Refinement and Evaluation of Korean Outpatient Groups for Visits with Multiple Procedures and Chemotherapy, and Medical Visit Indicators.
10.4332/KJHPA.2015.25.3.185
- Author:
Hayoung PARK
1
;
Gil Won KANG
;
Sungroh YOON
;
Eun Ju PARK
;
Sungwoon CHOI
;
Seunghak YU
;
Eun Ju YANG
Author Information
1. Technology Management, Economics, and Policy Graduate Program, Seoul National University, Seoul, Korea.
- Publication Type:Original Article
- Keywords:
Oupatient care, classification;
Insurance claim review;
Fee-for-service plans;
Prospective payment system;
Health care costs
- MeSH:
Classification;
Drug Therapy*;
Fee-for-Service Plans;
Fees and Charges;
Health Care Costs;
Hospitals, General;
Humans;
Information Systems;
Insurance;
Insurance Claim Review;
Insurance, Health;
Outpatients*;
Product Packaging;
Prospective Payment System;
Referral and Consultation
- From:Health Policy and Management
2015;25(3):185-196
- CountryRepublic of Korea
- Language:Korean
-
Abstract:
BACKGROUND: Issues concerning with the classification accuracy of Korean Outpatient Groups (KOPGs) have been raised by providers and researchers. The KOPG is an outpatient classification system used to measure casemix of outpatient visits and to adjust provider risk in charges by the Health Insurance Review & Assessment Service in managing insurance payments. The objective of this study were to refine KOPGs to improve the classification accuracy and to evaluate the refinement. METHODS: We refined the rules used to classify visits with multiple procedures, newly defined chemotherapy drug groups, and modified the medical visit indicators through reviews of other classification systems, data analyses, and consultations with experts. We assessed the improvement by measuring % of variation in case charges reduced by KOPGs and the refined system, Enhanced KOPGs (EKOPGs). We used claims data submitted by providers to the HIRA during the year 2012 in both refinement and evaluation. RESULTS: EKOPGs explicitly allowed additional payments for multiple procedures with exceptions of packaging of routine ancillary services and consolidation of related significant procedures, and discounts ranging from 30% to 70% were defined in additional payments. Thirteen chemotherapy drug KOPGs were added and medical visit indicators were streamlined to include codes for consultation fees for outpatient visits. The % of variance reduction achieved by EKOPGs was 48% for all patients whereas the figure was 40% for KOPGs, and the improvement was larger in data from tertiary and general hospitals than in data from clinics. CONCLUSION: A significant improvement in the performance of the KOPG was achieved by refining payments for visits with multiple procedures, defining groups for visits with chemotherapy, and revising medical visit indicators.
