Background: The Universal Health Care Law seeks to optimize financing of personnel costs without compromising quality and equitable health care among the health care facilities. This position statement aimed to identify strategies and policy recommendations for the cost-effective financing of health personnel in public healthcare facilities. Methods: A systematic review of literature was done to generate policy brief and key points for roundtable discussion in collaboration with the Department of Health (DOH). The discussion was guided by the three health financing options of DOH: (a) retain Personnel Services (PS) as DOH budget but shift Maintenance and Other Operating Expenses (MOOE) to PhilHealth; (b) shift PS and MOOE to PhilHealth, and (c) rationalize part-time status in government hospitals. Results: The pros and cons of financing options were cross-examined. In Option 1, physicians in government hospitals would receive fixed salaries from DOH / Local Government Units. In Option 2, there would be a monopsony between PhilHealth and provincial power. Payment will be performance-driven, and balance billing will be eliminated. Option 3 would be a set up of retaining part-time positions for physicians. Conclusion and Recommendation Participants deduced that for Option 1, provision of salary augmentation sources and ensuring adequate plantilla items and level of remuneration in government hospitals should be considered, in order to sufficiently compete with physicians’ income from private practice. For Option 2, the PhilHealth reimbursement system should ensure timely reimbursement so as not to subject care providers to financial instabilities. For Option 3, rationalizing part-time status should be flexible and can be applied regardless of how physicians are paid, as this would incentivize caregivers to work harder and smarter.
Universal Health Insurance ; Healthcare Financing ; Physicians ; Universal Health Care ; Reimbursement Mechanisms

The resource-based relative value scale (RBRVS) was introduced in Korea as a payment system in 2001. However, the health insurance fee schedule had many problems. Unbalanced insurance fee schedules still occur, and the relative value was not divided between physicians' work and practice expenses. Furthermore, malpractice fees were not included in the total RBRVS. The first refinement project of the health insurance relative value scales was conducted in 2003 and the second project started in 2010. In the first project, final relative values were calculated under budget neutrality by medical departments, and imbalances within the departments were resolved. However, imbalances still existed between departments. In the second project, final relative values were classified and computed by the type of medical treatment. The final RBRVS has been applied step by step since 2017 and the imbalance problem of the insurance fee schedule has been partially resolved. The government recently announced strengthening the plan for health insurance coverage. The current coverage rate for total medical costs by national health insurance is 63%. The purpose of this plan was to increase the coverage rate by up to 70%. The government has suggested detailed plans but there remain many controversial issues and limitations with regard to the practical aspects. Thus, further research and suggestions are needed.
Budgets ; Fee Schedules* ; Fees and Charges* ; Insurance ; Insurance Benefits ; Insurance, Health* ; Insurance, Health, Reimbursement ; Korea ; Malpractice ; National Health Programs ; Relative Value Scales

Rapidly expanding health insurance programs have accompanied the rapid economic development of Korea over the past five years. Now more than thirty percent of the total population is covered by the various health insurance plans. The objective of this study is to discover differences that may exist in medical care services in terms of quantity, length of stay, charges and quality of care in treating insured and non-insured patients. Five common diagnostic categories (name1y, appendectomy cholecystectomy, tonsillectomy, Cesarean section and respiratory tract infection) were examined. The results confirmed the major hypotheses of the study, although some of the results were in the expected direction but not statistically significant: total hospital charges and charges per day were higher among the non-insured; volume of services was greater among the insured; length of stay was longer among the insured; quality of care did not show statistically significant differences in treatment outcomes and complications.
Adult ; Diagnosis-Related Groups ; Female ; Health Services/standards* ; Hospitalization/economics* ; Human ; Insurance, Health* ; Insurance, Health, Reimbursement ; Korea ; Length of Stay ; Male ; Middle Age ; Quality of Health Care

With the adoption of national health insurance in 1977, Korea has been utilizing fee-for-service payment with contract-based healthcare reimbursement system in 2000. Under the system, fee-for-service reimbursement has been accused of augmenting national healthcare expenditure by excessively increasing service volume. The researcher examined in this paper two major alternatives including diagnosis related group-based payment and global budget to contemplate the future of reimbursement system of Korean national health insurance. Various literature and preceding studies on pilot project and actual implementation of Neo-KDRG were reviewed. As a result, DRG-based payment was effective for healthcare cost control but low in administrative efficiency. Global budget may be adequate for cost control and improving the quality of healthcare and administrative efficiency. However, many healthcare providers disagree that excess care arising from fee-for-service payment alone has led to financial deterioration of national health insurance and healthcare institutions should take responsibility with global budget payment as an appropriate solution. Dissimilar payment systems may be applied to different types of institutions to reflect their unique attributes, and this process can be achieved step-by-step. Developing public sphere among the stakeholders and striving for consensus shall be kept as collateral to attain the desirable reimbursement system in the future.
*Budgets ; Delivery of Health Care/economics ; Diagnosis-Related Groups ; Efficiency, Organizational/economics ; Fee-for-Service Plans/economics ; Forecasting ; Humans ; *Insurance, Health, Reimbursement ; National Health Programs/*economics ; Republic of Korea

PURPOSE: This paper analyzed alternative methods of calculating the conversion factor for nurse-midwife's delivery services in the national health insurance and estimated the optimal reimbursement level for the services. METHODS: A cost accounting model and Sustainable Growth Rate (SGR) model were developed to estimate the conversion factor of Resource-Based Relative Value Scale (RBRVS) for nurse-midwife's services, depending on the scope of revenue considered in financial analysis. The data and sources from the government and the financial statements from nurse-midwife clinics were used in analysis. RESULTS: The cost accounting model and SGR model showed a 17.6-37.9% increase and 19.0-23.6% increase, respectively, in nurse-midwife fee for delivery services in the national health insurance. The SGR model measured an overall trend of medical expenditures rather than an individual financial status of nurse-midwife clinics, and the cost analysis properly estimated the level of reimbursement for nurse-midwife's services. CONCLUSION: Normal vaginal delivery in nurse-midwife clinics is considered cost-effective in terms of insurance financing. Upon a declining share of health expenditures on midwife clinics, designing a reimbursement strategy for midwife's services could be an opportunity as well as a challenge when it comes to efficient resource allocation.
Costs and Cost Analysis ; Female ; Humans ; Insurance, Health, Reimbursement/*economics ; Korea ; National Health Programs/*economics ; Nurse Midwives/*economics ; Pregnancy ; *Relative Value Scales

BACKGROUND: Identification of blood use characteristics in medical facilities is essential for predicting blood demand and maintaining an efficient blood programme. We investigated the use of blood components and discard rate of blood in hospitals. METHOD: Blood component utilization of hospitals in 1998 and 1999 was analyzed by mail survey and co-work with eight university hospitals. RESULTS: A total of 1,510,862 blood component units in 1998 and 1,646,346 units in 1999 meaning an increase of 8.97 % percent were used by 59 hospitals investigated. Use of irradiated blood and single-donor platelets increased. Blood discard rate was less than five percent in most hospitals and many hospitals experienced improper cut in health insurance reimbursement. CONCLUSION: Use of blood components in hospitals is increasing and national guideline for transfusion is needed. A successive investigation on National wide blood utilization like this study is required for estimation of blood demand.
Hospitals, University ; Insurance, Health, Reimbursement ; Korea* ; Postal Service

This study was focused on developing a computerized decision support program for physician order entry of 20% albumin infusion and perineal care procedures in order to minimize inpatients'insurance claims rejects. The frequency of inpatients health insurance reimbursement claims rejects of a 800-bed tertiary care teaching university hospital in Seoul area was reviewed and the most common two orders of the reject were chosen for the study. The order decision support program was designed on the basis of Korean Health Insurance Reimbursement Guidelines. The server system used for the study was ProLiant 7000 and Pentium III was used for the program development. Windows 2000 was used as the operating system, MS SQL v7.o was used for the database. The software development languages were Visual basic V6.0 and Spread v3.0. This Decision Support Program was proven to be very useful when doctors and nurses wanted to reflect the Health Insurance Reimbursement Guidelines in their ordering practices.
Humans ; Inpatients ; Insurance, Health* ; Insurance, Health, Reimbursement ; Program Development ; Seoul ; Tertiary Healthcare

BACKGROUNDMedical consortium is a specific vertical integration model of regional medical resources. To improve medical resources utilization and control the health insurance costs by fee-for-service plans (FFS), capitation fee and diagnosis-related groups (DRGs), it is important to explore the attitudes of doctors towards the different health insurance payment in the medical consortium in Shanghai.

METHODSA questionnaire survey was carried out randomly on 50 doctors respectively in 3 different levels medical institutes.

RESULTSThe statistical results showed that 90% of doctors in tertiary hospitals had the tendency towards FFS, whereas 78% in secondary hospitals towards DRGs and 84% in community health centers towards capitation fee.

CONCLUSIONSThere are some obvious differences on doctors' attitudes towards health insurance payment in 3 different levels hospitals. Thus, it is feasible that health insurance payment should be supposed to the doctors' attitudes using the bundled payments along with the third-party payment as a supervisor within consortium.

Capitation Fee ; China ; Fee-for-Service Plans ; Insurance, Health ; Insurance, Health, Reimbursement ; Physicians ; psychology ; Surveys and Questionnaires

Colorectal endoscopic submucosal dissection (ESD) is not yet fully popularized in Korea, but is increasing steadily. The outcomes of colorectal ESD in Korea are comparable to those in Japan and other countries. ESD-related complication rates are decreasing as experiences accumulate. Particularly for rectal laterally spreading tumors, ESD is becoming more prevalent than transanal endoscopic microsurgery. Standard indication, qualified training system, and full medical insurance coverage should be established for the procedure to become popular in the long run.
Colonic Neoplasms ; Endoscopy ; Insurance Coverage ; Insurance, Health, Reimbursement ; Japan ; Korea ; Microsurgery

AIMThe objective of this discussion paper is to investigate whether the experience gained through the German paradigm shift in dental care can be of benefit in China's deliberations on the introduction of universal dental care for its people. METHODOLOGY A comparison of representative oral health outcome data from China and Germany, two countries at different stages in their development, is presented here in order to analyse whether the findings meet expected outcome and confirm the presumption that more developed countries perform better.

RESULTSThe epidemiological comparison reveals surprising findings concerning the severity of dental diseases and, in particular, missing teeth per person in adults and rates of total edentulousness in seniors. In all of these areas German adults and seniors show significantly inferior outcomes compared with the Chinese population. The main reason for these striking discrepancies, as it turned out, is the decisive role played by the treatment philosophies and strategies of German dentists.

CONCLUSION AND RECOMMENDATIONSIf dentists take a less interventionist approach, checking as well as treating dental diseases with preventive and strictly tooth-preserving methods, dental treatment results in oral health. Under these conditions it can be assumed that modern dentistry is generally good for the teeth. These findings are important for developing countries that are seeking to integrate dental care into their health care system. On the basis of long-term experience from highly industrialized Western countries and especially from Germany we will attempt to put forward proposals for creating an effective and efficient dental care system in China.

Adolescent ; Adult ; Aged ; Child ; Child, Preschool ; China ; epidemiology ; Community Dentistry ; Delivery of Health Care ; organization & administration ; Dental Caries ; epidemiology ; Dental Health Services ; organization & administration ; Dentists ; supply & distribution ; Germany ; epidemiology ; Health Care Reform ; Health Policy ; Health Priorities ; Health Transition ; Humans ; Insurance, Health ; Middle Aged ; Mouth, Edentulous ; epidemiology ; Oral Health ; Outcome Assessment (Health Care) ; Periodontal Diseases ; epidemiology ; Philosophy, Dental ; Preventive Dentistry ; Reimbursement Mechanisms ; Tooth Loss ; epidemiology ; Universal Coverage ; organization & administration ; Young Adult