• 치위생과학회지
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• 제15권6호
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• pp.815-824
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• 2015

이번 연구는 임상에 근무하고 있는 치과의사와 보험청구 담당자들의 건강보험관련 교육의 참여 실태를 파악하고, 교육경험이 그들의 요양급여비용의 산정기준에 대한 지식과 건강보험 실무 적용수준에 미치는 영향을 파악하고자 전국에 소재한 치과 병 의원에 근무하는 치과의사와 보험청구 담당자를 대상으로 설문 후 분석한 결과 다음과 같은 결론을 얻었다. 요양급여비용 산정기준에 관한 지식수준은 보험청구 담당자가 치과의사보다 높은 것으로 나타났다(p<0.01). 교육참여 횟수가 많을수록 보험청구 담당자의 요양급여비용 산정기준 지식수준이 통계적으로도 유의하게 높은 것으로 나타났고(p<0.001), 평균교육시간이 3시간 미만인 경우보다 3시간 이상인 경우 요양급여비용 산정기준에 대한 지식수준이 높게 나타났고, 통계적으로 유의한 차이를 보였다(p<0.05). 보험청구 담당자가 치과의사보다 건강보험 실무적용수준이 높은 것으로 나타났고, 통계적으로 유의한 차이를 보였다(p<0.001). 치과의사는 보험청구 경력이 많을수록 건강보험 실무 적용수준이 높은 것으로 나타났고(p<0.01), 보험청구 담당자는 연령이 적을수록, 교육 참여 횟수가 많을수록, 평균교육 시간이 길수록 건강보험 실무 적용수준이 높은 것으로 나타났다(p<0.05) 최근 3년간 건강보험관련 교육의 참여경험이 보험청구 담당자의 요양급여비용 산정기준 지식수준에 유의한 영향을 미치는 요인으로 나타났고(p<0.001), 보험청구 경력과 요양급여비용 산정기준 지식수준은 그들의 건강보험 실무 적용수준에 유의한 영향을 미치는 것으로 나타났다(p<0.01) 이러한 결과로 미루어볼 때 치과의사 및 보험청구 담당자의 건강보험에 관한 지식수준과 건강보험 실무적용 수준을 유지하기 위해서는 관련된 교육 관련된 교육을 지속적으로 받는 것이 필요할 것으로 판단된다.

• Journal of Preventive Medicine and Public Health
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• 제27권2호
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• pp.242-257
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• 1994

In Korea, female workforce has reached more than 40% of total working population, but the effects of work on spontaneous abortion are yet to be examined. This study as conducted to investigate the occupational effects on spontaneous abortion. Medical insurance claim data were used to examine the effects of the employment status and industry of employment on spontaneous abortion. The study population was composed of females, aged $15{\sim}44$, who were the beneficiary of medical insurance in the month of June, 1993. The working females covered by medical insurance for industrial workers, had the highest age-adjusted Spontaneous Abortion rate (SAB rate=claim frequency of spontaneous abortion/claim frequency of complication of pregnancy, childbirth and the puerperium), 6.65% whereas female dependants of medical insurance for industrial workers had the lowest age-adjusted SAB rate, 4.54%. Among industrial workers, the workers in manufacturing industry had the highest age-adjusted Spontaneous Abortion ratio(SAB ratio=claim frequency of spontaneous abortion/claim frequency of completly normal delivery), 43.2/100 whereas those in financing and service industry had age-adjusted SAB ratio, 16.2/100 and 20.5/100, respectively. The results of the study suggest the adverse effect of manufacturing Industry on reproduction. Work environments such as chemical exposures, overwork, awkard posture, and job stress should be further studied for their effects on reproductive functions of female.

• 보건행정학회지
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• 제26권1호
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• pp.71-78
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• 2016

The value of using health insurance claim database is continuously rising in healthcare research. In studies where comorbidities act as a confounder, comorbidity adjustment holds importance. Yet researchers are faced with a myriad of options without sufficient information on how to appropriately adjust comorbidity. The purpose of this study is to assist in selecting an appropriate index, look back period, and data range for comorbidity adjustment. No consensus has been formed regarding the appropriate index, look back period and data range in comorbidity adjustment. This study recommends the Charlson comorbidity index be selected when predicting the outcome such as mortality, and the Elixhauser's comorbidity measures be selected when analyzing the relations between various comorbidities and outcomes. A longer look back period and inclusion of all diagnoses of both inpatient and outpatient data led to increased prevalence of comorbidities, but contributed little to model performance. Limited data range, such as the inclusion of primary diagnoses only, may complement limitations of the health insurance claim database, but could miss important comorbidities. This study suggests that all diagnoses of both inpatients and outpatients data, excluding rule-out diagnosis, be observed for at least 1 year look back period prior to the index date. The comorbidity index, look back period, and data range must be considered for comorbidity adjustment. To provide better guidance to researchers, follow-up studies should be conducted using the three factors based on specific diseases and surgeries.

• Journal of Preventive Medicine and Public Health
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• 제54권1호
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• pp.8-16
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• 2021

This article aims to introduce the inception and operation of the COVID-19 International Collaborative Research Project, the world's first coronavirus disease 2019 (COVID-19) open data project for research, along with its dataset and research method, and to discuss relevant considerations for collaborative research using nationwide real-world data (RWD). COVID-19 has spread across the world since early 2020, becoming a serious global health threat to life, safety, and social and economic activities. However, insufficient RWD from patients was available to help clinicians efficiently diagnose and treat patients with COVID-19, or to provide necessary information to the government for policy-making. Countries that saw a rapid surge of infections had to focus on leveraging medical professionals to treat patients, and the circumstances made it even more difficult to promptly use COVID-19 RWD. Against this backdrop, the Health Insurance Review and Assessment Service (HIRA) of Korea decided to open its COVID-19 RWD collected through Korea's universal health insurance program, under the title of the COVID-19 International Collaborative Research Project. The dataset, consisting of 476 508 claim statements from 234 427 patients (7590 confirmed cases) and 18 691 318 claim statements of the same patients for the previous 3 years, was established and hosted on HIRA's in-house server. Researchers who applied to participate in the project uploaded analysis code on the platform prepared by HIRA, and HIRA conducted the analysis and provided outcome values. As of November 2020, analyses have been completed for 129 research projects, which have been published or are in the process of being published in prestigious journals.

• 한국병원경영학회지
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• 제9권3호
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• pp.71-97
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• 2004

This study conducted a comparative analysis of awareness level of review standards, continuing education, and awareness about the need for speciality and educational courses in order to improve quality of Korean health insurance review work and to present directions for policies of personnel development and continuing education to smoothly perform hospital's insurance claim work and Agency's review work. The analysis unit of the study is individuals, and survey was conducted among hospital's claim officers and Agency' review officers by distributing questionnaires. The major results of the study are as follows: First, it is found that hospital's claim officers and Agency's review officers have conflicting awareness about review standards; more Agency's review officers think that current review standards are universal and reasonable, while more hospital's claim officers believe that they need to be revised. Especially, hospital's claim officers replied that it is possible that review results can differ according to government's policies. Second, there is no significant difference between the two groups in the opinion that there are individual differences in awareness level of review standard. In particular, both groups share the opinion that review results can differ according to officer's interpretation of review standards. Third, Both review officer groups feel the need for further training and continuing education. Fourth, there is no difference between the two groups in the opinion that both groups members should be educated in review related educational institutions. However, while 81.5% of Agency's review officers the education should be offered at the Agency, only 45.2% of hospital's claim officers agreed to it. Fifth, both review personnel do not show any difference in awareness of needed experience to successfully perform review work; both groups replied that three to four years experience is necessary to smoothly perform claim work and review work. This study was tried in order to search for directions to improve Korean insurance review work in quality rather than to explore characteristics themselves of individual factors. In this sense, this study presupposed an intention that the educational subjects for further training and continuing education for the two groups should be the same in order to narrow the awareness gap between hospital's claim officers and Agency's review officers. Thus, this study suggests that it is desirable to offer beginner courses at junior colleges or in undergraduate courses and advanced courses in professional graduate school for six to twelve months. In that a comparison of awareness level of hospital's claim officers and Agency's review officers who are actually in practice should precede appropriate presentation of directions for the qualitative improvement of insurance review work in Korea, the significance of this study lies in comparatively analyzing the awareness level of hospital's claim officers and Agency's review officers and in presenting the establishment of future further training and continuing education.

• Journal of Preventive Medicine and Public Health
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• 제39권5호
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• pp.433-437
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• 2006

Objectives: The aim of this study is to develop a methodology for estimating a nationwide statistic for hernia operations with using the claim database of the Korea Health Insurance Cooperation (KHIC). Methods: According to the insurance claim procedures, the claim database was divided into the electronic data interchange database (EDI_DB) and the sheet database (Paper_DB). Although the EDI_DB has operation and management codes showing the facts and kinds of operations, the Paper_DB doesn't. Using the hernia matched management code in the EDI_DB, the cases of hernia surgery were extracted. For drawing the potential cases from the Paper_DB, which doesn't have the code, the predictive model was developed using the data mining technique called SEMMA. The claim sheets of the cases that showed a predictive probability of an operation over the threshold, as was decided by the ROC curve, were identified in order to get the positive predictive value as an index of usefulness for the predictive model. Results: Of the claim databases in 2004, 14,386 cases had hernia related management codes with using the EDI system. For fitting the models with applying the data mining technique, logistic regression was chosen rather than the neural network method or the decision tree method. From the Paper_DB, 1,019 cases were extracted as potential cases. Direct review of the sheets of the extracted cases showed that the positive predictive value was 95.3%. Conclusions: The results suggested that applying the data mining technique to the claim database in the KHIC for estimating the nationwide surgical statistics would be useful from the aspect of execution and cost-effectiveness.

• 의료법학
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• 제10권2호
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• pp.287-307
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• 2009

A person is injured in car accident caused by his/her slight negligence except he / she causes accident by his / her willfulness or gross negligence. Because the National Health Insurance Corporation (hereinafter called "Corporation") shall not provide any insurance benefit "when he has intentionally or through gross negligence caused a criminal conduct or intentionally contributed to the occurrence of an accident" referred to in Article 48 (1) 1 of the National Health Insurance Act. So, if he / she is insured by his / her own bodily injury coverage, he / she can be compensated for his / her medical expenses. The injured have the rights to file either National Health Insurance claim and Automobile Insurance claim but there is no clear and definite adjustment clause. The claim disputes between National Health Insurance (hereinafter called "NHI") and Automobile Insurance (hereinafter called "AI") in the own bodily injury coverage makes some problems. Firstly, there are some differences in co-payments which he / she chooses between NHI and AI. Profit per a patient is higher in the NHI than in the AI. Secondly, it can provoke criticism that people shall unnecessarily pay double contributions. Lastly, it can raise moral hazards. For example, if he / she can cover the compensations when the insured receives the compensations from his / her insurer, the Corporation can be claimed by medical care institution payment of the health care benefit costs. In conclusion, first of all, to improve the national health and preserve the insured's rights the Corporation shall keep notice these facts.

• Journal of Preventive Medicine and Public Health
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• 제33권4호
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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.

• 보건행정학회지
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• 제21권1호
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• pp.77-92
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• 2011

Objectives : This study examined the health policy researchers' needs and their accessibility towards health insurance claim datasets according to their academic capacity. Methods : An online questionnaire to capture relevant proxy variables for academic needs, accessibility, and research capacity was constructed based on previous studies. The survey was delivered to active health policy researchers through three major scholarly associations in South Korea. Seven-hundred and one scholars responded while the survey as open for 12 days (starting on December 20th, 2010). Descriptive statistics and logistic regression analysis were carried out. Results : Regardless of the definition for operational needs, the prevalent needs of survey respondents were not met with the current provision of claim data. Greater research capacity was shown to be correlated with increased demand for claim data along with a positive correlation between attempts to obtain claim datasets and research capacity. A greater research capacity, however, was not necessarily correlated with better accessibility to the claim data. Conclusions : The substantial unmet need for claim data among the healthcare policy research community calls for establishing proactive institutions which could systematically prepare and make available public datasets and provide call-in services to facilitate proper handling of data.

• 보건행정학회지
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• 제26권1호
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• pp.63-70
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• 2016

Background: Selective health benefit was introduced for decreasing economic burden of patients. Medical devices with economic uncertainty have been covered as selective health benefit by National Health Insurance since December 2013. We aimed to analyze impact of selective health benefit to medical expenditure and provider behavior focused on electrosurgery (ultrasonic shears, electrothermal bipolar vessel sealers) for gastric cancer patients covered since December 2014. Methods: We used the National Health Insurance claims data of 2,698 patients underwent gastric cancer surgery between August 2014 and March 2015. Medical cost and patient sharing per inpatient day were analyzed to verify that covering electrosurgery increased medical expenditure and changed provider behavior from open surgery to endoscopic or laparoscopic surgery. Additionally, we analyzed the claim rate of medical device or goods relating gastric endoscopic and laparoscopic surgery. Results: Medical cost and patient sharing per inpatient day were increased after covering electosurgery as selective health benefit (39,724/1,421 won). However, there were no medical expenditure increases after adjusting claim of electosurgery and patient sharing was decreased 1,057 won especially. The coverage of selective health benefit did not increase the claim rate of medical device or goods related endoscopic or laparoscopic surgery, either. Conclusion: Covering electosurgery decreased patient economic burden and did not change of provider behavior. Expanding selective health benefit is needed to decrease economic burden of severe patients. Further study should evaluate the long term effect with accumulated data.