• Journal of Society of Preventive Korean Medicine
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• v.19 no.2
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• pp.51-56
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• 2015

Objective : We analyzed present condition of cooperative medical care using claims data of HEALTH INSURANCE REVIEW & ASSESSMENT SERVICE form patients treated by Korean-Western cooperative medicine. The study aimed to offer guidelines in selecting disease-related research in developing Korean-Western convergence technology. Method : Based on the patients using Korean medical service, we analyzed claims data of patients using Korean medical service and western medical service from January 2012 to December 2013. We were assigned to the server remotely. With the concept of 'episode of care', we rebuilt claims data and analyzed present condition of cooperative medical usage. Results : We analyzed present condition of cooperative medical care per episode of care. Among outpatients, Low back pain, lumbar region(M5456) was the highest number. Among inpatients, Sciatica due to intervertebral disc disorder(M511) was the highest number. Conclusion : Based on the claims data provided by HEALTH INSURANCE REVIEW & ASSESSMENT SERVICE, we have derived a list of multy frequently disease frequently treated by cooperative medical care by analyzing present condition.

• Journal of Preventive Medicine and Public Health
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• v.28 no.1 s.49
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• pp.207-223
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• 1995

A new medical delivery system which regulated outpatient department(OPD) use from tertiary care hospitals was adopted in 1989. Under the new system, patients using tertiary care hospital OPD without referral slip from clinics or hospitals could not get any insurance benefit for the services received from the tertiary care hospital. This study was conducted to evaluate the Patient Referral System(PRS) with respect to health care expenditures and utilization. Two data sets were used in this study. One was monthly data set(from January 1986 to December 1992) from the Annual Report of Korea Medical Insurance Corporation(KMIC). The other was monthly joint data set composed of personal data of which 10% were selected randomly with their utilization data of KMIC from January 1988 to December 1992. The data were analyzed by time-series intervention model of SAS-ETS. The results of this study were as follows: 1. There was no statistically significant changes in per capita expenditures following PRS. 2. Utilization episodes per capita was increased statistically significantly after implementation of PRS. The use of clinics and hospitals increased significantly, whereas in tertiary care hospitals the use decreased significantly immediately after implementation of PRS and increased afterwards. 3. Follow-up visits per episode were decreased statistically significantly after implementation of PRS. The decrease of follow-up visits per episode were remarkable in clinics and hospitals, whereas in tertiary care hospitals it was increased significantly after implementation of PRS. 4. There was no statistically significant changes in prescribing days per episode following PRS. Futhermore, clinics and hospitals showed a statistically significant decrease in prescribing days per episode, whereas in tertiary care hospital it showed statistically significant increase after implementation of PRS. 5. Except high income class, the use of tertiary care hospitals showed statistically significant decrease after implementation of PRS. The degree of decrease in the use of tertiary care hospitals was inversely proportional to income. These results suggest that the PRS policy was not efficient because per capita expenditures did not decrease, and was not effective because utilization episodes per capita, follow-up visits per episode. and prescribing days per episode were not predictable and failed to show proper utilization. It was somewhat positive that utilization episodes per capita were decreased temporarily in tertiary care hospitals. And PRS policy was not appropriate because utilization episodes per capita was different among income groups. In conclusion, the PRS should be revised for initial goal attainment of cost containment and proper health care utilization.

• Health Policy and Management
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• v.32 no.2
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• pp.154-163
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• 2022

Background: The costliness index (CI) is an index that is used in various ways to improve the quality of medical care and the management of appropriate treatment in medical institutions. However, the current calculation method for CI has a limitation in reflecting the actual medical cost of the patient unit because the outpatient and inpatient costs are evaluated separately. It is desirable to calculate the CI by integrating the medical cost into the episode unit. Methods: We developed an episode-based CI method using the episode classification system of the Centers for Medicare and Medicaid Services to the National Inpatient Sample data in Korea, which can integrate the admission and ambulatory care cost to episode unit. Additionally, we compared our new method with the previous method. Results: In some episodes, the correlation between previous and episode-based CI was low, and the proportion of outpatient treatment costs in total cost and readmission rates are high. As a result of regression analysis, it is possible that the level of total medical costs of the patient unit in low volume medical institute and rural area has been underestimated. Conclusion: High proportion of outpatient treatment cost in total medical cost means that some medical institutions may have provided medical services in the ambulatory care that are ancillary to inpatient treatment. In addition, a high readmission rate indicates insufficient treatment service for inpatients, which means that previous CI may not accurately reflect actual patient-based treatment costs. Therefore, an integrated patient-unit classification system which can be used as a more effective CI indicator is needed.

• Health Policy and Management
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• v.32 no.2
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• pp.125-136
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• 2022

The costliness index (CI) is an index that is used in various ways to improve the quality of medical care and the management of appropriate treatment in medical institutions. However, the current calculation method for CI has a limitation in reflecting the actual medical cost of the patient unit because the outpatient and inpatient costs are evaluated separately. It is desirable to calculate the CI by integrating the medical cost into the episode unit. We developed an episode-based CI method using the episode classification system of the Centers for Medicare and Medicaid Services to the National Inpatient Sample data in Korea, which can integrate the admission and ambulatory care cost to episode unit. Additionally, we compared our new method with the previous method. In some episodes, the correlation between previous and episode-based CI was low, and the proportion of outpatient treatment costs in total cost and readmission rates are high. As a result of regression analysis, it is possible that the level of total medical costs of the patient unit in low volume medical institute and rural area has been underestimated. High proportion of outpatient treatment cost in total medical cost means that some medical institutions may have provided medical services in the ambulatory care that are ancillary to inpatient treatment. In addition, a high readmission rate indicates insufficient treatment service for inpatients, which means that previous CI may not accurately reflect actual patient-based treatment costs. Therefore, an integrated patient-unit classification system which can be used as a more effective CI indicator is needed.

• Korean Journal of Adult Nursing
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• v.15 no.3
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• pp.432-440
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• 2003

Purpose: The purposes of this study were to examine 1) functional status at 2 months after hip fracture surgery 2) health care utilization after a fall episode and 3) fear of falling experienced during first 2 months after a fall episode. Method: With a convenient sample of 99 elderly from six university or general hospitals with hip fracture from a fall, data were collected at 2-3 days before discharge and at 2 months after hip fracture surgery. Result: 1) At 2 months after hip fracture from a fall, significant proportion (25.3%) of elderly was not able to walk indoors. 2) Average length of hospital stay was 27.6 days with a range of 8 to 86 days. About 51% subjects received physical therapy during hospital stay, and only 6.1% subjects received physical therapy following discharge from the hospital. 3) Significant proportion (72.7%) had fear of falling after the fall episode. About 51% reported that they restricted their activities because they had fear of falling. Conclusion: Fall is a dreaded event which result in loss of independence and restriction of activity. Development and application of fall prevention program is critical especially for those with risk factors of fall.

• Journal of Preventive Medicine and Public Health
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• v.24 no.4 s.36
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• pp.485-495
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• 1991

This study examined the effects of referral requirements for insurance patients which have been enforced since July 1, 1989 when medical insurance coverage was extended to the whole population except beneficiaries of medical assistance program. The requirements are mainly aimed at discouraging the use of tertiary care hospitals by imposing restrictions on the patient's choice of a medical service facility. The expectation is that such change in the pattern of medical care utilization would produce several desirable effects including increased efficiency in patient care and balanced development of various types of medical service facilities. In this study, these effects were assessed by the change in the number of out-patient visits and bed-days per illness episode and the share of each type of facility in the volume of services and the amount of expenditures after the implementation of the new referral system. The data for analysis were obtained from the claims to the insurance for government and school employees. The sample was drawn from the claims for the patients treated during the first six months of 1989, prior to the enforcement of referral requirements, and those of the patients treated during the first six months of 1990, after the enforcement. The 1989 sample included 299,824 claims (3.6% of total) and the 1990 sample included 332,131 (3.7% of total). The data were processed to make the unit of analysis an illness episode instead of an insurance claim. The facilities and types of care utilized for a given illness episode are defined to make up the pathway of medical care utilization. This pathway was conceived of as a Markov Chain process for further analysis. The conclusion emerged from the analysis is that the enforcement of referral requirements resulted in less use of tertiary care hospitals, and thereby decreased the volume of services and the amount of insurance expenses per illness episode. However, there are a few points that have to be taken into account in relation to the conclusion. The new referral system is likely to increase the use of medical services not covered by insurance, so that its impact on national health expenditures would be different from that on insurance expenditures. The extension of insurance coverage must have inereased patient load for all types of medical service organizations, and this increase may be partly responsible for producing the effects attributed to the new referral system. For example, excessive patient load for tertiary care hospitals may lead to the transfer of their patients to other types of facilities. Another point is that the data for this study correspond to very early phase of the new system. But both patients and medical care providers would adapt themselves to the new system to avoid or overcome its disadvantages for them, so as that its effects could change over time. Therefore, it is still necessary to closely monitor the impact of the referral requirements.

• 대한예방의학회:학술대회논문집
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• 2004.10a
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• pp.47.1-47.1
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• 2004

• Journal of Preventive Medicine and Public Health
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• v.9 no.1
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• pp.31-37
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• 1976

This study was conducted for the purpose of obtaining basic information on the patterns of medical care expenditures, and identifying some determinants of medical care expenditures in the rural Korea. Nine guns were chosen from the eight provinces, excluding Cheju island. One gun in each province and two villages were selected from the each myon or ub within the selected guns. The total number of households was 1,789 and the sample size was 9,826 non-institutionalized people. Followings are the major findings of the study : 1) Medical care expenditures increase proportionally with age in terms of cost per patient, per episode of illness, per treated case, and per person. Averagely, it cost 2,756 won per patient, 2,614 won per spell of illness, 4,361 won per treated case, and 413 won per person. 2) Medical care expenditures increase proportionally with educational level of patients. College graduates spent the most, 4,726 won per patient, 5,987 won per treated case, and 670 won per person. 3) The male spent a little more than the female in terms of per patient, per episode, and per person. For example, a male spent 23 won more than a female. 4) Those who were suffering from illnesses longer than 1 year spent three times more than that had illnesses of less than 1 year duration. 5) The simple correlation coefficient between activity restriction and medical care expenditures was the highest among others, 0.491. The next was 0.294 between duration of illness and medical care expenditures. 6) Attempts are made to identify the explanatory variables in medical care expenditures. Thirty one per cent of the variances in tile expenditures can be accounted for by the selected 15 predictors. Those predictors belonged to clinical renditions, such as activity restriction, duration of illness, and nature of conditions, are proved to be the most potent independent variabes. Level of education and monthly family income are also significant in terms of beta coefficient. Further studies are called for to unreveal the determinants of medical expenditures.

• Environmental Analysis Health and Toxicology
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• v.30
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• pp.12.1-12.7
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• 2015

Objectives In South Korea, health insurance data are used as material for the health insurance of national whole subject. In general, health insurance data could be useful for estimating prevalence or incidence rate that is representative of the actual value in a population. The purpose of this study was to apply the concept of episode of care (EoC) in the utilization of health insurance data in the field of environmental epidemiology and to propose an improved methodology through an uncertainty assessment of disease course and outcome. Methods In this study, we introduced the concept of EoC as a methodology to utilize health insurance data in the field of environmental epidemiology. The characterization analysis of the course and outcome of applying the EoC concept to health insurance data was performed through an uncertainty assessment. Results The EoC concept in this study was applied to heat stroke (International Classification of Disease, 10th revision, code T67). In the comparison of results between before and after applying the EoC concept, we observed a reduction in the deviation of daily claims after applying the EoC concept. After that, we categorized context, model, and input uncertainty and characterized these uncertainties in three dimensions by using uncertainty typology. Conclusions This study is the first to show the process of constructing episode data for environmental epidemiological studies by using health insurance data. Our results will help in obtaining representative results for the processing of health insurance data in environmental epidemiological research. Furthermore, these results could be used in the processing of health insurance data in the future.

• Journal of Oriental Neuropsychiatry
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• v.14 no.2
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• pp.199-206
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• 2003

Objective : This is a case report of the patient diagnosed as the depressive episode mixed with organic depressive disorder. Method : We treat the patient with herbal medication and gave acupuncture treatment about 5 weeks, the symptom of the patient improved. The herbal medication and acupuncture treatment which we gave patient was based on Oriental medical diagnosis. Results : The patient had been taken the western medical treatment for 2 months, the symptom of the patient was not improved. But after the Oriental medical treatment, the patient is on the improving state. Conclusion : In the treatment of the depressive disorder which is mixed with organic depressive disorder, we found that the Herbal medication and Acupuncture based on correct 'Byonjung(辦證)' help the care of depressive episode which is mixed with organic depressive disorder.