Background: As the Philippines moves toward universal health coverage, it is imperative to examine how to eliminate inefficiencies, particularly misuse, overutilization, and risks of fraudulent claims. This position statement aimed to identify health services requiring copayments for cost-efficient health financing for the Universal Health Care Act. Methods: A qualitative study was employed using a systematic review of literature, and thematic analysis of policy roundtable discussion (RTD) was conducted. The systematic review of literature generated evidence for the policy brief and critical points for discussion in the stakeholders’ RTD forum. The RTD was organized by the UP Manila Health Policy Development Hub (UPM HPDH) with the Department of Health (DOH) and was participated by key stakeholders of the policy issue to attain consensus recommendations and develop criteria for identifying services requiring copayments. Results: An algorithm is proposed by the UPM HPDH based on collective expertise as a guide for policymakers to assess each benefit package in terms of overutilization, the danger of depleting government funds, and the risk of fraud. The use of clinical pathways is suggested to assess the misuse and overutilization of health services. In addition to copayments, benefits packages prone to fraudulent activities should be subjected to fraud prevention processes. Copayment should be linked inversely to the preventability level of the disease or condition. Conclusion There were gaps in the current policies to identify services requiring copayment services. Copayment schemes should be carefully determined to prevent misuse, overuse, and fraud of appropriate and necessary health services, while at the same time not limit access to needed care.
Universal Health Insurance ; Cost Sharing ; Medical Overuse

PURPOSE: The incidence of colorectal cancer in Korea has recently increased, making it the second most common cancer in men and the third most common cancer in women. Risk factors for colorectal cancer have been studied worldwide, but risk factors specific for the Korean population have not been established. In this study, we investigated incidence trends and risk factors of colorectal cancer in Korea.METHODS: A total of 8,846,749 subjects were included. Colorectal cancer incidence was investigated using Korea National Health Insurance Service claim data from 2004 to 2014. Colorectal cancer diagnoses were obtained by evaluating colorectal cancer diagnostic codes and the cancer registry for cost sharing. Risk factor identification for colorectal cancer was obtained from National Health Examination data from 2004 to 2005. Cox proportional hazard model statistical analysis was used to determine risk factors of colorectal cancer.RESULTS: The incidence of colorectal cancer gradually increased from 2006 to 2014 (from 45.4/100,000 to 54.5/100,000). There was a predominance among men (1.47:1), but incidence trends were similar in both sexes. Old age, high body mass index, and no history of colonoscopy were identified as risk factors in both sexes. High fasting blood glucose, familial history of cancer, frequent alcohol intake, and current smoker were identified as risk factors, especially in men.CONCLUSION: The incidence of colorectal cancer has been increasing in Korea. Colonoscopy screening was a protective factor for colorectal cancer, and active use of colonoscopy may reduce incidence. Early diagnosis and care are important, particularly for the high-risk group.
Blood Glucose ; Body Mass Index ; Cohort Studies ; Colonoscopy ; Colorectal Neoplasms ; Cost Sharing ; Diagnosis ; Early Diagnosis ; Fasting ; Female ; Humans ; Incidence ; Korea ; Male ; Mass Screening ; National Health Programs ; Population Characteristics ; Proportional Hazards Models ; Protective Factors ; Retrospective Studies ; Risk Factors

BACKGROUND: The purpose of this study is to analyze the effects of differential coinsurance policy on prescription drug coverage of outpatients by types of medical institutions. METHODS: In this study, we used a sample cohort database of the National Health Insurance Service and frequency analysis and marginal logistic regression model using generalized estimating equation were used for statistical analysis. RESULTS: The summary on the major research is followed. First, about 16% of patients who used only tertiary or general hospital due to 52 ambulatory care sensitive conditions before policy implementation moved to hospitals and clinics. However, about 57% of them still use tertiary or general hospital. Second, the factors influencing the utilization of hospitals and clinics after the implementation of the policy were gender, age, and income level. As a result, the policy is effective to reduce the medical use of outpatient mental patients in tertiary or general hospital, but the effect is not significant. CONCLUSION: Therefore, in order to achieve the purpose of the policy for establishing the health care delivery system, it is necessary to adjust the co-payment so as to feel the burden on the co-payment when the outpatient for 52 ambulatory care sensitive conditions is used at the tertiary or general hospital.
Ambulatory Care ; Cohort Studies ; Deductibles and Coinsurance* ; Delivery of Health Care ; Hospitals, General ; Humans ; Logistic Models ; Mentally Ill Persons ; National Health Programs ; Outpatients* ; Prescriptions

PURPOSE: This study was to ascertain whether there are differences in health care utilization and expenditure for Type I Medical Aid Beneficiaries before and after applying Copayment. METHODS: This study was one-group pretest posttest design study using secondary data analysis. Data for pretest group were collected from claims data of the Korea National Health Insurance Corporation and data for posttest group were collected through door to-door interviews using a structured questionnaire. A total of 1,364 subjects were sampled systematically from medical aid beneficiaries who had applied for copayment during the period from December 12, 2007 to September 25, 2008. RESULTS: There was no negative effect of copayment on accessibility to medical services, medication adherence (p=.94), and quality of life (p=.25). Some of the subjects' health behaviors even increased preferably after applying for copayment including flu prevention (p<.001), health care examination (p=.035), and cancer screening (p=.002). However, significant suppressive effects of copayment were found on outpatient hospital visiting days (p<.001) and outpatient medical expenditure (p<.001). CONCLUSION: Copayment does not seem to be a great influencing factor on beneficiaries'accessibility to medical services and their health behavior even though it has suppressive effects on outpatients' use of health care.
Cost Sharing ; Delivery of Health Care ; Early Detection of Cancer ; Health Behavior ; Health Care Costs ; Health Expenditures ; Humans ; Korea ; Medicaid ; Medication Adherence ; National Health Programs ; Outpatients ; Quality of Life ; Statistics as Topic ; Surveys and Questionnaires

China ; Cost Sharing ; Germany ; Health Care Reform ; economics ; Humans ; Insurance, Health ; economics

The Korean government implemented a new policy on October 1st, 2011, requiring that patients with type 2 diabetes in the general or university hospital system pay 40% or 50% rather than 30% of total prescription drug costs. The Diabetes Association of Korea performed a survey regarding satisfaction with the new policy among patients with diabetes from August 24th to September 2nd, 2011. A total of 548 patients participated in the survey through one-to-one interviews. About 90% of patients with diabetes regarded diabetes as a serious disease, while only 4.5% regarded diabetes as a mild disease. The reasons why patients regarded diabetes as a serious disease were risks of developing diabetic complications (64.3%), difficulty of diabetes care (18.0%), and difficulty of cure (15.1%). About 70% of patients felt burdened by the increased prescription drug costs and deductibles, while only 12% did not. Finally, 85% of patients thought that the new policy was unfair to patients with diabetes and about 75% of patients regarded the new policy as inappropriate. In conclusion, the Korean government's new high deductible policy for patients with diabetes in the general/university hospital system should be withdrawn immediately.
Deductibles and Coinsurance ; Diabetes Complications ; Diabetes Mellitus ; Drug Costs ; Humans ; Insurance, Health, Reimbursement ; Korea ; Prescriptions

OBJECTIVES: The purpose of this study was to analyze the effect of outpatient cost-sharing on health care utilization by the elderly. METHODS: The data in this analysis was the health insurance claims data between July 1999 and December 2008 (114 months). The study group was divided into two age groups, namely 60-64 years old and 65-69 years old. This study evaluated the impact of policy change on office visits, the office visits per person, and the percentage of the copayment-paid visits in total visits. Interrupted time series and segmented regression model were used for statistical analysis. RESULTS: The results showed that outpatient cost-sharing decreased office visits, but it also decreased the percentage of copayment-paid visits, implying that the intensity of care increased. There was little difference in the results between the two age groups. But after the introduction of the coinsurance system for those patients under age 65, office visits and the percentage of copayment-paid visits decreased, and the 60-64 years old group had a larger decrease than the 65-69 years old group. CONCLUSIONS: This study evaluated the effects of outpatient cost-sharing on health care utilization by the aged. Cost sharing of the elderly had little effect on controlling health care utilization.
Age Factors ; Aged ; Cost Sharing/*economics ; Health Services/*economics ; Humans ; Insurance Claim Review ; Middle Aged ; Office Visits/economics

PURPOSE: This study examined the effects of case management (CM) for Medicaid on healthcare utilization considering the Medicaid system. METHODS: Data were extracted from survey data on "Healthcare utilization and health status of Medicaid beneficiaries" conducted in 2007 and 2008 by the Ministry for Health, Welfare and Family Affairs. This study was designed to compare the effects on healthcare utilization between the CM group and the non-CM group. The subjects were 535 Type I Medicaid beneficiaries who utilized healthcare more than 365 days during 2006. RESULTS: The outpatient days and medication days of the CM group decreased significantly more than those of the non-CM group with the copayment system. There were no significant differences of healthcare utilization between the CM group and the non-CM group with the designated doctor system. CONCLUSION: CM worked effectively on Medicaid beneficiaries' outpatient healthcare utilization with the copayment system. However, its effects on hospitalization, which is a major cause increasing the total expense, were not observed. Therefore, future studies are needed to develop strategies to reduce hospitalization and Medicaid beneficiaries' outpatient healthcare utilization with the designated doctor system.
Case Management* ; Cost Sharing ; Delivery of Health Care* ; Hospitalization ; Humans ; Medicaid* ; Outpatients

OBJECTIVES: The Korean government in January 2006 instigated an exemption policy for hospitalized children under the age of six years old. This study examines how this policy affected the utilization of medical care in Korea. METHODS: A total of 1,513,797 claim records from the Health Insurance Review Agency were analyzed by complete enumeration methods. The changes of medical utilization were compared from 2005 to 2006. In addition, the changes of medical utilization between 2004 and 2005 were compared as a pseudocontrol group. RESULTS: The admission rate increased 1.14-fold from 15.20% in 2004 to 17.32% in 2005, and this further increased 1.08-fold to 18.65% in 2006. The increase of patients with a common cold (1.2-fold) was higher than that of both the general patients (1.08-fold) and the patients with the top 10 fatal diseases (0.91-fold). The average length of stay per case for clinics showed the highest increase rates (1.06-fold). The rates of patients with the common cold showed a higher increase (1.05-fold) than that of the general patients. The average medical expense per case was increased by 1.10-fold from 2005 to 2006, which was higher than that from 2004 to 2005 (1.04-fold). The increase rate for patients with the common cold was higher at 1.18-fold than that of the general patients. CONCLUSIONS: The cost exemption policy has especially led to an increase in the utilization of clinics and the utilization by patients with a common cold.
Child, Preschool ; Cost Sharing/*legislation & jurisprudence ; *Health Policy ; Health Services/*utilization ; Hospitalization ; Humans ; Insurance Claim Review ; Korea ; Length of Stay

OBJECTIVE: The purpose of this study was to compare the hospital stay and cost-effectiveness between treatment modalities in ectopic pregnancy for proper management. METHODS: In this study, the authors studied 121 cases retrospectively who had been admitted and treated at Department of Obstetrics and Gynecology, Konyang University Hospital from February 1, 2000 to August 31, 2003. We analyzed clinical features, treatment modality, hospital stay and cost-effectiveness between each groups. One-way ANOVA test was used and p<0.05 was regarded as statistically significant. RESULTS: There was no difference in clinical features between treatment modalites. Of total 121 cases, operative procedures were done in 105 cases (explo-laparotomy in 58, laparoscopy in 43, dilatation and curettage in 4) and medical treatment in 16 cases (Multiple dose methotrexate protocol in 11, Single dose methotrexate protocol in 5). Average of length of hospital stay was 5.3 +/- 0.2 days in explo-laparotomy, 3.8 +/- 0.2 days in laparoscopy, 2.8 +/- 1.4 days in dilatation and curettage, 6.5 +/- 0.5 days in multiple dose methotrexate protocol, 2.4 +/- 0.4 days in single dose methotrexate protocol. According to treatment modality, there was significant difference in total cost and cost sharing. Total cost in explo-laparotomy (875,324 +/- 25,977 Won) was more expensive than that of laparoscopy (734,375 +/- 35,179 Won). But, cost sharing in explo-laparotomy (156,543 +/- 9,583 Won) was less expensive than laparoscopy (319,493 +/- 26,255 Won). Total cost and cost sharing in multiple dose methotrexate protocol (323,231 +/- 33,972 Won, 184,465 +/- 17,344 Won) was more expensive than that of Single methotrexate protocol (192,495 +/- 31,180 Won, 68,793 +/- 13,422 Won). CONCLUSION: Based on these results, it is very important that we should have an interest in ectopic pregnancy for early detection and proper management. Consequently, Achievement of precise decision and successful methotrexate treatment can be possible to decrease hospital stay and cost-effectiveness.
Cost Sharing ; Dilatation and Curettage ; Female ; Gynecology ; Laparoscopy ; Length of Stay* ; Methotrexate ; Obstetrics ; Pregnancy ; Pregnancy, Ectopic* ; Retrospective Studies ; Surgical Procedures, Operative