• Journal of Korean Academy of Nursing
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• v.41 no.3
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• pp.302-312
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• 2011

Purpose: The purpose of this study was to develop a resource-based relative value scale (RBRVS) and its conversion factor for advanced nursing practices carried out by critical care nurse practitioners (CCNP) in intensive care units. Methods: The methodology was developed by calculating CCNP's RBRVS for 32 advanced nursing services based on CCNP's workload and time spent in the context of national health insurance. A cost analysis was performed to estimate the conversion factor of CCNP's RBRVS. The share of CCNP's contribution to fee-for-service in intensive care units was also analyzed. Results: Calculation of the RBRVS of 32 advanced nursing practices showed a range of points from 100.0 to 1,181.4 and an average of 296.1 points. The relevant conversion factor for advanced nursing practices in CCNP were estimated at 37.3-48.4 won. The contribution rate of CCNP's advanced nursing practices in the relative value scale of the national health insurance was estimated at 0.1-31.3%. Conclusion: Measuring the economic value of advanced nursing services will be a basis for esta-blishing a reimbursement system for CCNP's practices and thus encourage a social demand for advanced nurse practitioners.

• Health Policy and Management
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• v.25 no.3
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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.

• Journal of Preventive Medicine and Public Health
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• v.44 no.1
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• pp.48-55
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• 2011

Objectives: The purpose of this study was to examine the impact of Diagnosis-Related Group (DRG)-based payment on the length of stay and the number of outpatient visits after discharge in for patients who had undergone caesarean section. Methods: This study used the health insurance data of the patients in health care facilities that were paid by the Fee-For-Service (FFS) in 2001-2004, but they participated in the DRG payment system in 2005-2007. In order to examine the net effects of DRG payment, the Difference-In-Differences (DID) method was adopted to observe the difference in health care utilization before and after the participation in the DRG payment system. The dependent variables of the regression model were the length of stay and number of outpatient visits after discharge, and the explanatory variables included the characteristics of the patients and the health care facilities. Results: The length of stay in DRG-paid health care facilities was greater than that in the FFS-paid ones. Yet, DRG payment has no statistically significant effect on the number of outpatient visits after discharge. Conclusions: The results of this study that DRG payment was not effective in reducing the length of stay can be related to the nature of voluntary participation in the DRG system. Only those health care facilities that are already efficient in terms of the length of stay or that can benefit from the DRG payment may decide to participate in the program.

• Journal of Preventive Medicine and Public Health
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• v.22 no.4 s.28
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• pp.542-554
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• 1989

The skyrocketing inflation of medical costs has become a major health problem among most developed countries. Korea, which recently covered the entire population with National Health Insurance, is facing the same problem. The proportion of health expenditure to GNP has increased from 3% to 4.8% during the last decade. This was remarkable, if we consider the rapid economic growth during that time. A few policy analysts began to raise cost containment as an agenda, after recognizing the importance of medical cost inflation. In order to Prepare an appropriate alternative for the agenda, it is necessary to find out reasons for the cost inflation. Then, we should focus on the reasons which are controllable, and those whose control are socially desirable. This study is designed to articulate the theory of medical cost inflation through literature reviews, to find out reasons for cost inflation, by analyzing aggregated data with a deterministic model. Finally to identify determinants of changes in both medical demand and service intensity which are major reasons for cost inflation. The reasons for cost inflation are classified into cost push inflation and demand pull inflation, The former consists of increases in price and intensity of services, while the latter is made of consumer derived demand and supplier induced demand. We used a time series (1983-1987), and cross sectional (over regions) data of health insurance. The deterministic model reveals, that an increase in service intensity is a major cause of inflation in the case of inpatient care, while, more utilization, is a primary attribute in the case of physician visits. Multiple regression analysis shows that an increase in hospital beds is a leading explanatory variable for the increase in hospital care. It also reveals, that an introduction of a deductible clause, an increase in hospital beds and degree of urbanization, are statistically significant variables explaining physician visits. The results are consistent with the existing theory, The magnitude of service intensity is influenced by the level of co-payment, the proportion of old age and an increase in co-payment. In short, an increase in co-payment reduced the utilization, but it induced more intensities or services. We can conclude that the strict fee regulation or increase in the level of co-payment can not be an effective measure for cost containment under the fee for service system. Because the provider can react against the regulation by inducing more services.

• Journal of the Korea Academia-Industrial cooperation Society
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• v.11 no.4
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• pp.1504-1510
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• 2010

According to a research analysis of the factors which affect the medical utilization fee after an increase of health insurance benefits for patients with serious illnesses based on 225 patients over 6 months, both before and after the increase of benefits, from January, 1st, 2005 to June 30th, and also from January, 1st, 2006 to June 30th. In terms of genders, 67.8% of males were affected, whereas only 32.2% of females were effected, a much higher rate of men than women. Men also had higher rates before and after the increase of benefits. Out of 5 categories related to medication and treatment, radiation testing was the most expensive at about 5,300,000, operation fees were 590,000, and costs of other testing approximately 200,000 with the least expensive category being 120,000 for medication. By looking at the relationship between the fees and increase of benefits, medication was a hospital charge (p<0.01), injection fees were hospital charges (p<0.01), operation fees were hospital charges (p<0.01). Medication fees (p<0.01) and injection fees (p<0.01) were found to be related.

• Journal of Korean Academy of Nursing Administration
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• v.19 no.4
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• pp.449-461
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• 2013

Purpose: The purpose of this study was to explore the relationship between cost and revenue for inpatient nursing activities in general wards. Methods: Data were collected from 12 medical-surgical wards in one general hospital from January 1 to December 31, 2010. The nursing activities were categorized into 2 groups according to nursing service payment type in terms of the Korea health insurance system. Descriptive statistics were used to identify nursing activities and nursing activity costs. Results: Of 140 nursing activities identified as performed in general wards, payment for 69 items was included in nursing management fees. The percentage of each cost for the nursing units was 90% for labor, 4% for materials, and 6% for operating expenses. The cost for medical support nursing service accounted for 38% of costs and nursing management fees, 62%. The average profit and loss was -237,257,000 won. The cost recovery rate for nursing service was only 44%. Conclusion: The results indicate a need to measure the economic value of nursing activities performed in general wards and use it as a basis for establishing an adequate reimbursement system for nursing service.

• Journal of Preventive Medicine and Public Health
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• v.33 no.4
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• pp.393-401
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• 2000

Objectives : To evaluate the impacts of the DRG payment system on the behavior of medical insurance claimants. Specifically, we evaluated the case-mix index, the numbers of diagnosis and procedure codes utilized, and the corresponding rate of diagnosis codes before, during and after implementation of the DRG payment system. Methods : In order to evaluate the case-mix index, the number of diagnosis and procedure codes utilized, we used medical insurance claim data from all medical facilities that participated in the DRG-based Prospective Payment Demonstration Program. This medical insurance claim data consisted of both pre-demonstration program data (fee-for-service, from November, 1998 to January, 1999) and post-demonstration program data (DRG-based Prospective Payment, from February, 1999 to April, 1999). And in order to evaluate the corresponding rate of diagnosis codes utilized, we reviewed 820 medical records from 20 medical institutes that were selected by random sampling methods. Results : The case-mix index rate decreased after the DRG-based Prospective Payment Demonstration Program was introduced. The average numbers of different claim diagnosis codes used decreased (new DRGs from 2.22 to 1.24, and previous DRGs from 1.69 to 1.21), as did the average number of claim procedure codes used (new DRGs from 3.02 to 2.16, and previous DRGs from 2.97 to 2.43). With respect to the time of participation in the program, the change in number of claim procedure codes was significant, but the change in number of claim diagnosis codes was not. The corresponding rate of claim diagnosis codes increased (from 57.5% to 82.6%), as did the exclusion rate of claim diagnosis codes (from 16.5% to 25.1%). Conclusions : After the implementation of the DRG payment system, the corresponding rate of insurance claim codes and the corresponding exclusion rate of claim diagnosis codes both increased, because the inducement system for entering the codes for claim review was changed.

• Journal of the Korea Academia-Industrial cooperation Society
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• v.18 no.6
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• pp.119-128
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• 2017

This study estimated the optimal nursing workforce and financial costs of providing comprehensive nursing services at hospitals under the national health insurance system. Data on registered nurses, nursing aids, medical institutions, and number of patients were obtained from the Health Insurance Review and Assessment Service. The optimal size of the nursing workforce was calculated using the workload model. A bottom-up approach was used to estimate the annual total financial cost of comprehensive nursing services. The number of registered nurses and nursing aids would need to be increased by 81.75% and 83.23%, respectively, in order to fully apply comprehensive nursing care on a national scale. The additional financial costs for comprehensive nursing services at all hospitals was estimated to be as much as 110.39% of the current cost. For the comprehensive nursing service, nurses with a career and newcomers need to be retained at their hospitals, and the validity of the nurse-patient ratio should be continuously checked. The financial shock to the national health insurance system could be minimized by gradually extending the system to all hospitals.

• Journal of Acupuncture Research
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• v.33 no.3
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• pp.67-73
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• 2016

Objectives : The objective of this study is to discuss problems and potential improvements of national health insurance fees associated with miniscalpel acupuncture according to Korean medical doctors' workload, material cost and degree of risk. Methods : We researched the change of relative value points, national health insurance fees, the acupuncture process, and Korean medicine doctors' workload related to Miniscalpel acupuncture, as compared to general meridian point acupuncture. We also examined material cost by surveying pharmacies, internet shopping malls and medical appliance shops. Results : Relative value point for Miniscalpel acupuncture decreased from 2010 to 2012, and remained the same from 2012 to 2016. National health insurance fees for Miniscalpel acupuncture increased by a small margin annually for rise of equivalent index. There was no reporting on workload related to Miniscalpel acupuncture. Material cost of Miniscalpel acupuncture was 18.2~20.7 times higher than actual cost of procedure. There were few studies examining medical accidents related to Miniscalpel acupuncture, and thus we could not evaluate degree of risk. Conclusion : We suggest revaluating Korean medical doctors' workload related to including Miniscalpel acupuncture, to consider the material costs of Miniscalpel acupuncture, and investigate its degree of risk by researching medical accidents.

• Health Policy and Management
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• v.28 no.3
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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.