• Title/Summary/Keyword: insured

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Pathway of Medical Care Seeking of Insured Patients (보험환자의 의료이용 추구경로)

  • 한달선;김병익;이영조;권순호
    • Health Policy and Management
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    • v.2 no.1
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    • pp.115-147
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    • 1992
  • The purposes of this paper are twofold : to identify what pathway insured patients are seeking medical care services through, and then, to provide the basis for the prediction and evaluation of the effects of a new policy intervention. To change the patient flow across different types of medical care facilities, this intervention has been enforced since July 1, 1989. It is mainly aimed at discouraging the use of the tertiary hospitals by imposing some restrictions on the patient's choice. The data for analysis were obtained from the claims to the insurance for govermment and school employees. The sample was drawn from the claims for about 1% of the enrollees using medical care facilities during 2 years since January 1, 1985. The sample included 91, 483 for 1985 and 81,914 for 1986, among them the number of patients to initiate the use of medical care service were 66,757 and 59,498 respectively. This paper analysed what types of and how many medical care facilities the patient with same disease had used.

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Frequency Analysis of Clinical Prescriptions in the Korean Medicine Hospital Pusan National University based on Herb Weight Ratio(1) - Focusing on Insured Herbal Mixture Extracts - (본초 중량비를 이용한 부산대학교 한방병원의 첩약 사용 빈도 분석(1) - 보험처방을 중심으로 -)

  • Heo, Kwang-ho;Hwang, Eui-hyoung;Lee, Byung-wook
    • Herbal Formula Science
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    • v.23 no.1
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    • pp.67-76
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    • 2015
  • Objectives : This Study aims to search for the actual prescriptions worth being Insured Herbal Mixture Extracts(IHME), which frequently used frequently in the clinical settings by comparing clinical prescriptions with the list of prescriptions covered under the national health insurance system. Methods : By making comparisons of the herb weight ratios of IHME with those recorded in EMR, the frequency is measured on the basis of the IHME and the frequency indication is computed for the clinical prescriptions with lower level of differences. Results & Conclusions : On the basis of the details of the clinical prescriptions used at the EMR, we have found out that many clinical prescriptions of EMR are similar for banhasasim-tang, banhabaekchulcheonmatang, bojungikgi-tang and jaeumganghwa-tang in the national health insurance system. And we could analyze indications of those prescriptions. So, if we can make a similarity criteria of prescriptions and this methods are used at nationwide research, we will be able to obtain a satisfactory result in study, medical industry and clinics.

A study on the problems about the obligation to notify in marine cargo insurance (해상적하보험에서 통지의무의 문제점에 관한 고찰)

  • Kim, Hee-Kil
    • THE INTERNATIONAL COMMERCE & LAW REVIEW
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    • v.46
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    • pp.211-235
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    • 2010
  • According to the commercial law in Korea, a marine cargo insurance contractor (policyholder, insured person, agent) has the duty to disclose risks before establishing an insurance contract and the obligation to notify changes in risks after before establishing the contract. Marine cargo insurance policy clauses include one about the obligation to notify changes in risks. This clause assumes that an insurance contract should be implemented according to what has been answered to the important questions asked by the insurer in connection with the insurant's duty to disclose before establishing an insurance contract, and it stipulates that, if any change in what has been disclosed should be notified to the insurer since it is regarded as a change in risks. Neglecting the obligation to notify may lead to the termination of the appropriate insurance contract by the insurer. The problems here concern the clauses about changes in risks and about the obligation to notify. The problems are like these. Can it be that the circumstances which might be seen in the past as changes in risks according to the territorial sea laws and institute cargo clauses stipulated long ago are considered as such still today? And a marine cargo insurance policy till valid when changes in risks have not been properly notified by the original discloser of risks to the insured who currently holds the marine cargo insurance policy, which, unlike other insurance policies, is a marketable security? In Korea, the commercial law has a clause the obligation to notify changes in risks established based on the territorial sea laws and institute cargo clauses. In this regard, this study aims to consider if the clause still valid today or not and, if not, to propose alternatives to the clauses.

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Development of the Fraud Detection Model for Injury in National Health Insurance using Data Mining -Focusing on Injury Claims of Self-employed Insured of National Health Insurance (데이터마이닝을 이용한 건강보험 상해요인 조사 대상 선정 모형 개발 -건강보험 지역가입자 상해상병 진료건을 중심으로-)

  • Park, Il-Su;Park, So-Jeong;Han, Jun-Tae;Kang, Sung-Hong
    • Journal of Digital Convergence
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    • v.11 no.10
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    • pp.593-608
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    • 2013
  • According to increasing number of injury claims, the challenge is reducing investigation of cases of injuries by selecting them more delicately, while also increasing the redemption rates and the amount of restitution. In this regards, we developed the fraud detection model for injury claims of self-employed insured by using decision tree after collecting medical claim data from 2006 to 2011 of the National Health Insurance in Korea. As a result of this model, subject types were classified into 18 types. If applying these types to the actual survey compared with if not applying, the redumption collecting rate will be increasing by 12.8%. Also, the effectiveness of this model will be maximize when the number of claims handlers considering their survey volume and management plans are examined thoroughly.

The Effects of Changed Selective Treatment System on Medical Service Usage and Payments for Lung Cancer Patients (선택진료제도 개선이 폐암환자 의료이용 및 본인부담액에 미치는 영향)

  • Jeon, Insook;Lee, Haejong
    • Korea Journal of Hospital Management
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    • v.22 no.4
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    • pp.61-73
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    • 2017
  • In the Health Insurance System of South Korea, patients must pay high out-of-pocket expenditures for the medical service by uninsured medical benefits. So, the government implemented a policy to relieve the burdens of patients by lowering the uninsured selective-medical treatment costs in August, 2014. This study investigate the policy effects of selective-medical treatment(SMT) on the medical service's usage and cost with severe lung cancer patients. The patients are selected in one university hospital(with 1,000 beds), between one year before and after policy implementation. The study find that the usages of outpatient(visit number) and inpatient (length of stay) are not changed by statistically significant. It means that there are no effect in medical service behavior between before and after the policy. In medical expenses, outpatients decreased in their out-of-pocket payments by policy, but total medical expenses and insured medical benefits is not changed, because of the increased another medical insurance fees. For inpatient, although the SMT costs are statistically significant decrease, the total out-of-pocket payments and insured medical expenses are not changed statistically significant. Those findings show that the political decision making about SMT made lowing the selective-medical expenses, but total insured cost and patient's out-of pocket money were not changed by the new increased medical insurance fees. It means that the policy about SMT gave no particular benefit for patients. So, it need another benefit plans to lower the medical expenses of severe lung cancer patients with a high medical service usage and much total medical expense.

A Study on the Origin and Current Status of the Utmost Good Faith in the Marine Insurance Act -Focused on the Carter v. Boehm case- (영국해상보험법상 최대선의의무의 기원과 최근 동향에 관한 고찰 - Carter v. Boehm 사건을 중심으로 -)

  • Pak, Jee-Moon
    • Korea Trade Review
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    • v.44 no.2
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    • pp.83-94
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    • 2019
  • Article 17 of the Marine Insurance Act (MIA) states that "A contract of marine insurance is a contract based upon the utmost good faith, and if the utmost good faith be not observed by either party, the contract may be avoided by the other party." In the Carter v. Boehm case, Lord Mansfield was the first to provide a comprehensive description of the duty of utmost good faith, which is analyzed here. This judgement not only laid the foundation for the Modern English Insurance Act, but it also influenced the draft of the English Insurance Act of 2015, which aimed at correcting distortions that occurred during the application of statue law and common law thereafter. The duty of utmost good faith, applied between Lord Mansfield's insured and insurer presents the context of information asymmetry of the insured and insurer entering contracts. In the absence of information asymmetry, in contrast to the effects of being in both sides of the duty of utmost good faith, alleviating the duty of disclosure of the insured, and it is also clear that the warning of the severity of the retrospective avoidance of the breach of duty of disclosure and the need for its limited application have already been pointed out. Furthermore, considering the principle of retrospective avoidance, the duty of utmost good faith should be understood as a concept limited to the duty of disclosure before a contract is concluded

Use of Herbal Decoction and Pharmacopuncture in Individuals with Chronic Disease: findings from a nationally representative panel

  • Chan-Young Kwon;Sunghun Yun;Bo-Hyoung Jang;Il-Su Park
    • Journal of Pharmacopuncture
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    • v.27 no.2
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    • pp.110-122
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    • 2024
  • Objectives: This study analyzed the Korea Health Panel Annual Data 2019 to investigate factors related to the use of non-insured Korean medicine (KM) treatment in individuals with chronic diseases. The non-insured KM treatments of interest were herbal decoction (HD) and pharmacopuncture (PA). Methods: Among adults aged 19 or older, 6,159 individuals with chronic diseases who received outpatient KM treatment at least once in 2019 were included. They were divided into three groups according to the KM treatment used: (1) basic insured KM non-pharmacological treatment (BT) group (n = 629); (2) HD group (n = 256); (3) PA group (n = 184). Logistic regression analysis was used to explore factors associated with favoring HD or PA use over BT. Potentially relevant candidate factors were classified using the Andersen Behavior Model. Results: Compared to BT, the 1st to 3rd quartiles of income compared to the 4th quartile (odds ratio: 1.50 to 2.06 for HD; 2.03 to 2.83 for PA), health insurance subscribers compared to medical aid (odds ratio: 2.51; 13.43), and presence of musculoskeletal diseases (odds ratio: 1.66; 1.91) were significantly positively associated with HD and PA use. Moreover, the presence of cardiovascular disease (odds ratio: 1.46) and neuropsychiatric disease (odds ratio: 1.97) were also significantly positively associated with HD use. Conclusion: The presence of some chronic diseases, especially musculoskeletal diseases, was significantly positively associated with HD and PA use, while low economic status was significantly negatively associated with HD and PA use, indicating the potential existence of unmet medical needs in this population. Since chronic diseases impose a considerable health burden, the results of this study can be used for reference for future health insurance coverage policies in South Korea.

A Study on Accounting for Nursing Cost by Korean Diagnosis Related Groups (K - DRGs) (종합병원(綜合病院)의 간호행위양상(看護行爲樣相)에 따른 간호원가(看護原價) 산정(算定)에 관(關)한 연구(硏究))

  • Oh, Hyo-Sook
    • Journal of Korean Public Health Nursing
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    • v.3 no.2
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    • pp.5-46
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    • 1989
  • The current medical payment Insurance Rates in Korea stipulate charges for medical treatment by the doctor, pharmaceutist, medical technician and maternity nurse. But unfortunately didn't specify those charges for nursing done by the professional nurse. Only basic nursing fee is accounted insufficiently in current medical insurance fee schedule. therefore, Being face with covering entire people by medical insurance by 1991, It seems that the problems pertaining to operating the hospital and medical insurance system would be incessantly expanded in that no mention is made of medical charges rendered by major medical producer service in the current system, For that reason, this study made an attempt to clarify the importance the professional nursing puts of the current medical payment. The purpose of this study was to accounting nursing fee which diveded into the current medical fee schedule. (Method) 1. Data collection; Importance and difficulties in nursing activities was conducted in 'S' National University Hospital. Total nursing activities were selected 72 items which included direct care and indirect care. This study was conducted to evaluating the degree of importance and difficulties according to nursing activities through questionnaire to 204 RN. and so relative difficulties (acuity) were computered because the nursing cost level of each nursing service was differently established by the equivalent coefficient according to degree of relative difficulty and time required. 2. Calculation of cost according to nursing activities; After 47 nursing activities were selected in General surgery nursing units, calculation of nursing cost was as follows Cost of Nursing activity = (relative difficulty X Average hourly wage and benefits of nurse) + material cost of nursing -t- Average nursing administration cost So, Calculated cost by nursing activities was compared to current non-insured and insurance rate. 3. Calculation of nursing cost by K - DRG ; Total of 578 patients who were hospitalized in General Surgery units from January to March 1988 ware classified by K - DRG After estimation of total nursing cost based on the K-DRG, verified the appropriateness of basic nursing fee in medical insurance rate (Results) 1. Analysis of degree of importance and difficulties were 4.16 and 3.67 based on 5 point scale. This score were judged that it is worthy specifying the nursing fee 2. The nursing cost of 47 nursing service items in general surgery patients showed that the average cost of nursing activity was \1374.5 and The lowest cost was \217 of 'oral administration nursing' item, The highest cost was \11,025 of 'saline enematill clear' item 3. The result of comparison between the calculated cost by nursing activities against the current non-insured and insurance rate showed that 13 items(27.7%) involved to payment of insurance rate, 9 items(19.1%) involved to non-insured rate, remainder 25 items (53.2%) were not charged anywhere of total 47 nursing activities 4. When calculated cost by nursing activities was 100. current insurance rate was 62.3, non-insured rate was 176.6. Therefore this showed that most of non-insured rate were higher than calculated nursing cost. The insurance rate, however, were lower than it. Reim-bursement was imputed to non-insured patients. So the current rate system became estrainged from cost system. When Remainder 25 items of nursing activities compared' to \1390 of daily basic nursing fee per patient belonged to payment as a insurance fee schedule, basic nursing fee schedule was 1-2% of calculated cost of nursing activities. Therefore it showed that nursing fee was not counted adequately in it. 5. Nursing cost by K-DRG estimated in chart review based on counting number of nursing activities and length of stay The result showed that average amount of total nursing cost was \183828.1 Comparison of nursing cost calculated by K- DRG and basic nursing fee schedule showed that only 12.3% of nursing cost was charged (Conclusion) From the above research result, It is fact that nursing prime cost should be estimated more accurately and included adequately in current medical payment system. The payment system of nursing activities should be introduced not only nursing activities of drug administration and injection fee belonged to insurance fee schedule but also most nursing activities belonged not to mekical fee schedule. Even if introducing payment system of nursing activities, It should be estimated scientific method of Accounting nursing cost So nurses could offer nursing care of good quality, thereby they could make a great contribution not merely to the convalescence of the patient but to the promotion of the people's health.

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A Study on the Current Fire Insurance Subscription and Solutions for Ensuring the Safety of the Traditional Market (전통시장 안전성 확보를 위한 개선방안: 화재보험 가입실태를 중심으로)

  • Kim, Yoo-Oh;Byun, Chung-Gyu;Ryu, Tae-Chang
    • Journal of Distribution Science
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    • v.9 no.4
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    • pp.43-50
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    • 2011
  • Concerning the risk factors of the outbreak of a fire in a traditional market, most of those markets are located in downtown areas or residential areas; thus, although their location may be favorable in terms of marketability, they face a potential risk in that a fire may develop into a large blaze owing to poor environment or the absence of facilities prepared for disaster during a fire. Moreover, as many people are densely poised in the markets, it is very probable that a fire may occur owing to the excessive use of heaters in the winter as well as the reckless use of electric and gas facilities. It seems that traditional markets encounter difficulty being insured against fire, because of their vulnerability and that the vast majority of small-scale sellers are likely to suffer mental anguish and tremendous physical injury in case of a fire. However, most of those sellers in the traditional markets are hand-to-mouth sellers, and they lack awareness of safety concerns and have insufficient experience in safe facility management. As small-scale sellers constitute the majority in the traditional market, the subscription rate of fire insurance in most of the traditional markets is low for the reasons of their needy circumstances and their financial burden. Statistically, the subscription by street vendors is non-existent; therefore, these vendors have a fairly limited access to indemnification after fire damage. Because of these problems, this study's purpose is to identify the current level of insurance subscription by these markets, which are exposed to poor facilities and vulnerability to fire. In order to fix this, it appears that shop owners and consumers will have to band together. For this study, we executed a fire policyholder fact-finding mission at traditional markets with approximately 108 and 981 stores. The research method was executed by an investigation using one-on-one individual interviews using a questionnaire. The contents investigated current insurance subscriptions. The method of analysis looked at the difference of insured amount according to volume size through cross-tabulation of the difference of insured amount by possession form, difference of insured amount by market form, difference of insured amount by category of business, difference of insured amount by market size, etc. Furthermore, the study should be used to propose solutions for problems through theoretical review with the use of a literature research, because the field case study was through interviews with the persons concerned, and the survey of the current insurance subscriptions by traditional market shopkeepers. The traditional market would generally have difficulty affording fire insurance. Fire insurance subscription rates of most of the market proved to be inactive, because of the economic burden of payment. Lack of funds is thought to be the main factor that causes a lack of realization about the necessity of fire insurance. In addition to expensive insurance premiums, sometimes, the companies' valuation of the businesses is lower than their actual valuations, and they do not pay out enough during a claim. The research presents an improvement plan that, when presented at the traditional markets, may strengthen their ability to procure fire insurance through the help of the central government. Researchers connected with the traditional market mainly accomplish the initial research. However, although this research has its limitations, it offers considerable benefits. For future researchers, I would suggest looking at several regions for comparison.

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A Study on Sickness and Medical Care of Insured ana Non-insured Group -In Case of Naju Fertilizer Company- (의료보험가입군(醫療保險加入群)과 비가입군(非加入群)의 의료(醫療)에 관(關)한 조사(調査) -나주(羅州) 비료공장(肥料工場)의 경우(境遇)를 중심(中心)으로-)

  • Chang, Sae-Han
    • Journal of Preventive Medicine and Public Health
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    • v.7 no.2
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    • pp.319-325
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    • 1974
  • A study on the status of sickness and medical care of insured and non-insured groups of employee and his family in Naju fertilizer company, in the year of 1973, was carried out. The results obtained are as follows: 1. 66.8% of all employee was subscribed in this medical insurance program. No woman employee was subscribed and the rate of subscription was increased from 16.1% to 92.0% by age increases. 2. Also, as of period of service, the rate of subscription was increased from 11.3% to 89.4% by the period gets longer. 3. Employee who reside within boundary of the company (76.2%) subscribed more than that whom reside outside boundary (63.9%). 4. Rate of subscription was also indreased by family size becomes larger. In case of single, it was only 19.6% but in the case of family size became more than 6, it increased to 87.4%, 5. As of amount of monthly income, although no one had subscribed those who get less than 30,000 won a month. Subscriber, increased by monthly income get greater. 6. Subscribed family reside within company boundary utilized hospital 35.5 times a year whereas non-subscribed family reside within these utilized 12.5 times. And, subscribed family reside outside boundary utilized hospital 32.2 times a year and non-subscribed family utilized 9.6 times. Regardless of resident area, family who subscribed to this program utilized hospital more often than non-subscribed family. 7. The utilization of the hospital became gradually frequent from 15.6 times to 36.5 times per family by family size became larger. but in non-subscribed group, although it was increased from 8.3 times to 16.5 times per family, it was droped to the least 6.9 times at 2 person family. 8. 17,496 hospital visits were made by all employee and his family in the year 1973. 86.9% of them was made by subscribed group and the rest (13.1%) was made by non-subscribed group. Observing of the type of these sickness by the classification of WHO, only three types of VII (26.7%), XVII (25.0%) and IX(19.3%) were made more often by non-subscribed group while the others were made more by subscribed group. 9. Anual average medical expenditure per family was 13,098.9 won for subscribed family while it was 3,076.1 won for non-subscribed family. 10. Anual average hospital visits per capita was 6.5 times for subscribed groups and 3.4 times for non-subscribed group. Anual average medical expenditure per capita was 2,580.8 won for subscribed group while it was 1,061.0 won for non-subscribed one.

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