Abstract
Community-based case management for medical aid beneficiaries was implemented in Korea to promote the rational use of medical care and stabilize the financial system. This study investigated the economic impact of community-based case management on reductions in healthcare utilization and costs. This was a program study using a national database to evaluate the effectiveness of community-based case management in changing not only healthcare utilization and costs but also client-centered outcomes using the NHI database and 198 regional databases. A total of 1741 case management clients were included in this study. The case management clients were categorized into three targeted groups and were provided individualized services according to the groups. Client-centered outcomes, such as health-related quality of life (QOL), self-care ability, and having a support system, increased after case management. Healthcare utilization and costs decreased significantly after case management. However, there was no significant difference in the decrease between the groups. An increase in healthcare utilization among medical aid beneficiaries has been observed due to the aging population and an increase in the number of recipients. To reduce healthcare utilization and costs while maintaining the health status of the beneficiaries, it is necessary to expand targeted case management.
Highlights
The entire national population in Korea is covered by a healthcare system namely, the NationalHealth Insurance (NHI) program or Medical Aid Program
The repeated use target group was defined as beneficiaries from the top 30% of healthcare users among all beneficiaries enrolled in case management
The outpatient target group and the repeated use target group had more than 60% women, whereas the proportion of women in the inpatient target group was lower than in the other groups (X2 = 25.039, p < 0.001)
Summary
Health Insurance (NHI) program or Medical Aid Program. Most Koreans (96%) are covered by the NHI program, while 3–4% of the people who are unable to pay for their own healthcare coverage are covered by the Medical Aid Program [1,2]. The Medical Aid Program is considered a social security system, which covers medical services, such as illness, injuries, and childbirth, to prevent health effects caused by poverty [3,4,5]. The Medical Aid Program is financed by both the central government and the local government and is classified as type 1 or type 2 based on whether someone is incapable (those under 18 or over 65 years of age or disabled) or capable of working [2,6]. Even the out-of-pocket payments (OOPs) amount for type 2 is much lower compared to that for people covered by the NHI program [6]
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