Prediction of Health Care Cost Using the Hierarchical Condition Category Risk Adjustment Model / 보건행정학회지

BACKGROUND: This study was conducted to evaluate the performance of the Hierarchical Condition Category (HCC) model, identify potentially high-cost patients, and examine the effects of adding prior utilization to the risk model using Korean claims data. METHODS: We incorporated 2 years of data from the National Health Insurance Services-National Sample Cohort. Five risk models were used to predict health expenditures: model 1 (age/sex groups), model 2 (the Center for Medicare and Medicaid Services-HCC with age/sex groups), model 3 (selected 54 HCCs with age/sex groups), model 4 (bed-days of care plus model 3), and model 5 (medication- days plus model 3). We evaluated model performance using R² at individual level, predictive positive value (PPV) of the top 5% of high-cost patients, and predictive ratio (PR) within subgroups. RESULTS: The suitability of the model, including prior use, bed-days, and medication-days, was better than other models. R² values were 8%, 39%, 37%, 43%, and 57% with model 1, 2, 3, 4, and 5, respectively. After being removed the extreme values, the corresponding R² values were slightly improved in all models. PPVs were 16.4%, 25.2%, 25.1%, 33.8%, and 53.8%. Total expenditure was underpredicted for the highest expenditure group and overpredicted for the four other groups. PR had a tendency to decrease from younger group to older group in both female and male. CONCLUSION: The risk adjustment models are important in plan payment, reimbursement, profiling, and research. Combined prior use and diagnostic data are more powerful to predict health costs and to identify high-cost patients.

Differences between middle-aged and older people in association between income level and remaining teeth / 대한구강보건학회지

OBJECTIVES: To understand the relationship between monthly household income and number of remaining teeth as an indicator of oral health, and to find the differences between middle-aged and older people in this respect. METHODS: This study was conducted on data extracted from the Korean National Health & Nutrition Examination Survey, which surveyed all Korean citizens in 2012. From these data, data of 4502 people about 40 years of age who completed the questionnaires and examination survey were selected and analyzed. This study investigated the main factors affecting the remaining teeth, and analyzed the moderating effect of age on the relationship between income level and remaining teeth. RESULTS: The average number of remaining teeth was 25.17 for middle-aged people and 15.95 for older people, which was significantly different. The number of remaining teeth for middle-aged people showed a significant relationship with income level, education level, and smoking habit. The number of remaining teeth in older people was related to the same factors, along with an additional factor of whether or not they underwent oral examinations. From the interaction analysis conducted to find the moderating effect of age on the relationship between the number of remaining teeth and income level, the number of remaining teeth was more affected by income level in older people than in middle-aged people. CONCLUSIONS: Income level was strongly related to oral health, particularly in older people. Therefore, it can be concluded that an oral health promotion policy is necessary for low-income people, particularly those in the older age group.

The relationship of pit and fissure sealant in children and mother's socioeconomic status, mother's oral-health screening / 대한구강보건학회지

OBJECTIVES: This study examines the relationship between the implementation of pit and fissure sealant in children, and the prevention level of teeth based on household income by a cross-sectional study. METHODS: The study population consisted of a representative community sample of 1,701 subjects, ranging from 6-18 years in children and over 27 years in mothers, from the 4th Korea National Health and Nutrition Examination Surveys in 2009. Mother's indicators included age, occupation, education, household income, smoking, brushing frequency, oral health screening, self-related oral health, and mother's concern. We used a multiple logistic regression to identify and quantify the risk factors for the pit and fissure sealant. RESULTS: In multiple analyses, age of children, household income level, and oral health screening were significant factors for the implementation of pit and fissure sealant for the children. The multiple-adjusted odds ratio (95% confidence interval) for the implementation of pit and fissure sealant, comparing the lowest to 101-200, 201-300, 301-400, 401-500 and 501 ten thousand Korean Won or more were 2.2 (1.15-4.10), 2.5 (1.38-4.61), 2.0 (1.04-3.90), 2.8 (1.46-5.53), and 3.6 (1.82-6.94), respectively. CONCLUSIONS: It was concluded that the implementations of the pit and fissure sealant were positively related with the household income level and mother's oral health screening.

Direct Medical Costs for Patients with Type 2 Diabetes and Related Complications: A Prospective Cohort Study Based on the Korean National Diabetes Program

We analyzed the direct medical costs for Korean patients with type 2 diabetes according to the type of complications and the number of microvascular complications. We analyzed costs for type 2 diabetes and associated complications in 3,125 patients. These data were obtained from the Korean National Diabetes Program (KNDP), a large, ongoing, prospective cohort study that began in 2005. The cost data were prospectively collected, using an electronic database, for the KNDP cohort at six hospitals. The costs were analyzed according to complications for 1 yr from enrollment in the study. Among 3,125 patients, 918 patients had no vascular complications; 1,883 had microvascular complications only; 51 had macrovascular complications only; and 273 had both complications. The annual direct medical costs for a patient with only macrovascular, only microvascular, or both macrovascular and microvascular complications were 2.7, 1.5, and 2.0 times higher than the medical costs of patients without complications. Annual direct medical costs per patient increased with the number of microvascular complications in patients without macrovascular complications. The economic costs for type 2 diabetes are attributable largely to the management of microvascular and macrovascular complications. Proper management of diabetes and prevention of related complications are important for reducing medical costs.

A Factor of Fasting Blood Glucose and Dietary Patterns in Korean Adults Using Data From the 2007, 2008 and 2009 Korea National Health and Nutrition Examination Survey / 예방의학회지

OBJECTIVES: This study was performed to identify the socioeconomic factors, health behavior factors and dietary patterns that have an influence on the fasting blood glucose in adults. METHODS: This study used data collected from the 2007, 2008, 2009 Korea National Health and Nutrition Examination Survey. The final sample included 4163 subjects who were 30-59 years old and who had completed the necessary health examinations, the health behaviors survey and nutrition survey. RESULTS: Eleven dietary patterns emerged from the factor analysis with different factor loading. After controlling for potential confounders, multiple regression analysis of the dietary patterns showed that 'fruits', 'alcohols', and 'starchy foods' affected the fasting blood. Lower consumption of 'fruits' and higher consumption of 'alcohols' and 'starch foods' were significantly associated only with an increased risk of high blood glucose. CONCLUSIONS: In the light of the results of this study, it appears pretty likely that the risk of developing high blood glucose can be reduced by changing a person's dietary patterns.

Evidence-based management and treatment of high-risk individuals with pre-diabetes

The prevalence of type 2 diabetes (T2DM) has increased dramatically during the last decade, especially in Asian population. The control of hyperglycemia is very important for diabetes patients. Prevention of T2DM should be a major public health goal because of its substantial effect on heath. Treatment of high-risk individuals with impaired fasting glucose and impaired glucose tolerance to prevent T2DM has important medical, economic, social, and human implications. Identifying risk factors affecting transition diabetes is thus very important. Having defined a patient population at high-risk for developing diabetes, the intensive intervention of diet, physical activity, lifestyle modification, and drug therapy (metformin) can substantially affect the delay and prevention of T2DM. Tight glucose control has the potential to reduce the incidence and prevalence of T2DM.

Sex Difference of Type 2 Diabetes Affected by Abdominal Obesity versus Overall Obesity

PURPOSE: This research compares the predictive value of the abdominal obesity indicator, waist circumference (WC), and the overall obesity indicator, body mass index (BMI), among men and women with regard to type 2 diabetes. MATERIALS AND METHODS: This study used data collected from 4,400 households selected by a stratified multistage probability sampling method during the 2001 Korea National Health and Nutrition Examination Survey (KNHANES). The final study sample included 4,684 subjects over 30 years of age who had completed the health examination required for the analysis of the health interview and health behavior surveys. RESULTS: Both men and women showed significant differences in fasting blood glucose (FBG) or HbA1c levels based on abdominal obesity irrespective of BMI. However, the presence of overall obesity among men with abdominal obesity was not significantly correlated with FBG or HbA1c levels, while the presence of overall obesity among women with abdominal obesity was significantly different in regard to FBG or HbA1c levels. CONCLUSION: Both WC and BMI emerged as a measures of risk factors for type 2 diabetes among women while only WC emerged as a risk factor for diabetes among men.

Health Promotion Services and Chronic Disease Management and Preventive services

The goal is to improve the national health level in our country. To achieve this how to manage the chronic diseases cost-effectively is very important. Population-based comprehensive Chronic Care Model approach should be arranged in the national health insurance framework. It is necessary that private health promotion services are launched in the market, but we should focus on which way of delivering preventive services can benefit in the future.

The effect of music therapy at surgical extraction of mandibular impacted 3rd molars

PURPOSE: This research was intended to evaluate the sedative effect of the music by measuring the anxiety-level, the pain-level, the blood pressure, and the pulse rate in patients who were going through extraction of the mandibular impacted 3rd molar. MATERIALS AND METHODS: Patients were selected among those who visited St. Vincent's Hospital in Suwon for the surgical extraction of 3rd molar from April to May, 2007 and were divided into two groups : the first, experimental group consisting of 32 people was going through extraction with the music and the second, control group also consisting of 32 people was going through extraction without the music. The anxiety-level was measured by filling out Spielberger's State-Trait Anxiety questionnaire. The pain-level was measured by VAS (Visual analog Scale). The blood-pressure and the pulse rate were recorded at waiting period, preparation and anesthesia period, 5 minutes after anesthesia, beginning of extraction and every five minutes after extraction to the end of surgery. RESULTS: The anxiety-level was significantly lower in the experimental group than in the control group during the extraction procedure (p<0.01). The pain-level was significantly lower in the experimental group than in the control group (p<0.05). The mean systolic blood pressure was significantly lower in the experimental group than in the control group at the beginnig of extraction and 10 minutes after extraction (p<0.01, p<0.05 each). The mean diastolic blood pressure was significantly lower in the experimental group than the control group at 10 minutes after extraction (p<0.01). The mean of pulse rate was significantly lower at the beginning of extraction (p<0.05). CONCLUSION: The music therapy could offer not only the psychological stability but also the physiological stability during the surgical extraction of impacted 3rd molar.

An Analysis of Medical Costs of Diabetic Patients in a University Hospital (1996~2005) / 당뇨병

BACKGROUND: The aim of this research was to find out the costs of diabetes, as research in a prospective cohort study looking into the development of diabetic complications followed by treatment intervention by a medical institution. The research compared the changes in medical costs by following-up on the treatment details of diagnosed diabetes for the last 10 years in a university hospital. METHODS: The research used data of outpatient, inpatient, pharmaceutical and total medical costs, from 1996 to 2005, of individual patients who were diagnosed with diabetic patients, to analyze the outpatient and inpatient total medical cost changes over the years. RESULTS: After antidiabetic drug, in the case of outpatient treatment, pharmaceutical costs increased on average by about 25,000 won a month for diabetic patients without complications and by 35,000 won for diabetic patients with microvascular complications. Outpatient medical costs were affected after drug treatment by as much of an increase as created by the pharmaceutical costs. The total medical costs, that is the sum of inpatient and outpatient costs, decreased by 30~40% compared to that before drug treatment. In the case of total medical cost, MI or ESRD cost 2~3 times more in pharmaceutical costs than before the development of complications. The total medical costs of diabetic patients with CVA, MI and ESRD complications increased in the first year after development of the complication, and this was followed by a decrease in the next year, showing a tendency to remain constant with no increase or decrease over subsequent years. This means that the total medical costs of patients with complications remain continuously large throughout the life of the diagnosed patient. CONCLUSION: For diabetic patients, pharmaceutical costs are the most important factor in determining outpatient medical costs.

Risk Factors Influencing the Occurrence of Injuries in Koreans Requiring Hospitalization

PURPOSE: This study focused on local communities and the factors influencing injuries requiring hospital admission that affect the quality of life for Koreans. MATERIALS AND METHODS: This study used data collected from 4,400 households during the 2001 Korea National Health and Nutrition Examination Survey (KNHANES). A stratified multistage probability sampling method was applied and the final sample included 7,924 subjects over 20 years old who had completed the questionnaire regarding factors influencing injuries requiring hospital admission. Multiple logistic regression analysis was used to estimate the risk factors influencing injuries. RESULTS: The incidence of injuries requiring hospital admission in Koreans was higher in men than in women at 2.3% (95% CI: 1.8-2.8) and 1.7% (95% CI: 1.3-2.1), respectively. Statistically significant factors affecting the occurrence of injuries requiring hospital admission were marital status (OR: 2.60, 95% CI: 2.22- 5.56), state of health (OR: 0.63, 95% CI: 0.43-0.92), frequency of heavy drinking (OR: 1.96, 95% CI: 1.01-3.79), normal physical activities (OR: 1.68, 95% CI: 1.07-2.65), and sleep (OR: 1.54, 95% CI: 1.01-2.35). CONCLUSION: The results of this study can be used to develop measures to prevent fatal injuries and be used as basic data for community health programs.

Relationship Between Metabolic Syndrome and Familial History of Hypertension/Stroke, Diabetes, and Cardiovascular Disease

This research analyzes the prevalence of metabolic syndrome (MS) in Korea and examines how the presence of a familial history of diseases related to MS, such as hypertension/stroke, cardiovascular disease, and diabetes, affect the development of MS in Koreans. The prevalence of MS and its components, as defined by the Nation-al Cholesterol Education Program Adult Treatment Panel guidelines, were evalu-ated in nationally representative samples of non-institutionalized civilian Koreans. This analysis is based on the 2001 Korea National Health and Nutrition Examina-tion Survey, which used a stratified multistage probability sampling design. The final study included 5, 742 adults who had completed the necessary health examinations and met the diagnosis of MS. The prevalence of MS was 25.5% in men and 28.7% in women. Odds ratio for MS among men with a familial history of hypertension/stroke was higher than that among men who did not have this history. The OR for MS among women with a familial history of hypertension/stroke or diabetes was higher than that among women who had no familial history of these diseases. These results show that familial history of hypertension/stroke and diabetes was significantly related to the presence of MS in both young men and women.

Benign Prostatic Hyperplasia in Community-Dwelling Elderly in Korea / 간호학회지

BACKGROUND: This study was done to identify the prevalence of benign prostatic hyperplasia (BPH) and BPHrelated symptoms among community-dwelling elderly men in Korea. In addition, quality of life and health care-seeking behavior were explored. METHODS: A total of 417 elderly men were surveyed using the IPSS (International Prostatic Symptom Score) and a structured questionnaire on health care-seeking behaviors. RESULTS: The prevalence of BPH was 19.7%. Of those with BPH, 80.3% reported mild symptoms, 13.2% moderate symptoms, and 6.5% severe symptoms. The severity of BPH-related symptoms was significantly correlated with quality of life. Among those with BPH, 42.7% had never consulted with anyone about their symptoms. CONCLUSIONS: BPH has emerged as a serious public health problem in elderly men. Elderly people who experience worse symptoms of BPH have a lower quality of life. Many elderly with BPH do not seek health care, mainly due to misconceptions about BPH. The provision of educational programs for BPH may significantly improve the quality of life of elderly men.

Community-Oriented Primary Care: Preparing Physicians for the Future in the United States / 한국의학교육

As the health care system continues to evolve, there will be a shift in the care that physicians are asked to provide: from high-tech to patient-centered, from treatment-focused to prevention-focused. To improve the health of communities, health providers need to apply skills beyond those contained in the traditional biomedical model and must strive to encompass the community-based public health model. Physicians must function effectively within a multidisciplinary team in order to provide optimal health care in a setting of complex needs which far exceed the capacity of any one health discipline to address adequately. Students need first hand experience working with population issues in all learning settings - the hospital, the clinic and the community - to stimulate their interest in a population perspective. The medical education community needs to search for innovative, creative approaches to help the students develop the knowledge skills, and attitudes to practice. Community-oriented primary care (COPC) addresses the need to train practitioners in primary care practice that is community-responsive and that includes a public health perspective. It helps bridge the gap between academic medicine and the community it is designed to serve while fostering linkages among providers and community groups. It provides the structure for the various members of a public health team, often isolated from one another within their own institutions, to share ideas that focus on the need for integrity and simplicity in a community- responsive health care system. But perhaps most importantly, it restores the social contract between medicine and society.

Attitudes toward Complementary and Alternative Medicine in Suwon City / 예방의학회지

OBJECTIVES: The aim of this study was to investigate the attitudes toward complementary and alternative medicine among 1,490 residents(339 households) in Suwon city. METHODS: All respondents were asked about types, frequency, effects, side-effects, views, and cost of complementary or alternative medicine through a questionnaire from July 24th to 27th. Six therapies were investigated: diet; acupuncture/ massage/ chiropractic etc.; mind control such as Ki/ Yoga/ spiritual therapy/ relaxation therapy etc.; nutritional supplements, cultural remedies; and Herb medications. RESULTS: The results of this survey were as follows: 35.6% of respondents had experiences with at least one or more types of complementary and alternative medicine. The average number of different types of therapies used was 3.4. More experience with various types of therapies were found among those respondents of higher education, older age group, higher income, married group, religious group than among the opposite groups of respondents. Herb medications were used most frequently(39.8%), followed by minor grains(37.9%), Ginseng(23.8%), Boshintang(21.5%), acupuncture(20.3%), Gaesojou (15.3%), Gingko nut(12.0%), mushroom(11.5%), Cupping therapy(10.2%), and black goat(0.0%). Acupuncture and Herb medications were used for treatment of hypertension the most frequently; minor grains or silkworm for treatment of diabetic mellitus; vegetables for treatment of obesity; acupuncture, Cupping Therapy, Herb medications for treatment of rheumatism; and acupuncture, Herb medications, or exercises for treatment of Cerebro Vascular Accident(CVA). The average costs of treatment were 108,000 Won for hypertension, 87,200 Won for diabetic mellitus, 16,800 Won for obesity, 68,800 Won for rheumatism, and 87,500 Won for CVA. Among 10.9% of respondents, there were 13 cases of side-effects with acupuncture, Herb medications, and Gaesojou. Among the cases of side-effects, majority was due to Herb medications. Respondents reported that Cupping Therapy was the most effective, followed by acupuncture, Ginseng, Gingko nut, Boshintang, black goat, minor grains, Gaesojou, Herb medications, vegetables, and mushroom. In response to the views of complementary and alternative medicine which they had used, they recommended minor grains first, followed by Ginseng, acupuncture, Gingko nut, Cupping Therapy, vegetables, Boshintang, black goat, mushroom and Herb medications. In contrast, they did not recommend Herb medications, acupuncture, nor Gaesojou. CONCLUSIONS: These findings indicate that many people use various complementary and alternative medicine without any guidelines for treatment of serious chronic diseases not even to invigorate themselves. It is, therefore, suggested that medical doctors or scientists verify the true effects or side-effects from the most common complementary or alternative therapies through experiments. Also medical doctors should provide a comfortable atmosphere for discussion among doctors and patients who would like to try these therapies.

A study on appropriateness of price of medical care service in health insurance / 예방의학회지

By expanding health insurance, customers will carry a smaller burden of medical costs. As a result, the number of visits to a physician increase and this result in the improvement of medical accessibility. But medical care utilization may be changed not only by insurance status but also by socio-demographic factor, economic status and other factors. The question thus remains, at which level of accessibility and what price of medical care service in health insurance will the customer and the medical care service be satisfied. The price of medical care service is comprised of the customer's out-of-pocket money and the costs not covered by health insurance. If the price of medical care services in health insurance are appropriate, medical care utilization should not differ because of the difference in income status or the acuteness of illness. But If the price is not adequate, low income groups will receive relatively low medical care utilization, particularly in the case of chronic disease. The purpose of this study is to evaluate the differences in medical care utilization among the various income groups and those with varying acuteness of illness. The major hypotheses to test in this study are : (I) whether there are differences in medical care utilization among different income groups exist, (II) whether differences in medical care utilization among different income groups exist with the hospital type. (III) whether differences in medical care utilization among different income groups exist with the acuteness of illness and with age. The data was collected from the JongRo District Health Insurance Society in Seoul. A total of 118,336 persons were selected as the final sample for this study. The major findings of this study were as follows ; 1. The volume of ambulatory utilization among users was statistically significant by income level. 2. Among different income groups, the volume of ambulatory utilization was statistically significant by the acuteness of illness. 3. Higher income groups with chronic diseases had a greater volume of ambulatory utilization than other groups.

A Survey of Students' Opinions on Evaluation and Refinement the New Teaching Program Of Medical Ethics / 한국의학교육

This survey was performed for evaluating and refining the new teaching program for medical ethics which was developed by faculities in Ajou university. Most of the students showed interest and satisfactions as well as con fidences in ethical judgement through the new course of medical ethics. Specific evaluation was as follows; Most of cases in discussion and debates were appropriate for understanding of medical ethical issues. They expressed that they learned how to collaborate in group, accept different opinions and views, build a sense of sharing community and work with an indivisual resposibility. Several ideas for improving medical ethics cirricula were suggested that some cases should be replaced to realistic cases, more clinicians from relevant departments should be involved in discussion, and educational environment should be changed to discuss and debate easily.

Strategic Planning and Development Plan Model for a Hospital Information System / 대한의료정보학회지

The IS(Information System) strategic planning must be based on objectives and strategic planning of the organization. The IS strategic planning for a hospital is not different from other organizations. Perhaps it can be more important than other types of organizations. Hospitals possess unique characteristics which hinder implementation of the IS. Therefore when the objectives and the focus of IS are clear, the resources can be allocated effectively and integrated IS can be applied. This study will suggest general objectives and strategic planning of the hospital. Thereby we will propose the strategic planning and development planning model of IS for hospitals. Suppose that the objectives of a hospital are the quality service and effective costs reduction. To achieve these objectives we will propose the strategies such as procurement of qualified physician and personnel, maximization of productivity, maintenance of good services and comfortable environments, and redesign of business process. Thus strategic planning of IS for hospital organizations is established as the follows: 1. The objectives of the IS for a hospital are to monitor the outcome of medical services and hospital performance, and to deliver the doctor's order in order to provide the quality services to patients. Therefore the IS design strategy for the hospital should be planned to achieve these objectives. To establish these goals all hospital data should be computerized and the IS should be able to monitor the performance of the hospital. Direct dat input environment is essential for the system. 2. The direction of master plan of the IS for a hospital is the integrated system. The methods of approach for the integrated system is selected to cover the all primary data from medical services rather than functional units. 3. The objectives of development of medical service information system, first phase of master plan, include : on-line input and delivery system of all doctor's orders, inquiry about all test in any time at any places in the hospital, automated scheduling of nursing work at nurse station, hospital billing, and ancillary services. 4. In order to achieve the goal, CSFs(critical success factors) to be resolved are : doctors must enter their own orders, the employee consents to replace the manual paper work with IS, the system is maintained with rapid response even though peak time, many functions must be constructed in the short period. 5. Therefore development strategic planning of IS is suggested to maximize user's convenience, specially, for doctors, to apply several data servers with independent functions, and to introduce client-server system, and to use the commercial DBMS.

A study on the determinants of hospital profitability / 예방의학회지

Financial stability is the foremost prerequisite for the continuous growth and development of hospitals. The present study aimed at developing a deterministic model using the factors which affect the hospitals profitability and at discovering which factor affected the hospital profitability. The study conducted questionnaire surveys on all general hospitals, with the exception of special hospitals, with over eighty hospital beds. Of the 274 subject hospitals, 136 of them, consituting 49.6% of the whole, were used in the study. The results are as follow. 1. In the deterministic model, outpatient revenue was affected more by the number of physician visits than by outpatient service intensity. Inpatient revenue was found to be affected more by the number of discharged patients than by inpatient service intensity. However, the increase rate of the service intensity not only contributed in stepping up the operating margin by 4~8% in outpatient and 3~6% in inpatient, but it was statistically significant. 2. Among the factors which determined the operating cost within the deterministic model, the number of patients had a greater impact on the operating cost than the resource consumption per patient. 3. The resource consumption per patient were proved to have the greatest effect on the profitability within the probabilistic model. The management cost per adjusted patient, in particular, was proven to have a statistically significant effect on the profitability in all hospitals.

Impact of increasing the level of copayments on the number of physician visits / 예방의학회지

The level of copayment increased in order to stabilize the financial condition of the health insurance on 1986. An important question regarding the policy was whether the increase in the level of copayments reduced the utilization of medical services in the poor selectively. In spite of the importance of the research question, no study has been reported. This study was designed to find out changes in nuniU rs of physician visits, to explain charac teristics influencing the difference of utilization before and after the program. Finally the interaction effect between the program and the level of income was examined for the abover question. A total of 10,421 persons from eight institutions was selected as the study sample. Research findings are as follows. 1. The number of physician visits decreased by ten percent as a result of increasing the level of copayment. 2. The decrease was remarkable in some groups such as children, rural area and large family. 3. The most important factor which explained the difference was the number of physician visits before the introduction of the new program.. The more numbers of physian visits during the last year were, the more numbers of physian visits decreased after the program. 4. The interaction term between the program and the level of income was statistically significant in the multiple regression model which explained physician visits and its coefficient was negative. It means that an increase in copayment did not reduced the number of physician visits in the poor, selectively. 5. It can be concluded that imposing adequate copayment reduces the use of medical services as well as medical costs without serious damage in access especially for the poor pule.