A methodological study on simplifying claims review system in medical insurance / 예방의학회지

After the introduction of National Medical Insurance in 1989, the medical demand has rapidly increased. The impact of increased medical demand was followed by an increase in the number of claims in need of review. We studied a new, fair method for reducing the number of claims reviewed. we analysed 90,583 outpatient claims submitted between september and october; claims were made for services given August of 1994. We finally suggested a screening system for claims review using a statistical method of discriminant analysis of the medical costs. The results were as follows. 1. In the cut-off group, age, days of medication, number of hospital or clinic visits, and total change were significantly high The cut-off rates according to the hospital-type and existence of accompanied disease were significantly different. 2. According to ICD, the cut-off rate was highest in peripheral enthesopathies and allied syndromes(20.76%), lowest in acute sinusitis(0.93%). The mean charges were significantly different according to ICD and existence of cut-off. 3. we build discriminant functions by ICD with such discriminant variables as patient age, sex, existence of accompanied disease, number of hospital or clinic visits, and 9 detailed hospital or clinic charges included in claim. 4. we applied the discriminant function for screening those claims that were expected to be cut-off. The sensitivities comprised from 40% to 70%, and specificities from 70% to 95% by ICD. Acute rhinitis had highest sensitivity(100.00%)and other local infections of skin and subcutaneous tissue had highest specificity(98.45%). The excepted number of cut-off was 17,762(19.61%). The total sensitivity was 49.62%, the total specificity was 82.57% and the error rate was 19.66%. We lacked economic analysis such as cost-benefit analysis. But, if the few method of screening claims using discriminant analysis were applied, the number of claims in need of review will reduce considerably.

Analysis of Medical Charges in Industrial Accident Compensation Insurance System / 대한산업의학회지

A recent increase in hospital cost in Industrial Accident Compensation System has caused an issue. Especially the many problems in assessing and paying hospital cost have made necessary improvement measures on this. For this purpose the study analyzed 179,442 medical bills for industrial accident patients during 1986~1988. And various annual statistic data, references and documentations are also reviewed. The results of this study were as follows: 1. The average days for medical treatment per injury decreased depending upon hospital grade in the order of clinic, hospital, and general hospital, and the average hospital charges per injury decreased in the order of general hospital, hospital and clinic. 2. The inpatients' leading injury was traumatic amputation of fingers, and the open wound of fingers came to leading injury among the outpatients. The proportions of 10 leading injuries among inpatients and outpatients were 42.7% and 49.2% respectively. 3. As a consequence of the analysis of average medical charges, fractures of neck of femur in inpatients, and intervertebral disc disorders in outpatients were obtained as the most prevalent injuries. The coal workers' pneumoconiosis and injury to nerve roots and spinal plexus were most prominent injuries with repect to the days for medical treatment. 4. According to annual days for medical treatment, fracture of tibia and fibula was the most prevalent in inpatients, and sprains and strains of back was the most prevalent in outpatient. Traumatic amputation of fingers and other 10 leading injuries has a 42.6% share of total inpatients' hospital charges, and fracture of phalanges of hand and other 10 leading injuries possessed 53.4% of total outpatients' hospital charges. 5. Multiple regression analysis revealed that length of hospital stay, number of revealed that length of hospital stay, number of radiologic examinations, duration of operation, age, and others were the major determinants of total hospital charges. A comparision with medical insurance and car insurance for hospital charges and days for treatment showed 2-4 times higher than medical insurance, but showed 0.4~1.0 times lower than medical insurance and car insurance for daily treatment charges.

Health Care Utilization and Its Determinants among Island Inhabitants / 예방의학회지

Island regions suffer from a shortage of health care in part because they are less developed, they cover a widespread area relative to the population, and due to transportation barriers. The purpose of this study was to assess the level of illness and the magnitude of medical care utilization, and to investigate the determinants of utilization in these area. The data were collected by means of a household survey conducted from February 16 to 25, 1987 on 5 islands which were selected in consideration of the size of the population, the distance from the main land, and the distribution of health care facilities. The household response rate was 89.1% (491 of 551 households), and 1971 persons were surveyed. The major findings of this study are as follows: 1) The morbidity rate of the island inhabitants was 27.7% during the two weeks, and 25.5 chronic illnesses and 9.1 acute illnesses per 100 persons, were noted. Differences in the magnitude of illness were statistically significant by sex, age, education, and family size. 2) The magnitude of total ambulatory care utilization was 16.8 visits per 100 persons during the two weeks, which was less than that of other regions; and differences in the magnitude of total ambulatory care were statistically significant by sex, age, education, occupation, and family size. 3) Unmet needs were classified as 56.0% in chronic illnesses and 19.6% in acute illnesses; and differences in unmet needs were statistically significant by sex, age, education, occupation, income, and family size. 4) Statistically significant determinants in medical care utilization included the frequency of acute illness and chronic illness, and income in total utilization; the frequency of chronic illness and acute illness, and medical care insurance in physician visits. 5) According to the results of the path analysis, need factors had the greatest effect on utilization, and predisposing factors had more indirect effects through enabling or need factors than direct effects.