Medical Insurance Fees Research Articles

낙태죄 비범죄화 이후

Access to safe abortion is a key aspect of sexual and reproductive rights. However, even after the decriminalization of abortion in 2021, abortion care has not been normalized in South Korea. This study analyzes the current state of medical assistance and access to abortion after decriminalization, with a focus on abortion due to sexual violence, keeping in mind that abortion, even before decriminalization, was not punished and it was included in the government’s medical expenses subsidy. In-depth interviews with sexual violence victim support workers and healthcare providers revealed that while decriminalization has improved access to care and information, many interviewees did not see any significant changes in medical support for abortion for sexual violence victims. Both support organizations and providers often felt that “abortion has not been legal yet” and as a result, they felt that they were under pressure to make sure that a pregnancy was the result of sexual violence in order to justify providing assistance to victims. As a result they tend to impose strict requirements on victims for providing medical assistance for them. In some cases, support organizations required a complaint of sexual violence, DNA matching of the perpetrator and the fetus, a case conference decision by an external advisor, or parental consent for adolescent victims as prerequisites for medical assistance, which made it impossible for victims to receive assistance. In addition, the Ministry of Gender Equality and Family’s guidelines discourage supporting organizations to apply for assistance as the guidelines stress the possibility of being accused of false accusation and redeeming of support money. It was also pointed out that the guidelines do not specify whether to support medical expenses for pregnancies resulting from prostitution, so the possibility of support is ambiguous. The most difficult thing with regard to supporting abortion was to find a medical professional who would provide medical care ad abortion to victims. Despite being a victim of sexual violence, women were frequently rejected by healthcare providers and were not officially provided with information on which hospitals could provide abortion care. The experiences of being rejected by medical professionals or support organizations in itself caused worse stigma and pain of abortion for victims. Even at hardly found hospitals, it was often the case that hospitals refuse abortion operation expenses be covered by medical insurance and charged high fees while abortions were mostly performed surgically. Parental consent was required for all processes of investigation and medical assistance, leading adolescent victims to abandon their requests for assistance because they were unable to inform their guardians about their problems. There were also challenges in ensuring the right to self-determination for victims with developmental disabilities. Secondary victimization has been found occurred during the medical assistance, investigation, and victim assistance processes. Post-abortion support for contraception was limited, and counseling and follow-up support were scarce. Since the decriminalization of abortion, amendments to the abortion law were submitted to the National Assembly which maintain the punishment of abortion but limiting them based on respective of reasons. The Ministry of Women and Family Affairs’ policy regarding abortion is that it will only fund abortions in some cases of sexual violence. However, the results of the in-depth interviews show that no support for abortion is possible while criminalizing or stigmatizing it in principle. Given the above-mentioned interview results, this study recommends the measures to ensure the right to abortion for sexual violence victims.

The current status and implications of the medical insurance fee schedule in Japan

Background: Korea has the most rapidly aging population in the world. Medical costs for the elderly are quickly increasing, which raises concerns about the sustainability of health insurance finances. Accordingly, the need to allocate limited medical resources efficiently has increased, with improving the fee schedule seen as an effective way to achieve this. Japan has experienced a super-aging society for at least 20 years prior to Korea and has been successful in improving its fee schedule. Korea’s fee schedule, however, needs to overcome the challenge of being relatively limited in type and simplicity.Current Concepts: The new patient consultation fee in Japan is the same regardless of the type of medical institution and is approximately 40% higher than found in Korea. In the case of established patient consultations, the fee for medical institutions with fewer than 200 beds are substantially higher than for large medical institutions, thereby suppressing re-examination at large hospitals. Japan’s additional points consist of 71 types of items, which is more diverse than Korea’s 28 types, and the additional points for children under six years of age, holidays, and late nights are set significantly higher than that found in Korea.Discussion and Conclusion: Japan designed its fee schedule to structurally reduce the consumption of medical resources and to effectively compensate for the behavior of medical providers. This policy is a standard which Korea’s fee schedule should aim for. In the future, it will be necessary to prepare measures to respond to the super-aging environment through detailed research concerning Japan’s fee schedule.

Hospital-Based Case Management for Suicide High-Risk Group Using Delphi Survey.

Objective As of 2019, suicide is serious problem in Korea, with the highest suicide rate among OECD countries. To reduce suicide rates Emergency Department Based Post-Suicide Attempt Case Management carried out with government funding in South Korea, but it is insufficient to address the issue. Aim of this study is to prevent suicide attempts through continuous provision of mental health services even after discharge from acute care. Methods We selected 15 mental health specialists who are multidisciplinary experts in Suicide Prevention. Two-round Delphi survey was conducted on them to reach an agreement for hospital-based case management. Results The first Delphi survey consisted of 8 areas and 39 questions. Among them, 30 questions draw agreement above the reference value. The second Delphi survey, consisted of 37 questions, resulted in 32 above-standard questions. Conclusion Consensus was reached in most category of the Hospital Based Case Management for Suicide High-Risk Group. Core of the developed plan was to provide services to patients who visited the hospital, pursue the stability and universalization of services through a medical insurance fee system. In the future, hospital-based case management service will be implemented as a new model contributing to the reduction of suicide rates in Korea.

Research on Application of Big Data Technology in Cost Control of Medical Insurance For China

With the increasing aging of the population, medical insurance cost control has become a worldwide problem. In order to control the medical insurance fee, since 2009, China's medical insurance payment system has changed from the post payment system mainly based on projects to the prepayment system based on total amount control, but not only failed to control the growth of medical insurance expenditure, but also resulted in the phenomenon that the insured's right to medical treatment has been damaged. Using big data technology and other information-based means to fine manage medical insurance expenditure has become an urgent matter. The paper is divided into four parts. The first part introduces the characteristics of big data and the concept of big data technology; the second part, under the background of the reform of China's medical insurance payment system, analyzes the necessity and possibility of using big data technology to control medical insurance expenses; the third part, puts forward some measures of using big data technology to control medical insurance expenses; finally, the conclusion is drawn that the use of big data technology can realize the fine management of medical insurance control fee.

Disparity in Accessibility to and Prognosis of Kidney Transplantation According to Economic Inequality in South Korea: A Widening Gap After Expansion of Insurance Coverage.

Nationwide studies on the effects of wealth inequality on kidney transplantation are rare, particularly in a country with an expanded National Health Insurance Service and in Asian countries. In this nationwide, population-based cohort study, we reviewed the national claims database of Korea in which details of nationwide health insurance are provided. From 2007 to 2015, 9 annual cohorts of end-stage renal disease patients were included. The annual financial statuses were collected and stratified into 5 subgroups in each year: the aided group in which insurance fee was waived and the 4 other groups divided by quartiles of their medical insurance fee. Time trends of incidence proportion of kidney transplantation among end-stage renal disease patients in each year were initially assessed. The risk of graft failure, both including death-censored graft failure and death with a functioning graft, was analyzed as a prognostic outcome within the transplant recipients. Significant disparity in the accessibility of kidney transplantation was present, and it was further widening, particularly from 2009 in which the National Health Insurance Service started to cover desensitized kidney transplantation. Desensitized or preemptive transplantation was less common in the poorest group who were more frequently receiving transplantation after 5 years of dialysis in the latter years. The prognosis of kidney transplantation was significantly worse in the poorer people, and this disparity also worsened during the study period. Prominent disparity regarding accessibility to and prognosis of kidney transplantation was observed in Korea according to wealth inequality, and this disparity was worsening.

Setup and management of the multi-functional post for outpatients

Simplified outpatient service flow and higher service efficiency can save back-and-forth trips and queuing time of outpatients and better their medical experience. The authors introduced the hospital′s experience in establishing a one-stop multi-functional outpatient service center. This center integrated such departments as outpatient office service, medical insurance office service, and registration & fee payment. Such a multifunctional post provided a one-stop service for the patients, hence optimizing the workflow for creating a convenient and fast outpatient service. Key words: Services administration; Outpatient management; Multifunctional post; One-stop service; Workflow optimization

The Risk Measure of Hypertension and Diabetes by National Health Insurance Data

Introduction: Korea’s health insurance is a social insurance that the government is the insurer and the whole nation. All of the national medical benefits are claimed,reviewed and paid for. PURPOSE The study purpose is to investigate the relative risk(RR) of stroke, myocardial infarction and chronic renal failure due to hypertension and diabetes, and the population attributable risk(PAR) by using health claim data for all Koreans in Korea. Method: The research data are the claims for medical insurance fees from 1999 to 2006.We calculated the RR of stroke, myocardial infarction,and chronic renal failure in 2004 and 20respectively,among those who had been diagnosed with hypertension or diabetes even once in eight years from 1999 to 2006, compared with those in other populations.If a person who did not claim a medical fee for the disease for five years from 1999 to 2003 had a medical fee claim for that year,the person was defined as the treatment incidence.PAR of hypertension or diabetes for these complications was calculated using RR and treatment prevalence. Result: In 2005, the treatment prevalence rate of hypertension over 30 years old was 23.1% and the diabetes was 10.5%.The National Health and Nutrition Survey, which is a nationwide survey,has 27.9% hypertension and 8.1% diabetes.The RR of stroke was 11.0,the RR of myocardial infarction was 13.6, and the RR of chronic renal failure was 30.3.The PAR of hypertension or diabetes to stroke was 73.0% over 30 years old. Myocardial infarction was 77.3% and chronic renal failure was 88.8%. In other words, 73% of patients with stroke, 77.3% of patients with myocardial infarction,and 88.8% of patients with chronic renal failure could not have developed if hypertension and diabetes is completely managed. Discussion: Although it is different from the official cohort data because it is measurement using the health insurance fee claim data,it is meaningful to be able to generally see the disease prevalence and the occurrence status for the whole nation. Disclosure K. Chun: None.

Survey on the State of Nutrition Support Team (NST) Activity: Comparison of the Questionnaire Survey 2016 vs. 2005 and the State of NST Activity since the Introduction of the Medical Insurance Fee

Survey on the State of Nutrition Support Team (NST) Activity: Comparison of the Questionnaire Survey 2016 vs. 2005 and the State of NST Activity since the Introduction of the Medical Insurance Fee Ji-Yoon Cho, Jung-Tae Kim, Seoung-Lan Kim, Korean Society for Parenteral and Enteral Nutrition Working Group, Nutrition Support Pharmacy Committee of Korean Society of Health-System Pharmacists Department of Pharmacy, Daegu Fatima Hospital, Daegu, Department of Pharmacy, Kyung Hee University Hospital at Gangdong, Department of Pharmacy, Asan Medical Center, Seoul, Korea

Studies of Product Structure Adjustment Routes for China's Pharmaceutical Industry: A View From the New Healthcare Reform Targets.

The 12th Five-Year Plan period is a critical period for the development of the pharmaceutical industry in China. A major focus coming with the New Healthcare Reform is a product structure adjustment in the pharmaceutical industry. Many researchers have been attracted in recent years to product structure adjustment studies. An empirical analysis of resources of the New Healthcare Reform was conducted by employing clustering analysis. A panel data model was established, with independent variables consisting of the city residents' medical insurance fund, drug fees per capita, city medical insurance fees per capita, rural medical insurance fees per capita, and number of people benefiting from the new rural cooperative medical scheme and the dependent variable being China's medical technology advancement fees. This study covered 29 provinces and regions and used panel data from 2007 to June 2012 to establish a fundamental regression equation for quantitative analysis. The city residents' medical insurance fund, rural medical insurance fees, and the new rural cooperative medical scheme are significant factors for pharmaceutical structure adjustment in China. The rural medical services market is the most important target market for pharmaceutical industrial transformation. The fundamental drug system and medical insurance system, which the New Healthcare Reform focuses upon, are closely related to the pharmaceutical product structure. For entities in which structural adjustment is not autonomous, changes can be achieved through sound coordination between organizational structure, technical structure, and repeated evaluation of consistency of drug product quality and overseas technical license.

Cost comparison between endoscopic submucosal dissection and transanal endoscopic microsurgery for the treatment of rectal tumors.

PurposeTo compare medical costs of endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) for the treatment of rectal tumors.MethodsThe records of 80 patients who underwent ESD and 32 who underwent TEM for the treatment of rectal tumors were collected. Factors compared in the two groups included patient age, sex and clinical characteristics, as well as hospital stay, procedure time, instrument use, medications, postoperative complications, and imaging and laboratory findings. Costs were analyzed based on medical insurance fees, as set publicly by the Ministry of Health & Welfare, Korea. Medical costs were also divided into patient copayments and National Health Insurance (NHI) Corporation charges.ResultsPatient characteristics, including age, sex, and comorbidities, were similar in the two groups, as were procedure time, histologic diagnosis, tumor size and distance from the anal verge, hospital stay, and complication rates. Median total hospital costs were significantly lower in the ESD than in the TEM group (1,214 United State dollars [USD] vs. 1,686 USD, P < 0.001). The costs for consumables, drugs and laboratory as well as operation fee were also significantly lower in the ESD than in the TEM group. However, patient copayments in the ESD group were significantly higher than in the TEM group (928 USD vs. 496 USD, P < 0.001), because ESD procedure for rectal tumors is not yet covered by the Korean NHI.ConclusionOverall direct medical costs were significantly lower for ESD than for TEM in the treatment of rectal tumors.

공공병원의 4인병실 도입에 따른 경제적 타당성에 관한 연구

Purpose: At the moment, a lot of Public Hospitals in Korea have adopted 5 or 6 bedrooms as a standard multi-bedroom type. However 5-6 bedrooms have many problems related to inpatient satisfaction and nosocomial diseases. Therefore 4 bedroom is under considering for standard multi-bed room in Public Hospitals in Korea. This paper tries to prove that adoption of 4 bedroom in Public Hospitals has nothing to do with economic loss which is now an obstacle in adopting 4 bedrooms. Methods: 3 Methods have been used in this paper. 1) Comparative analysis between medical insurance fee and service cost for hospitalization has been conducted through literature survey. 2) Scenario analysis has been used for the estimation of inpatient number when 4 bedrooms are adopted in Public Hospitals. 3) Relation analysis between profit and proportion of 4 bedroom in Public Hospitals. Results: Adoption of 4 bedroom as a standard multi-bedroom in Public Hospitals has been proved to have nothing to do with the economic loss of hospitals. Implications: It is necessary to introduce and expand 4 bedrooms instead of 5-6 bedrooms in hospitals for the upgrade of hospital environment and easy control of cross infection in inpatient bedrooms.

National Strategy of Maternal and Child Health Care according to Increase of Pregnancy with Diabetes

Pregnancy with diabetes can be categorized into two major groups: Pregestational diabetes mellitus (PGDM) and Gestational diabetes mellitus (GDM). Early detection and intervention for GDM can be beneficial in mother and child. Moreover, it can be a significant national health care business that contributes to the national maternal-child health service. Recently, GDM has expended into worldwide, a comprehensive approach to maternal-child health service is needed. Development and implication of an integrated self-management program, standards for educational method and didactic programs, coordinated teamwork between internal medicine and obstetrics, and enrollment of medical insurance fee for educational programs can be key strategies to improve pregnancy outcomes for women and child. In addition, the ever increasing quality standard of national health care insurance and on-going policy support for the pregnancy health management, development and governance of the procedure of the programs for pregnancy with diabetes are desperately needed at the national level. Through this, the government should provide assurance for women's reproductive health, which is influenced by not only women's self but also the reproduction the society for generations to come.

1 Years after beginning of DRG services system

Today's diagnosis related group (DRG) services system has improved medical insurance fees and subdivisions of disease compared with the past DRG system, but does not appropriately take into account the development of complications of severe disease and does not properly compensate care providers for the costs of using the newest medical devices. The Korean DRG system model needs to reflect the medical environment and the latest developments. Therefore, Cooperation with the government, medical service personnel, and citizens is necessary for the improvement of the DRG services system.

NIC과 연계된 산부인과 환자 간호중재에 대한 한국 건강보험 수가체계와 미국 ABC 코드체계와의 수가 비교 분석

Purpose: This study was performed to compare the costs of nursing interventions implemented for the obstetrical and gynecological patients using Korean Reimbursement System and ABC codes system developed in the US for costing out interventions performed by health care professional. Methods: First, the narrative data on nursing interventions were extracted from electronic medical record system of a tertiary university and mapped with Nursing Intervention Classification (NIC) by two researchers until 100% consent was reached. Narrative nursing interventions mapped with NIC were then remapped with ABC codes system using the electronic program developed in the research. The mapping data were analyzed with real numbers, frequency, percentage, mean, and standard deviation. Results: More nursing interventions were mapped with ABC codes than Korean reimbursement system. Total of 97 different types of narrative interventions could be mapped with NIC, 43 NIC interventions could be reimbursed by ABC code but only 16 NIC interventions were reimbursed by Korea Reimbursement System. Conclusion: Korean medical insurance fee system needs amendment to include more comprehensively interventions performed by nurses which are very important to patient outcomes. Further study is needed to develop strategies to costing out nursing interventions.

의료시장 개방에 대한 치과위생사의 인식과 대응방안

Objectives : This research seeks to present the data needed for the development of coping strategy, following medical market opening by identifying dental hygienists' perspective and coping measures towards the opening. Methods : One hundred eighty-eight dental hygienists were targeted to identify their level of perception towards medical market opening, attitude towards medical market opening, question of whether they agree or not with the opening and reasons, and coping measures and benefits of the medical market opening. t-test, chi-square test and cross-tabulation analysis were used for the analysis Results : First, team leaders are more aware of the medical market opening and hold greater sense of crisis towards opening compared to the rank and file. Second, the reasons cited for agreeing with the medical market opening included improvement of medical services' quality and diversification of services. As for the reasons for disagreeing, they cited the increase medical expenses paid by public. Third, limitation of the hospital management technique was cited the most when it comes to the scope of Korean hospitals' management crisis, followed by the limitations of the diagnosis procedure, limitations of the medical services, limitations of the medical techniques and increase in the number of large hospitals, in the order cited. Fourth, team leaders perceive greater need to seek coping measures from the aspect of realizing medical insurance fee from the policy development, service and system level aspects when it comes to the coping measures depending on their ranks. Conclusions : Therefore, Dental Hygienist has a comparatively low awareness of medical market opening, coping measures need to be explored to cope with the medical market opening by ensuring the dissemination of accurate knowledge through the education on the fees for dental hygienist and seminars in relation to the medical market opening.

Fees for outpatient operations in Germany: development, evaluation and European comparison

In Germany, discussions on the fees for statutory sickness insurance for ambulatory surgery has, in the last few years, become almost a symbol of dispute for the German health services. Outpatient surgeons complain about the fact that the fees do not cover their services. They see innovation severely threatened by bureaucracy, profitability by planned economy, rights by reasons of State, aggravated by the ‘reform’ attempts of the Greens and Socialist coalition Federal Government. On the other hand their opponents complain about the money mindedness of the doctors. Intentional panic or real disaster? The fundamental consideration to clarify this question is based on a comparison of the German statutory medical insurance fees and private fees with our neighbours. In Europe an economic area with similar prices for goods, services and wages, even ‘outpatient operations’ services with comparable cost rates should be paid for at a corresponding level. Any discrepancies would give cause to look for an explanation by analysing the historic development of fees and the question of a fair comparison between operations and the non-operative services.

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