• Journal of Preventive Medicine and Public Health
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• v.45 no.3
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• pp.148-155
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• 2012

Since the reformation of the National Health Insurance Act in 2000, the Health Insurance Review and Assessment Service (HIRA) in the Republic of Korea has performed quality assessments for healthcare providers. The HIRA Value Incentive Program (VIP), established in July 2007, provides incentives for excellent-quality institutions and disincentives for poorquality ones. The program is implemented based on data collected between July 2007 and December 2009. The goal of the VIP is to improve the overall quality of care and decrease the quality gaps among healthcare institutions. Thus far, the VIP has targeted acute myocardial infarction (AMI) and Caesarian section (C-section) care. The incentives and disincentives awarded to the hospitals by their composite quality scores of the AMI and C-section scores. The results of the VIP showed continuous and marked improvement in the composite quality scores of the AMI and C-section measures between 2007 and 2010. With the demonstrated success of the VIP project, the Ministry of Health and Welfare expanded the program in 2011 to include general hospitals. The HIRA VIP was deemed applicable to the Korean healthcare system, but before it can be expanded further, the program must overcome several major concerns, as follows: inclusion of resource use measures, rigorous evaluation of impact, application of the VIP to the changing payment system, and expansion of the VIP to primary care clinics.

• The Korean Society of Law and Medicine
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• v.14 no.2
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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.

• Journal of the Korean Dietetic Association
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• v.28 no.2
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• pp.67-84
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• 2022

This study aimed to explore the status of food service outsourcing behavior of long-term care institutions (LTCIs) through a cross-sectional survey using a questionnaire administered between July 16th and August 7th, 2020. The survey respondents were either dietitians or facility managers, who worked at 731 nursing homes, 477 group homes, and 673 day-care centers. Approximately 25.9% of nursing homes, 11.7% of group homes, and 33.1% of day-care centers used a managed-services company to operate their food service units. The main reason for outsourcing food service by nursing homes was related to the staffing of dietitians and cooks, whereas group homes and day-care centers outsourced food services due to factors relating to meal costs and the cooking process. Almost all the LTCIs entered into private contracts for outsourced food services. Only a few food service contracts included the types of meals, nutrition standards such as protein and calories per meal, and the parameter or ratio of food cost. Of the respondents, 84.5% from nursing homes, 87.5% from group homes, and 87.1% from day-care centers agreed that the quality of outsourced food services of the LTCIs should be regulated. Meals are essential for maintaining the health and functional status of LTCI users. As more LTCIs outsource their food services, we suggest the following: (1) Increasing the minimum dietitian staffing standards for LTCIs as per the Welfare of Senior Citizens Act and requiring at least one dietitian for every nursing home, (2) Making it mandatory to use a standard food service contract template when drafting food service contract, and (3) Developing realistic standards for food service operations considering the size and operation type of the LTCIs.

• The Journal of the Korean dental association
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• v.54 no.6
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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.

• Journal of the Korea Academia-Industrial cooperation Society
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• v.13 no.12
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• pp.5816-5825
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• 2012

As the society has been ageing, senile dementia increase rapidly. Thus social costs of dementia treatment and management increase exceedingly. There is a desperate need of finding out improvements.. For example, foreign countries come with the solutions about this issue by establishing national strategy about Dementia, setting effective Dementia Management in national level and preparing legal systems. Older Welfare Act, Long Term Care Insurance Act for the Aged and Dementia Management Act exist as legal system of improvements. Improvement about this issue is needed due to more effective Dementia management and pushing ahead policies. First of all, the government needs to include dementia checkup into the list of national health insurance checkup toward senior citizen of older than 65-year-old. Secondly, as one of the characteristics of dementia, when more symptoms of dementia appear, there is less effect of treatment. Therefore, in order to reduce the social costs of Dementia, the government needs to promote Dementia prevention industry and early checkups. Thirdly, there is a need of setting a class judgement standard appeasement policy and expansion of using target. The reason of processing this statement is that there are difficulties of satisfying the needs of senior citizens due to current conformity of long-term pay recuperation according to laws of welfare.

• Health Policy and Management
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• v.18 no.2
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• pp.1-18
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• 2008

As medical insurance had been implemented for Magnetic Resonance Imaging (MRI) from January 1, 2005, this study investigated whether there had been any change in the amount of the medical care utilization of patients who undertook MRI before and after the insurance coverage, and was to examine factors affecting the amount of medical care utilization of MRI. Data were collected from patients who undertook MRI before and after the insurance coverage for a year at a general hospital in Kyeanggi-do. $X^2$ and t-test were used for the analysis of their general characteristics, the number of MRI, and its medical costs before and after the insurance coverage, and hierarchical multiple regression analysis for the factors affecting the amount of the medical care utilization of MRI. The results of this study were as follows. First, the number of MRI after the insurance coverage was significantly decreased. Second, there was no significant difference in the total medical costs of MRI after the insurance coverage, but a significant difference was found in patient's share of medical costs. Third, six variables were found to be affecting the amount of the medical care utilization of MRI, and the variables showed to lead the number of MRI decrease after the insurance coverage. These six factors explained 21.4% of the total number of MRI. As MRI had been covered by insurance, the use of MRI and patient's share of the costs were deceased, but the total medical costs were not affected. Reasons for that could be found in that MRI insurance, different from the case of CT insurance coverage, was allowed not to cover some items and the kinds of diseases subjected to the insurance coverage were extremely limited, lowering insurance prescription rate. In addition to that, the average medical cost of MRI was not changed after the insurance coverage. Therefore, as future measures for the MRI insurance, coverage, it should be considered to allow insurance coverage to no coverage items and to expand the scope of benefit coverage, or to lower patient's share of the costs. Furthermore, researches should be done to explore how recipients will act and how suppliers will react if the coverage is expanded, including expanding the scope of coverage and reducing patient's share of the costs, as well as to conduct research on its economic analysis according to case mix.

• The Korean Society of Law and Medicine
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• v.21 no.1
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• pp.33-67
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• 2020

The hospitals that are owned by non-medical personnel result when non-medical personnel with resources conspire with newly graduated medical doctors who cannot afford the enormous amount of capital required at the beginning of the establishment of a medical institution. Such hospitals, though they may have met the external requirements as medical institutions, disrupt the medical market as it should be centered by medical personnels, In addition, such hospitals are causing a huge social problem as it is illegally receiving and reducing various benefits such as medical care benefits and subsidies from the government, resulting in a significant financial leak in the national health insurance. The illegality of the opening of a non-medical personnel hospital is so high that it nullifies the contractual arrangement for the establishment, imposes criminal penalties on all persons involved in the establishment under the Korean Medical Law, and imposes administrative sanctions on medical personnel. In case the hospital was aware of the illegality of its opening, but had applied to receive medical care benefits from the National Health Insurance Act and the Medical Care Act, such actions will result in the return of the benefits under the National Health Insurance Act and the Medical Care Assistance Act, subject to the penalty for the crime of fraud, and aggravated punishment for specific economic crimes based on the amount of gain, as well as civil liability for torts. In this study, we will examine the current status of the regulations on the non-medical personnel hospital and present the basis for future legislative directions by looking at the legal regulations and the attitude of the precedents.

• Journal of Sasang Constitutional Medicine
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• v.29 no.4
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• pp.299-310
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• 2017

The Sasang Constitutional Examination, which is a medical treatment for Korean medicine, is a insurance non-coverage item. It is necessary to diagnose the constitution for medical treatment and to know the health regimen according to the constitution. We plan this project in order to expand the insurance guarantee reinforcement for Sasang Constitutional Examination and Counselling. This study was to investigate the status of insurance coverage and non-coverage items and to investigate objectivity and standardization of Sasang Constitutional Examination and Counselling. In addition, according to medical field, the items of Sasang Constitutional Examination and Counselling were divided. We reviewed the status of constitutional health care services and applied it to the financial budget for the medical care costs. Finally we propose Sasang Constitutional Examination and Counseling of Korean Medicine Act Classification (plan) and propose Insurance Coverage of Sasang Constitutional Examination and Counselling (plan).

• The Korean Society of Law and Medicine
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• v.8 no.1
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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.

• Journal of Home Health Care Nursing
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• v.14 no.2
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• pp.98-105
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• 2007

Home health care system in Korea has been classified into three types of home care programs based on different laws and regulations; for example, home health care nursing(HHCN) is based on medical laws, visiting health care nursing (VHCN) is based on long-term health care insurance, and visiting health care(VHC) is based on the regional health care act. HHCN in Korea has taken on an important role under the mandate of the national health care system since 2000. VHCN will commence its role under the long term health care insurance system in 2008. The strengthening of VHC commanded health promotion and prevention for vulnerable families in the community in 2007. This is an important turning point for increasing quality management for home health care program; it suggests certain possibilities for building a foundation for further changes in the service delivery structure. Accordingly, the home health care policy makers in Korea have a major function and role that consists of developing an agenda and alternatives for policy making in a systematic manner and clearly presenting implementation strategies for elderly health care system.