equity, and cost effect of treatment, emergency of treatment, consumption of expense, efficacy of treatment, patient's receptiveness, patient's demand, severity of disease, and patient's responsibility for the disease. 3. In oral diseases, severe diseases including oral cavity cancer are low in rate, and in-hospital treatments are few. From the above findings, it is suggested that dental insurance should establish discriminative criteria for priority setting by reflecting the aspects of dental diseases and system difference between dental and other health insurances and taking account of efficiency of treatment through prevention, cost effect, prevalence and incidence of generalized diseases, and individual's financing burden.

• 대한치과의사협회지
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• 제54권6호
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• pp.448-456
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• 2016

Dental care is becoming more available on the NHI(National Health Insurance) in Korea. Especially, complete denture, partial denture, dental scaling, and dental implant has been applied by NHI from 2012 to 2014. Although, the entire nation is not eligible for the benefit now, the more dental coverage of NHI is extended, the more regulaition is tightened. Essential documents for proof of correctness of dental treatment covered by NHI are dental records and the receipt book. Summary of regal regulation about them is as follows 1. Chief complaints of patients, diagnosis, progress, and act of treatment, drugs and materials of treatment, doctor's sign, date and hour should be placed accurately on dental record 2. Dental clinic should collect patients sharing of the dental cost covered by NHI. 3. Dental clinic should keep the receipt as proof of purchase of dental drugs or materials.

• 한국융합학회논문지
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• 제13권5호
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• pp.77-84
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• 2022

본 연구는 치과의료기관의 건강보험 청구 만족도 및 건강보험 지식정도에 따른 청구 결과의 차이를 분석하여 향후 지속 가능한 건강보험제도를 마련하는데 필요한 기초 자료를 제공하고자 한다. 본 연구는 치과 의료기관 종사자 209명을 대상으로 2019년 3월~5월까지 자기기입식 온라인 설문을 시행하였다. 분석결과 건강보험 청구 만족도에 따른 치과건강보험청구 관련 전문인력의 요구도는 전문인력 자격요건(p<.05) 항목에서 통계적으로 유의하였다. 지식정도를 측정하는 지표인 자격증 유무에 따른 전문인력 요구도는 의료기관에 따라 청구 전문인력 필요 이유가 상이한 것으로 나타났으며(p<.05) 통계적으로 유의하였다. 따라서 치과건강보험 청구 전문인력의 필요성을 확인하였으며 이를 위한 정책이 마련되어야 할 것이다.

• 보건행정학회지
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• 제29권4호
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• pp.379-381
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• 2019

Korea's healthcare is in great danger of sustainability. In 2020, the baby boomer will begin to be older, and there is no promise that the total fertility rate of 1.0 or less will rebound, and Korea's economic growth rate is predicted to be less than 2%. Together with these phenomena, Plan for Benefit Expansion in Nation Health Insurance (Moon Jae-in Care) will seriously threaten the sustainability of health insurance finance. In addition, health care in Korea has many problems: excessive medical utilization, rapidly increasing elderly medical costs, concentrating patients into big hospitals, low healthcare personnel but many healthcare facilities and equipment, bad quality of primary and mental care, and fast-growing health expenditure. For sustainability, healthcare of Korea should be reformed. The direction of the reform is people-centered and integrated healthcare in the community which is composed of empowering and engaging people, strengthening governance and accountability, reorienting the model of care, coordinating services, and creating an enabling environment.

• Journal of Trauma and Injury
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• 제25권4호
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• pp.178-187
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• 2012

Purpose: In Korea, the nation's medical expenses were 12 billion won in 2010. The medical costs for individuals can also be overwhelming. If a patient has sustained severe trauma, his/her insurance company responsible may pay only part of the medical bills. In Korean, there are diverse types of medical insurance, such as health insurance, automobile insurance, and industrial accident compensation insurance. And each insurance system has a different type of payment system. Our study will be essential for establishing the optimal medical expense payment system. Methods: From January to December 2011, we retrospectively reviewed the medical charts of 161 patients who were admitted to our hospital's emergency room after having undergone severe trauma. Of those 161 patients, 125 were retrospectively reviewed. Written permission was obtained from all of the patients. We analysed the demographic characteristics, clinical outcomes, data of the trauma, type of the patient's insurance, and the entire bill when the patient was discharged. Results: Seventy-one patients had health insurance, 48 automobile insurance, and six industrial accident compensation insurance. High-deductible insurance included health insurance and industrial accident compensation insurance, with the deductibles up to 20.6% and 19.1%, respectively. We attempted to analyze the cause of the high deductible rate. In patients with health insurance, medicines, primarily sedatives, pain killers, antibiotics, and fluids. comprised a large proportion. On the other hand, industrial accident compensation insurance deducted for a high-grade hospital room charge. Conclusion: We found that medical expenses were diverse according to the type of insurance. In particular, health insurance forced patients to pay too much of the medical expenses. Therefore, in Korea we should try to identify the insurance problems and improve the wage system.

• Journal of Preventive Medicine and Public Health
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• 제39권5호
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• pp.397-403
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• 2006

Objectives: We estimated the asthma-related health care utilization and costs in Korea from the insurer's and societal perspective. Methods: We extracted the insurance claims records from the Korea National Health Insurance claims database for determining the health care services provided to patients with asthma in 2003. Patients were defined as having asthma if they had ${\geq}$2 medical claims with diagnosis of asthma and they had been prescribed anti-asthma medicines, Annual claims records were aggeregated for each patient to produce patient-specific information on the total utilization and costs. The total asthma-related cost was the sum of the direct healthcare costs, the transportation costs for visits to health care providers and the patient's or caregivers' costs for the time spent on hospital or outpatient visits. Results: A total of 699,603people were identified as asthma patients, yielding an asthma prevalence of 1.47%. Each asthma patient had 7.56 outpatient visits, 0.01 ED visits and 0.02 admissions per year to treat asthma. The per-capita insurance-covered costs increased with age, from 128,276 Won for children aged 1 to 14 years to 270,729 Won for those aged 75 or older. The total cost in the nation varied from 121,865 million to 174,949 million Won depending on the perspectives. From a societal perspective, direct health care costs accounted for 84.9%, transportation costs for 15.1 % and time costs for 9.2% of the total costs. Conclusions: Hospitalizations and ED visits represented only a small portion of the asthma-related costs. Most of the societal burden was attributed to direct medical expenditures, with outpatient visits and medications emerging as the single largest cost components.

• 보건교육건강증진학회지
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• 제23권4호
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• pp.13-28
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• 2006

Objectives: This study used the characteristics of the knowledge discovery and data mining algorithms to develop hypertension predictive model for hypertension management using the Korea National Health Insurance Corporation database(the insureds' screening and health care benefit data). Methods: This study validated the predictive power of data mining algorithms by comparing the performance of logistic regression, decision tree, and ensemble technique. On the basis of internal and external validation, it was found that the model performance of logistic regression method was the best among the above three techniques. Results: Major results of logistic regression analysis suggested that the probability of hypertension was: - lower for the female(compared with the male)(OR=0.834) - higher for the persons whose ages were 60 or above(compared with below 40)(OR=4.628) - higher for obese persons(compared with normal persons)(OR= 2.103) - higher for the persons with high level of glucose(compared with normal persons)(OR=1.086) - higher for the persons who had family history of hypertension(compared with the persons who had not)(OR=1.512) - higher for the persons who periodically drank alcohol(compared with the persons who did not)$(OR=1.037{\sim}1.291)$ Conclusions: This study produced several factors affecting the outbreak of hypertension using screening. It is considered to be a contributing factor towards the nation's building of a Hypertension Management System in the near future by bringing forth representative results on the rise and care of hypertension.