• 보건행정학회지
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• 제8권2호
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• pp.76-87
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• 1998

This study analyzed the effect of foreign currency exchange rate on the increasing rate of medical care cost by items of fee schedule of Korean Medical Insurance. This study uses the data of cost analysis including cost of imported goods and the data of for a university hospital National Federation's Medical Insurance for a trend of claim. The method of cost analysis is as same as that used in the study of the development of Korean RBRVS(Resource Based Relative Valus Scale). The main findings of this study are as follows; 1. The proportion of imported goods in cost related to Medical Insurance fee schedule is 7.93%, and in case of substitution of available domestic goods 6.96%. 2. If foreign currency exchange rate changes from 800wen per $1 to 1,300won, the affecting rate of Medical Insurance fee schedules is 5.00%. If the imported goods will be substituted with available domestic goods, the rate 4.35%. Our results can be used a data for updating Medical Insurance fee schedule. But this result is limited to be generalized, because this study used the cost analysis for a university hospital.

• 치위생과학회지
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• 제11권1호
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• pp.31-35
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• 2011

본 연구는 치과 의료기관의 건강보험 청구실태를 파악하여 향후 효율적인 치과 건강보험 청구관리를 위한 기초자료를 제공하고자 2010년 4월 20일부터 6월 20일까지 서울, 인천 경기, 부산 울산 및 일부 지역에 소재한 치과 의료기관을 대상으로 설문조사를 실시한 결과 다음과 같은 결론을 얻었다. 1. 치과 건강보험 청구형태는 병원 내 인력을 활용하여 청구하는 단독청구가 45.4% 응답하였으며, 대행청구 54.6%이었다. 청구자의 직종은 치과위생사 78.2%, 일반사무원 7.2%, 간호조무사 6.5%, 치과의사 4.5%, 기타 3.5%로 조사되었다. 청구건수는 200건 이하가 23.9%, 201건-400건이 40.3%, 401건 이상이 35.8% 이었다. 2. 청구건수에 의한 분석에서 청구 건수가 적은 경우일수록 대행청구는 하는 의료기관이 76.3%로 많았고 청구건수가 많을수록 단독청구의 비율이 높아졌으며, 개원기간에 따른 분석에서는 단독청구를 하는 의료 기관은 개원기간이 5년 이하인 경우 82.7%, 개원기간이 16년 이상인 경우 31.3%로 개원기간이 짧을수록 단독청구를 하는 의료기관이 많았다(p<0.000). 3. 병원 인력 수에 따른 분석에서 4인 이하인 경우는 단독청구가 25.4%, 대행청구가 74.6%로 대행청구가 많았으나 9인 이상인 경우에는 단독청구가 71.1%, 대행청구가 32.6%이었다(p<0.000). 4. 치과위생사 수에 따라 청구방식의 차이를 분석한 결과 치과위생사가 없는 경우는 86.5%가 대행청구를하고 있었으며 치과위생사 수가 많아질수록 단독청구 방식을 선택하고 있었으며 통계적으로 유의한 차이가 있는 것으로 분석되었다(p<0.000). 5. 치과 의료기관에서 대행청구를 하는 이유를 분석한 결과 복잡한 청구절차가 28.0%로 가장 많았으며 다음으로 청구업무의 실력부족 22.6%, 청구업무인력의 인재부재가 20.8%이었다.

• 의료법학
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• 제8권2호
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• pp.69-118
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• 2007

In providing general medical treatments, the medical service contract between the patient and the doctor is the mutually responsible onerous contract. However, the nature of the mutually assumed contract standings of the patient and the doctor has been changing since the implementation of the national health insurance program. For instance, besides the cases of beyond excessive medical charges and medical negligence, if the doctor charged for his/her medical treatments violating the post-treatment/nursing cover criteria, the overpaid medical charge, regardless of being collected with the patient's consent, has to be refunded back to the patient. Medically needed aspects, treatment results, and unfair benefits favoring the patient are not at all taken into consideration in the health insurance scheme. This makes it easier for patients to get refunds for their share of the medical payments by involving the Health Insurance Review & Assessment Service or the National Health Insurance Corporation, without engaging in civil law suits (for reimbursement claim) against doctors. In other words, the doctor's responsibility to provide medical treatments and the patient's responsibility to pay for the medical treatment provided within the contractual realm are being demolished by the administrational arbitration of the National Health Insurance system. The basic rights of medical service providers, and the patient's right to choose are as important constitutional rights, as the National Health Insurance program, which is essential in the social welfare system. Furthermore, the development of the medical fields should not be prevented by the National Health Insurance system. If the medical treatment services can be divided into necessary treatments, general treatments, and high quality treatments, the National Health Insurance is supposed to guarantee the necessary and general treatments to provide medical treatments equally to all the insured with limited financial resources. However, for the high quality treatments, it is recommended that they should not be interfered by the National Health Insurance system, and that they should be left to the private contract between the patient and the doctor.

• 한국병원경영학회지
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• 제28권2호
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• pp.9-20
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• 2023

Purpose: This study classified the actual functions of geriatric hospitals and examined the differences in their characteristics, in order to provide a basis for discussions on defining the functions of geriatric hospitals and how to pay for care. Methodology: This study used various administrative data such as health insurance data and long-term care insurance data. Cluster analysis was used to categorize geriatric hospitals. To examine the validity of the cluster analysis results, we conducted a discriminant analysis to calculate the accuracy of the classification. To examine cluster characteristics, we examined structure, process, and outcome indicators for each cluster. Findings: The cluster analysis identified five clusters. They were geriatric hospitals with relatively short stays for cancer patients(cluster 1; cancer patient-centered), geriatric hospitals with relatively large numbers of patients using rehabilitation services(cluster 2; rehabilitation patient-centered), geriatric hospitals with a high proportion of relatively severe elderly patients(cluster 3; severe elderly patient-centered), geriatric hospitals with a high proportion of mildly ill elderly patients with various conditions(cluster 4; mildly ill elderly patient-centered), and geriatric hospitals with a significantly higher proportion of dementia patients(cluster 5; dementia patient-centered). The largest number of geriatric hospitals were categorized in clusters 4 and 5, and the structure and process indicators for these clusters were generally lower than for the other clusters. Practical Implications: We have confirmed the existence of geriatric hospitals where the medical function, which is the original purpose of a geriatric hospital, has been weakened. It has been observed that the quality level of these geriatric hospitals is likely to be lower compared to hospitals that prioritize enhanced medical functions. Therefore, it is suggested to consider the conversion of these geriatric hospitals into long-term care facilities, and careful consideration should be given to the review of care-giver payment coverage.

• 보험의학회지
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• 제29권2호
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• pp.22-28
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• 2010

Medical risk selection or mortality analysis is very important in insurance medicine. Among many kind of source articles there have been several limitations. There are few long-term follow-up studies in rare disease, as Romeo's article. We can do mortality analysis of this type using cause of death within the article and assumption of expected mortality q'. In the case of article which is published in foreign country such as Tikkanen et al, we can use comparative group from the control group within source article. It is another way for mortality analysis of limited article. However Retrospective study even performed in Korea, is unusable for estimation of extra-mortality.

• 한국병원경영학회지
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• 제26권3호
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• pp.13-27
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• 2021

Purpose: We examined the relationship between operating income and volume of medical services provided at general hospitals in 2018 according to characteristics of general hospitals and measured as operating income(net income) and volume(adjusted inpatient days) covered or non-covered by National Health Insurance(NHI). Methodology: Finance data from income statement reports in 212 general hospitals and the national health insurance claim data of these hospitals were used. The characteristics of the general hospital were divided into structural, operational, financial, and patient aspects. Operating income and volume were divided into covered and non-covered by NHI. Findings: The results showed high volume hospitals tended to be more profitable than low volume hospitals, especially in non-covered services. Operating income was more likely to be sensitive to non-covered services volume than to covered services volume. Practical Implications: It is necessary to understand the volume of services in non-covered, in order to obtain reliable cost information to be used for the fee schedule. Researches on small size hospitals(<160 beds) are needed, with a large variation in the volume of services and a strong tendency to compensate for the loss in the covered part in non-covered part.

• 보건행정학회지
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• 제19권3호
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• pp.125-141
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• 2009

The purpose of this study was to examine the role of provider practice patterns in the difference in health expenditure between the two types of patients: Health Insurance and Medical Aid type 1. The study used the outpatient claim data for all Medicaid and health insurance patients of hypertension who received medical services from 8,454 primary care physicians during the first half of 2006. The data were stratified by patient's gender and age for the two groups of patients who received care from the same physician. The dependent variables were the differences in medical expenditure per case, patient days per case and medical expenditure per patient day between Medicaid patients and health insurance patients. Empirical results showed that physician characteristics, such as physicians under age 50, greater proportion of pediatric Medicaid patients, lower proportion of new Medicaid patients and the greater number of comorbidity of Medicaid patients are associated with the greater difference between the two types of patients (i.e., greater expenditure of Medicaid patients relative to health insurance patients). This study shows that factors associated with provider practice patterns need to be taken into account in Medicaid policy.

• Journal of Preventive Medicine and Public Health
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• 제34권1호
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• pp.28-34
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• 2001

Objectives : To investigate the changing pattern of medical utilization claims following the economic crisis in Korea. Methods : The original data consisted of the claims of the 'Medical insurance program of self-employees' between 1997 and 1998. The data was selected by medical treatment day ranging between 8 January and 30 June. Medical utilizations were calculated each year by the frequency of claims, visit days for outpatients, length of stay for inpatients, total days of medication, and the sum of expenses. Results : The length of stay as an inpatient in 1998 was decreased 4.7 percent in comparison to 1997. However, inpatient expenses in 1998 increased 10.8 percent as compared to 1997. Inpatient hospital claims in 1998 increased 6.2 percent over 1997, although general hospital inpatient claims in 1998 decreased 3.3 percent in comparison to 1997. The outpatient claim frequency decreased 7.3 in 1998 percent as compared to 1997 Outpatient visit days of in 1998 were decreased 8.5 percent in comparison to that recorded in 1997. Outpatient claim frequencies of 'gu region' in 1998 decreased 10.5 percent comparison to that in 1997, but 'city and gun region' decreased less than 'gu region'. Conclusions : Medical utilization in 1998 deceased in relation to 1997 Medical utilization by outpatients decreased more than that of inpatients. Medical utilization by 'gu region' decreased mere than the other regions.

• 보험의학회지
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• 제24권
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• pp.27-42
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• 2005

Among medical claims review, decision of malignancy is very important. According to the pathologic report may be ordinary pathway. Some tumors are not completely studied especially malignancy. Wheather malignancy or benign is the important thing in medical claims review. We here disscuss on the debatable tumors such as carcinoid tumor, gastrointestinal stromal tumor (GIST), desmoid tumor, MALToma, and pseudomyxoma peritonei. Another controversial subject in the medical claims review is selection of pathologic report. If the result of the pathologic report is not same in one patient, We prefer the selsection of the report from more professional hospital. We have called this professional hospital l as "third hospital" or 'refferal hospital".

• 한국병원경영학회지
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• 제8권2호
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• pp.93-110
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• 2003

Fiscal crisis in the medical insurance has put the pressure upon hospitals by increasing the rate of curtailment, since the implementation of the separation between prescription and dispensing of Drug. The purpose of this study is to analyze the curtailment for antibiotics, injected drug and other drugs expenditure before and after the system of separation between prescribing and dispensing. Data were gathered from 13 general hospitals and used for analysis of trends on antibiotics and injected drug expenditure, and curtailment in 2000-2001 at three months intervals. The results were as follows; The curtailment rate of antibiotics expenditure has been increased in outpatient and inpatient since 2000. The curtailed antibiotics cost and injected drug cost in outpatient under the prescription within the hospital and in inpatient increased. The ratios of curtailment versus expenditure had increased in antibiotics, injected drugs, anticancer drugs, antiulcer drugs, albumine, antiinflammatory drugs. These results suggest that claim review system in social health insurance were over-focused mainly to control the cost and it might to impede the validity of claim review function in health insurance system. Therefore, it's needed to develope the scientific and reasonable parameter & criteria for claim review of drug expenditure.