• 한국병원경영학회지
• /
• 제29권2호
• /
• pp.37-47
• /
• 2024

Purpose: This study aimed to determine the effect of adjusted out-of-pocket maximum rules in the 'differential co-payment ceiling', which means having a higher burden of co-payment, that expanded to the entire ceiling level in long-stay admission patients in long-term care hospitals(LTCH). Methodology: We used health insurance claim data between January 1, 2022, and December 31, 2022 received from the National Health Insurance Service. The study populations were inpatients in long-term care hospitals more than 1 days during the study period. We performed the difference in characteristics of the LTCH patient of the differential and general ceiling by the chi-square test. We estimated the change of the population, cost, and co-payments per person under the assumption of restructuring. Finding: Based on adjusted out-of-pocket maximum rules in 2023, it was expected that the number of benefits decreases at the high-income level while increasing at the low-income level. The burden of health expenditure after reimbursement of co-payment ceiling, is expected to increase by 65.1% in the highest medical necessity, whereas the low medical necessity would decreases compared to 2022. Practical Implications: The results demonstrate that the current out-of-pocket maximum rules do not reflect the needs of medical necessity. This study suggested the need to reflect the medical necessity in LTCH on the out-of-pocket maximum rules in the future.

• 대한한의학회지
• /
• 제44권1호
• /
• pp.1-15
• /
• 2023

Objectives: National health insurance herbal prescription of Korean medicine has been serving important role in public healthcare in spite of continuous demand on revision of system. However, the categories of insurance herbal prescriptions are not equally distributed throughout the KCD-based major disease categories. We analyzed statistical database of claimed national health insurance classified as major disease categories by years. We classified all 56 herbal prescriptions as per their total medical indications into 22 major disease categories to analyze their distribution. Significant increase of M and S-T code claims were found, whereas decrease of U code claims by years. We figured out that the 56 prescriptions were unequally distributed along with enrichment of certain codes such as K and J. Meanwhile, the insurance claim of each prescription was positively correlated with number of code types of their indications. As a result, we believe that the reform of national health insurance herbal prescription list is necessary to promote use of it in clinic.

• Journal of Preventive Medicine and Public Health
• /
• 제45권5호
• /
• pp.291-300
• /
• 2012

Objectives: We aimed to estimate the annual socioeconomic burden of coronary heart disease (CHD) in Korea in 2005, using the National Health Insurance (NHI) claims data. Methods: A prevalence-based, top-down, cost-of-treatment method was used to assess the direct and indirect costs of CHD (International Classification of Diseases, 10th revision codes of I20-I25), angina pectoris (I20), and myocardial infarction (MI, I21-I23) from a societal perspective. Results: Estimated national spending on CHD in 2005 was $2.52 billion. The majority of the spending was attributable to medical costs (53.3%), followed by productivity loss due to morbidity and premature death (33.6%), transportation (8.1%), and informal caregiver costs (4.9%). While medical cost was the predominant cost attribute in treating angina (74.3% of the total cost), premature death was the largest cost attribute for patients with MI (66.9%). Annual per-capita cost of treating MI, excluding premature death cost, was $3183, which is about 2 times higher than the cost for angina ($1556). Conclusions: The total insurance-covered medical cost ($1.13 billion) of CHD accounted for approximately 6.02% of the total annual NHI expenditure. These findings suggest that the current burden of CHD on society is tremendous and that more effective prevention strategies are required in Korea.

• 한국방사선학회논문지
• /
• 제14권6호
• /
• pp.801-810
• /
• 2020

본 연구에서는 PET 검사의 건강보험 적용 및 급여기준 변경 현황을 살펴보고, 지난 10년간 건강보험 이용량을 분석하였다. PET 검사가 건강보험으로 적용된 것은 2006년으로 ¹⁸F-FDG가 최초로 건강보험으로 적용된 이후 여러 가지 방사성동위원소를 이용한 PET 검사가 건강보험으로 적용되고 있다. 2019년 기준 PET 검사 수는 198,651건, 진료금액은 약 883억원이며, 일반적 특성에 따른 검사 수는 남성이 여성보다 많았고, 연령별로는 60대에서 검사수가 가장 많았다. 외래 검사수가 입원 검사수 보다 많았고, 상급종합병원 검사수가 68.2%로 종합병원, 병원보다 월등히 많았다. 검사부위는 토르소 검사가 86.6%로 가장 많았으며, 방사성동위원소는 ¹⁸F-FDG를 이용한 검사수가 93.6%로 가장 많았다. 10년간 건강보험 이용량 변화로는 2010년 부터 2014년까지 꾸준히 증가하였으나 2014년 정부의 건강보험 적용기준 변경에 따라 무증상 장기추적 검사의 인정이 삭제되면서 이용량이 이후 급격히 감소하였다. 정부의 건강보험 적용기준 변경이 건강보험 이용량 변화에 큰 영향을 주는 만큼 향후 지속적인 모니터링이 필요할 것이다.

• 한국병원경영학회지
• /
• 제23권2호
• /
• pp.18-27
• /
• 2018

Purposes: This study aims to investigate the policy effect of mandatory application of DRG for 7 disease groups in general and tertiary hospitals. Methodology: As DRG was fully implemented in July 2013, this study compares two periods before and after the change(from July 2012 to June 2013, and from July 2013 to June 2014). The benefit claim data of the National Health Insurance Service was used for the comparison. Target patients were those who visited general or tertiary hospitals between July 2012 to June 2014. For pharmaceutical consumption, Interrupted Time Series (ITS) analysis was used to see the effect of DRG mandatory application. Findings: The number of drugs prescribed per patient and pharmaceutical expenditure both showed significant reduction compared to before the DRG implementation. Practical Implications: This study used 2 sets of 1 year period data from before and after the full implementation of DRG to analyze pharmaceutical consumption. When the comparison data accumulates further, it would be possible to conduct more diverse analysis to assess policy effect and to provide way forward for the future.

• Journal of Chest Surgery
• /
• 제49권sup1호
• /
• pp.37-43
• /
• 2016

Background: While demand for cardiovascular surgery is expected to increase gradually along with the rapid increase in cardiovascular diseases with respect to the aging population, the supply of thoracic and cardiovascular surgeons has been continuously decreasing over the past 10 years. Consequently, this study aims to achieve guidance in establishing health care policy by analyzing the supply and demand for cardiovascular surgeries in the medical service area of Korea. Methods: After investigating the actual number of cardiovascular surgeries performed using the National Health Insurance claim data of the Health Insurance Review and Assessment Service, as well as drawing from national statistics concerning the elderly population aged 65 and over, this study estimated the number of future cardiovascular surgeries by using a cell-based model. To be able to analyze the supply and demand of surgeons, the recent status of new surgeons specializing in thoracic and cardiovascular surgeries and the ratio of their subspecialties in cardiovascular surgeries were investigated. Then, while taking three different scenarios into account, the number of cardiovascular surgeons expected be working in 5-year periods was projected. Results: The number of cardiovascular surgeries, which was recorded at 10,581 cases in 2014, is predicted to increase consistently to reach a demand of 15,501 cases in 2040-an increase of 46.5%. There was a total of 245 cardiovascular surgeons at work in 2014. Looking at 5 year spans in the future, the number of surgeons expected to be supplied in 2040 is 184, to retire is 249, and expected to be working is 309-an increase of -24.9%, 1.6%, and 26.1%, respectively compared to those in 2014. This forecasts a demand-supply imbalance in every scenario. Conclusion: Cardiovascular surgeons are the most central resource in the medical service of highly specialized cardiovascular surgeries, and fostering the surgeons requires much time, effort, and resources; therefore, by analyzing the various factors affecting the supply of cardiovascular surgeons, an active intervention of policies can be prescribed for the areas that have failed to meet the appropriate market distributions.

• Safety and Health at Work
• /
• 제14권4호
• /
• pp.398-405
• /
• 2023

Background: Starting from March 2020 until December 2021, different phases of Covid-19 pandemic have been identified in Italy, with several containing/lifting measures progressively enforced by the National government. In the present study, we investigate the change in occupational risk during the subsequent pandemic phases and we propose an estimate of the incidence of the cases by economic sector, based on the analysis of insurance claims for compensation for Covid-19. Methods: Covid-19 epidemiological data available for the general population and injury claims of workers covered by the Italian public insurance system in 2020-2021 were analyzed. Monthly Incidence Rate of Covid-19 compensation claims per 100,000 workers (MIRw) was calculated by the economic sector and compared with the same indicator for general population in different pandemic periods. Results: The distribution of Covid-19 MIRw by sector significantly changed during the pandemic related to both the strength of different waves and the mitigation/lifting strategies enforced. The level of occupational fraction was very high at the beginning phase of the pandemic, decreasing to 5% at the end of 2021. Healthcare and related services were continuously hit but the incidence was significantly decreasing in 2021 in all sectors, except for postal and courier activities in transportation and storage enterprises. Conclusion: The analysis of compensation claim data allowed to identify time trends for infection risk in different working sectors. The claim rates were highest for human health and social work activities but the distribution of risk among sectors was clearly influenced by the different stages of the pandemic.

• Journal of Korean Medical Science
• /
• 제33권44호
• /
• pp.276.1-276.10
• /
• 2018

Background: The National Health Insurance Service (NHIS) established a healthcare claim database for all Korean citizens. This study aimed to analyze the NHIS data and investigate the patterns of breast cancer treatments. Methods: We constructed a retrospective female breast cancer cohort by analyzing annual incident cases. The annual number of newly diagnosed female breast cancer was compared between the NHIS data and Korea National Cancer Incidence Database (KNCIDB). The annual treatment patterns including surgery, chemotherapy, radiation therapy, endocrine therapy and targeted therapy were analyzed. Results: A total of 148,322 women with newly diagnosed invasive breast cancer during 2006-2014 was identified. The numbers of newly diagnosed invasive breast cancer cases were similar between the NHIS data and KNCIDB, which demonstrated a strong correlation (r = 0.995; P < 0.001). The age distribution of the breast cancer cases in the NHIS data and KNCIDB also showed a strong correlation (r = 1.000; P < 0.001). About 85% of newly diagnosed breast cancer patients underwent operations. Although the proportions of chemotherapy use have not changed during 2006-2014, the total number of chemotherapy prescriptions sharply increased during this period. The proportions of radiotherapy and anti-hormonal therapy increased. Among the anti-hormonal agents, tamoxifen was the most frequently prescribed medication, and letrozole was the most preferred endocrine treatment in patients aged ${\geq}50$ years. Conclusion: Along with the increased breast cancer incidence in Korea, the frequencies of breast cancer treatments have increased. The NHIS data can be a feasible data source for future research.

• 대한약침학회지
• /
• 제24권3호
• /
• pp.142-151
• /
• 2021

Objectives: Although Korean Medicine (KM) subsidized by the National Health Insurance (NHI) has been used for a long time, there has been no active analysis using claims data. Therefore, the purpose of this study was to examine the NHI KM utilization trend using NHI statistics and to measure the level of market concentration by year. Methods: By restructuring the contents of NHI Statistics for Pharmaceuticals for 2010-2019, the claim cases, costs, and annual growth rates of KM were demonstrated by year, sex, age group, region, therapeutic group, and KM treatment. The proportion of highly used k treatments in cost was calculated as the concentration ratio (CR) k and its trend by year was investigated. Results: In 2019, the NHI cost on KM amounted to ₩38.2 billion KRW, increasing by 11.6% per year on average in 2010-2019. Notably, KM was used more frequently among women and patients aged ≥ 65 years, and the mixed formulation accounted for 95% of the total cost of KM. The CR of the simple formulation increased rapidly, whereas that of the mixed formulation remained constant. In 2019, three simple formulation treatments- peony, licorice, and ginseng- accounted for 93.8% of the total cost for KM (CR3 = 93.8%). Conclusion: NHI KM is rapidly increasing. Investigating the CR of KM confirmed that KM prescriptions have been concentrated in small numbers over the past 10 years.

• 디지털융복합연구
• /
• 제11권10호
• /
• pp.593-608
• /
• 2013

상해상병으로 청구되는 건수가 증가함에 따라 조사 대상을 보다 정교하게 선정하여 상해요인 조사 대상을 줄이면서 환수율 및 환수금액을 올릴 수 있는 방안을 마련할 필요가 있다. 이를 위해서 2006~2011년까지의 상해요인 조사자료를 수집하여 의사결정나무 모형을 활용하여 지역가입자 상해상병 진료건에 대한 부당환수 조사대상 선정모형을 개발하였다. 최종 개발된 모형결과에 따르면, 조사대상 유형은 18개로 분류되었고, 이러한 분류결과는 실제 조사가 시행될 시, 모형을 적용하지 않았을 때 보다 최고 12.8배 높은 부당환수결정율을 나타낼 수 있을 것으로 분석되었다. 또한, 본 연구에서 개발된 조사 대상자 선정 모형을 실제 업무에 적용하기 위해서는 조사물량 대비 국민건강보험공단의 조사인력 및 운영 계획을 보다 면밀히 검토해야만 모형 적용의 효과성이 극대화 될 수 있을 것으로 판단된다.