Research on medical insurance data sharing mode based on " City-customized Medical Insurance" / 中华医院管理杂志

With the explosive growth of " City-customized Medical Insurance" products, the voice of commercial health insurance needs medical insurance data support is increasing.The authors took " City-customized Medical Insurance" as the representative of commercial health insurance, analyzed the demands and motivations of stakeholders in medical insurance data sharing through the power-interest matrix model, and summarized the medical insurance data sharing path at the commercial insurance product design end and claim settlement end. It is suggested to strengthen the top-level design, build the implementation path of standardized sharing of medical insurance data and the operation mechanism of hospital data docking, to realize the value increment of all stakeholders.

Present situation about the medical resources used for emergency patients with medical insurance in China based on analysis of large numbers of data / 中华急诊医学杂志

Objective To investigate the current status and features of the use of medical resources for emergency patients with medical insurance in China clarified by analysis of large numbers of data.Methods Using the database from China Medical Insurance Research Association's research group,the total amount and the average cost of emergency medicines for patients with medical insurance,as well as the proportion of emergency medicines in total medical resources used in the emergency department were statistically analyzed.Additional analyses were made based on cities and medical institutions of different levels.Results The data were collected from more than 63 million pieces of medication information,from which 260 thousand pieces of information involved in emergency medicine used within 100 sorts of emergency medicines.The use of emergency medicines for emergency cases accounted for a low proportion of over all medicine used in emergency department in our country,and the specifications of emergency medicine were limited in a few kinds of medicine such as tetanus antitoxin injectio (1500 U),50％ glucose solution in 20 ml water,and 50 g mannitol in 250 ml water frequently used as the leading essential agents.The sum of consumption of emergency medicines in tertiary hospitals was the highest among all levels of medical institutions,and the proportion of which in all medicine used in the emergency department also in the first place of the list.In the third-tier cities,although the sum of consumption of emergency medicines accounted for a small proportion of the whole country,the proportion of which in all kinds of medicine used in the emergency department was highest,while the situation of first-tier cities was just on the contrary.Except for only a few medicines,the ranking of the use of any emergency medicine else varied little in different cities and in various medical institutions.Conclusions On one hand,the current status and characteristics of the use of emergency medicines for emergency patients with medical insurance in China may be related to the characteristics of emergency departments and emergency cases,and on the other hand,they could also be influenced by medicines in clinical needs,clinical compliance,and shortages.This study showed the clinical application of emergency medicines in China in the past three years,which can provide some clinical data for the revision of emergency drug list in the future.

The Usefulness of the Secondary Database for Occupational Asthma Surveillance System in Korea / 한국역학회지

Occupational asthma is defined as a disease that is characterized by airway narrowing and bronchial hyperresponsiveness caused by specific working environment. It is estimated that occupational asthma cases in Korea have been underreported. This study, using Korean Medical Insurance Data(KMID), examined the distribution of asthma patients' occupations and the frequency of high risk occupations for occupational asthma in Seoul, Korea to evaluate the usefulness of the KMID data as a database for active occupational asthma surveillance system. Six hundreds and forty two(30.7%) of 2093 patients who were finally chosen as a study population by using 1995-year KMID, were contacted by telephone. 296 persons(47.4%) of 642 patients replied that they were diagnosed as asthma. The occupations of 296 asthma patients were classified by Korean standardized industrial classfication (KSIC). The most common occupations included Wholesale and Retail trade(19.5%), Real estate, Renting and Business activities(14.9%), Construction(14.9%), Manufacturing(12.3%). Forty(13.5%) of 296 patients who could be classified by KSIC were working at high risk jobs for occupational asthma. KMID could be used as a useful data for occupational asthma surveillance system if the limitations of KMID, which is the accuracy of diagnosis, data accessibility, difficulty of following up study subjects, would be solved. The prevalence of occupational asthma could be estimated if the follow-up study diagnosing occupational asthma for asthma patients working in high risk jobs would be held.

Estimation of Disease Code Accuracy of National Medical Insurance Data and the Related Factors / 예방의학회지

This study was undertaken in order to estimate the accuracy of disease code of the Korean National Medical Insurance Data and disease the characteristics related to the accuracy. To accomplish these objectives, 2,431 cases coded as notifiable acute communicable diseases (NACD) were randomly selected from 1994 National Medical Insurance data file and family medicine specialists reviewed the medical records to confirm the diagnostic accuracy and investigate the related factors. Major findings obtained from this study are as follows: 1. The accuracy rate of disease code of NACD in National Medical Insurance data was very low, 10.1% (95% C.I.: 8.8-11.4). 2. The reasons of inaccuracy in disease code were 1) claiming process related administrative error by physician and non-physician personnel in medical institutions (47.0%), 2) input error of claims data by key punchers of National Medical Insurer (31.3%) and 3) diagnostic error by physicians (21.7%). 3. Characteristics significantly related with lowering the accuracy of disease code were location and level of the medical institutions in multiple logistic regression analysis. Medical institutions in Seoul showed lower accuracy than those in Kyonngi, and so did general hospitals, hospitals and clinics than tertiary hospitals. Physician related characteristics significantly lowering disease code accuracy of insurance data were sex, age group and specialty. Male physicians showed significantly lower accuracy than female physicians; thirties and forties age group also showed significantly lower accuracy than twenties, and so did general physicians and other specialists than internal medicine/pediatric specialists. This study strongly suggests that a series of policies like 1) establishment of peer review organization of National Medical Insurance data, 2) prompt nation-wide expansion of computerized claiming network of National Medical Insurance and 3) establishment and distribution of objective diagnostic criteria to physicians are necessary to set up a national disease surveillance system utilizing National Medical Insurance claims data.

The Possibility of Regional Health Insurance Data in Blueprinting the Local Community Health Plan / 예방의학회지

The health center has to play an important role in promoting community health and satisfying a variety of community health needs and demands in the decentralized Korea. The nearly enacted Community Health Act compels every health center to make its own health plans which intend to deal with local health problems and plan its future health care. This obligation is obviously a big burden to most health centers. They do not have experiences in and abilities of making local health care plans. In order to establish a systematic community health plan, health centers have to concentrate their efforts on enhancing the ability of making health care plan through gathering and analysing the local health informations. However, it is very difficult in reality. This is simply because it will take long time to accomplish these activities. It seems natural that various professionals and researchers participate in carrying out the process of making community health plan in the initial stage. No standardized methodology and analysing framework exist even in the health professional society. Nonetheless, it is common to introduce survey research methodologies in analysing consumer's health care utilization and cost, and in identifying factors influencing health behaviors. Many researchers and professionals have applied social survey methodologies in obtaining information on providers and health policy makers as well. The authors have found that few studies have ever utilized local health data stored at the self-employed medical insurance society as the data source of planning activities. The purpose of this study is to illustrate the usefulness of the data stored at the Sung-Dong Gu Self-employed Medical Insurance Society in establishing the community health plan. The major contents of this study are as follows ; 1. Frequency of utilization by age, area, sex, type of medical care institutions, and some major diseases 2. Medical treatment by type of medical care institutions, by classification of 21 diseases, by frequency of three-character categories 3. Medical treatment of major neoplasm and some chronic diseases by age, sex, and area. The conclusion of this study is that it is of great potentiality to find out the local health problems and to use them in blueprinting the community health plan through comparing the frequency of medical utilization analyzed by a variety of variables with NHI health data or the health data from survey research.