• Health Policy and Management
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• v.33 no.1
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• pp.55-64
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• 2023

Background: Despite the various activities of the regional public hospitals, discussions are being made as to whether or not to continue due to the issue of financial deficit. Therefore, the main factors affecting the fiscal deficit were analyzed with 10-year data. Methods: This study is a panel analysis that analyzed the characteristics of 34 regional public hospitals and influencing factors on medical benefits for 10 years from 2010 to 2019. First, we analyze the determinants of medically vulnerable areas set by the government, analyze the trend of medical profit per 100 beds and medical profit rate from 2010 to 2019, and identify the factors that affect them. Results: Differences in medical profit per 100 beds and medical profit-to-medical profit rate were caused by market share representing regional characteristics, and both indicators improved as the number of outpatients increased. The important influencing variables are the number of doctors and nurses, and both indicators improve when there are specialists, but medical benefits decrease as the number of doctors increases when judged by the number of people per 100 beds. In addition, the number of nurses per 100 beds does not contribute to medical profit and has a negative effect on the medical profit ratio. Conclusion: As only regional characteristics were taken into account for medically vulnerable areas, operational characteristics need to be considered. The greatest impact on the finances of local medical centers is the proper staffing of doctors and nurses, and their efficient arrangement is the most important factor in financial stability.

• Journal of Preventive Medicine and Public Health
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• v.53 no.4
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• pp.285-288
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• 2020

The health insurance system in Korea is well-established and provides benefits for the entire national population. In Korea, when patients are treated at a hospital, the hospital receives a partial payment for the treatment from the patient, and the remaining amount is provided by the health insurance service. The Health Insurance Review and Assessment Service (HIRA) assesses whether the treatment was appropriate. If HIRA deems the treatment appropriate, the doctor can receive payment from the health insurance service. However, this system has several drawbacks. In this study, we aimed to provide examples of the problems that can occur in relation to HIRA assessments in Korea through actual clinical cases.

• Journal of Korean society of Dental Hygiene
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• v.24 no.1
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• pp.9-16
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• 2024

Objectives: The demand for dental care is expected to increase as the population ages. This study aimed to predict the utilization of dental implant care following the expansion of national health insurance benefits for dental implants. Methods: Multiple linear regression analysis was performed on HIRA big data open portal data and DNN-based artificial intelligence models to forecast the utilization of dental care in relation to the national health insurance coverage for dental implants. Results: National health insurance coverage of dental implants was found to be associated with the number of patients using dental implant services and demonstrated a statistical significance. The dental implant services utilization increased with the increased dental implant health insurance benefits for the elderly population, increased mean by region, increased number of dental institutions by region, and increased health insurance coverage rate for dental implants. However, the dental implant services utilization decreased with the increased number of older people living alone and increased size of dental institutions. Conclusions: With the expansion of the national health insurance coverage for dental implants, it is predicted that the utilization of dental implant medical services will increase in the future.

• Health Policy and Management
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• v.4 no.1
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• pp.77-106
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• 1994

This study attempts to evaluate the beneficial equity and operational efficiency of the three Korean medical insurance programmes and thereby suggest directions for their policy improvement. Concepts of the equity and effciency were reviewed to develop indicators for comparative analysis. For the analysis, statistical and financial accounting data for 1991, issued by the National Federation of Medical Insurance and the Korea Medical Insurance Corporation, on the operational status and performances of the programmes, were collected and rearranged to be suited to the purpose of the study. The analysis reveals that beneficial inequity exists between self-employed and employee programs. and that operational inefficiency is prominent in both programms for self-employeds and for Government employees and private school teachers. In order to improve the beneficial inequity of the self-employed program, it is suggested that policies be formulated and implimented toward increasing the program revenue through increasing subsidies from the Government, and through inter- program finance adiustment. For the operational inefficiency of the two programs, it is judged that, toghether with the administrative support and control from the Government and the insurance society bodies, self- efforts be initiated to improve the internal mangement styles and systems of the insurance societies. Finally, from the viewpoint of the structural efficiency, expansion of the preventive insurance benefits by the insurance soceties is recommended both for beneficial equity and operational efficiency.

• The Journal of the Korea Contents Association
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• v.16 no.8
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• pp.366-375
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• 2016

This study evaluates the degree of the inequality of medical care expenditure and private health insurance benefits and the relation with household income inequality in korea health care system. This study used the 2014 korea Health Panel survey, and study method is Gini coefficient. The main results are as follow. First, average household income in 1st income quartile is 6,290,000won and 10st income quartile is 101,930,000won. And Gini coefficient of Korea household income is 0.3756. In other words, family income inequality is quite serious. Second, the Gini coefficient of the public institution supported medical care expenditure, such as health insurance and public assistance, is 0.0761, and the Gini coefficient of the expenditure of transportation fee and medical materials etc that don't supported is 0878. The inequality in medical care expenditure in public health care system and without public support aren't serious all. Third, Gini coefficient in excluding household medical care expenditure from household income slightly increased. That is, the medical care expenditure of our country household is the factor of aggravating the inequality of household income. Fourth, Gini coefficient of private health insurance benefits is 0.0927. Therefore, the ineqality in private insurance benefits is low. In addition, the Gini coefficient of the sum of private insurance benefits and household income is 0.3672. it decrease from Gini coefficient(0.3756) of household's. Private health insurance perform the functions somewhat weaken household income inequality. However, it is very little improvement.

• Health Policy and Management
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• v.10 no.1
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• pp.57-94
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• 2000

Korea's social health insurance system was introduced in 1977, which has made a universal coverage possibly by July 1989. Korean government had pursued a single objective for the last decade to put the whole population under the coverage of medical security, and the objective was achieved within 12 years. The rapid accomplishment is primarily due to such factors as limited benefits, high copayment rate, low contributions as well as rapid economic growth. There are several sources of pressure for the implementation of social health insurance such as health professional group, labor unions, politicians, international organizations etc.. However it is important to look at the feasibility of social health insurance. Among other things, it is necessary to identify the administrative infrastructure of insurance system and to assess income for source of fund. As many developed countries, Korea began to apply health insurance to the employees of the large firms, and the expansion based on employment status. Thus the several funds system was inevitable according to the gradual expansion strategy. However many persons had criticized several funds system in respect with equity and efficiency aspects. In the short history of the Korean health insurance, whether one fund or sever or funds had been the most controversial issue. In Febrary 1999, the National Assembly passed the act of one fund system. From July 2000 separate funds will be unifed under new health insurance scheme. In this study we will analyze the policy making process on implementation, expansion and integration of health insurance system of Korea. And also analyse problems related to policy making.

• The Korean Society of Law and Medicine
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• v.15 no.1
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• pp.123-164
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• 2014

Under the new system of 'Separation of pharmaceutical prescription and dispensing' in Korea, which was implemented in 2000, physician could not dispense a medicine, and outpatient should have a physician's prescription filled at a drugstore. After pharmacist makes up outpatient's prescription, National Health Insurance Service(NHIS) pay for outpatient's medicine to pharmacist, except an outpatient's own medicine charge. And NHIS only pay for outpatient's prescription fee to physician and, physician doesn't derive profit from dispensing medicine in itself. Nevertheless, if physician writes out a prescription with violation of 'Criteria for the Medical Care Benefits', NHIS clawed back the payment of outpatient's prescription and medicine from the physician or the medical institution which the physician belongs to. In the past, NHIS's confiscation was in accordance with 'the National Health Care Insurance Act, Article 52, Clause 1'. But, since 2006 when the Supreme Court declared that there was no legal basis on the NHIS's confiscation of outpatient's medicine payment, NHIS had put in a claim for illegal prescriptions on the basis 'the Korean Civil law, Article 750(tort)'. So, Many medical institutions filed civil actions against NHIS. The key point of this actions was whether the issuing outpatient prescriptions with violations of Criteria for the Medical Care Benefits constitute of the law of tort. On this point, the first trial and the second trial took different position. Finally the Supreme Court acknowledged the constitution of the law of tort in 2013. In this paper, the author will review critically the decision of the Supreme Court, and consider the relativeness between the legal effect of Criteria for the Medical Care Benefits and the constitution of the issuing outpatient prescriptions with violations of Criteria for the Medical Care Benefits as the law of tort.

• Journal of Preventive Medicine and Public Health
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• v.28 no.1 s.49
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• pp.153-174
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• 1995

This study was conducted to examine the determinant factors for expenditure of the medical insurance program for self-employeds based on the analysis of 1991 'The Medical Insurance Program for Self-Employeds Statistical Yearbook', and also similar yearbooks in the metropolitan and other provinces. The major findings are as follows : We have divided benefits into these four components such as the utilization rate for out-patients, expenses per claim for out-patients as paid by the insurer, utilization rate for in-patients, and the expenses per claim for in-patients as paid by the insurer, in order to examine the determinant factors for it. The results of the study revealed the following findings, in urban areas, the supply of medical care had more influence on the benefits than other demographic and economic variables, while, in county areas, both the supply of medical care and the rate of those aged over 65 affected the provision of benefits. The determinant factors for financial balance of the medical insurance program for self-employeds are, first, the determinant factor for administrative expenses was the number of households. The more the number of households, the less the administrative expenses per the insured. This shows that the economy of scale is being. And so, the administrative district must be taken into consideration in the incorporation of small regional medical societies and should be re-organized for more efficient management. Second, in urban areas, the supply of medical care had more influence on utilization rate and expenses per claim as paid by insurer, and therefore it is necessary to control it. In county areas, the supply of medical care and the rate of those aged over 65 raised the utilization rate and expenses per claim as paid by insurer. For the financial stability of county areas, a common fund for medical care for the aged and expansion of finance stabilization fund would be necessary. But, in county areas, it would be unnecessary to control the supply of medical care because it was much more insufficient than in urban areas. The vitalization of public health facilities must be carried out in county areas, for they reduced benefits. Sice the more insured in a single household, the less the utilization of the medical insurance program, benefits for habilitation at home should be given consideration. The law of majority and the economy of scale were applied here, and therefore the incorporation of regional medical societies must be taken into consideration. In integrating regional medical societies, it would be absolutely necessary to review the structural differences among all regional medical societies, the medical demand of each region, and also the local characteristics of each region.

• Korea Journal of Hospital Management
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• v.11 no.4
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• pp.63-81
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• 2006

This study was conducted to evaluate needs and intention of hospitals and clinics to join network with private health insurance, and to discover obstacles of participation of the networks. We carried out the questionnaire survey of the network managers of 236 medical institutions between December 27th, 2005 and January 25th, 2006. The result showed that the participation intention of network were different to the type of hospitals. Primary care clinics answered that participation intention and possibility were low. Secondary care hospitals was relatively affirmative regarding a network participation. Tertiary hospitals responded that they need the network with private health insurance, but participation possibility was lower than needs. The reason is that they worried about the side effect of the network with private health insurance. Depending on the type of hospitals, expected benefits from networking with private health insurance were different. We found that hospitals which already had affiliation with other hospitals answered in the affirmative regarding the network with private health insurance. In conclusion, to increase the effectiveness of network systems between hospital and private health insurance, the network is expected to consider different needs of the each hospital.

• Health Policy and Management
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• v.33 no.3
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• pp.295-310
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• 2023

Background: The long-term care (LTC) group has higher rates of chronic disease and disability registration compared to the general older people population. There is a need to provide integrated medical services and care for LTC group. Consequently, this study aimed to identify medical usage patterns based on the ratings of LTC and the characteristics of benefits usage in the LTC group. Methods: This study employed the National Health Insurance Service Database to analyze the effects of demographic and LTC-related characteristics on medical usage from 2015 to 2019 using a repeated measures analysis. A longitudinal logit model was applied to binary data, while a linear mixed model was utilized for continuous data. Results: In the case of LTC ratings, a positive correlation was observed with overall medical usage. In terms of LTC benefit usage characteristics, a higher overall level of medical usage was found in the group using home care benefits. Detailed analysis by medical institution classification revealed a maintained correlation between care ratings and the volume of medical usage. However, medical usage by classification varied based on the characteristics of LTC benefit usage. Conclusion: This study identified a complex interaction between LTC characteristics and medical usage. Predicting the requisite medical services based on the LTC rating presented a challenge. Consequently, it becomes essential for the LTC group to continuously monitor medical and care needs, even after admission into the LTC system. To facilitate this, it is crucial to devise an LTC rating system that accurately reflects medical needs and to broaden the implementation of integrated medical-care policies.