OBJECTIVE: This study examined the Risk Sharing Agreement (RSA) on pharmaceutical pricing system in Korean national health insurance. Through RSA, the insurer was able to maintain the principles in the price listing process while managing the budget effectively and improving patient access to new drugs. Despite these positive effects, there are still issues raised by some stakeholders, such as lack of transparency in the listing process and doubts about its effectiveness. Therefore, we investigated the impacts of RSA on national health insurance financing and patient access to analyze the effects of RSA. METHODS: The impact of RSA was investigated by analyzing the health insurance claims data for 2014~2016. The degree of improvement in patient access was determined by the decreased amount of patients' payment. RESULTS: Results showed that the financial impact of RSA was not significant and patients' access to the new drug greatly improved. CONCLUSION: These results show that RSA is a good system for improving patient access to new drugs without additional expense on insurance.
Budgets ; Humans ; Insurance Carriers ; Insurance* ; Insurance, Health ; National Health Programs*

Advances in technology lead to advances in medical devices, and these advances have the positive effect of creating opportunities for beneficial developments in healthcare, such as innovating traditional healthcare processes or expanding opportunities for diagnosing and treating diseases. Nonetheless, device developers, suppliers, users, insurers, and patients all face the challenge of balancing patient safety and health effectiveness with a reasonable profit. In Korea, the New Health Technology Assessment system aims to introduce safe and effective health technology, but this is only effective for the entry of devices onto the healthcare market. This system is not enough for creating a healthy ecosystem in which high-quality technologies and devices survive in the market and naturally exit from the market if not successful. The nation must not lag in the rapid development of medical devices, but the concomitant requirement for patient safety is like two rabbits moving in different directions. There is not enough time to resolve each source of uncertainty for both developers and users. The early adoption of health technologies, including medical devices, offers new opportunities for treatment and diagnosis, but also poses unexpected health risks. Thus, we need to design a plan to generate scientific evidence related to medical devices after they introduced into practice. Additionally, regarding the use of individual medical devices, we believe that the creation of a healthy ecosystem for medical devices by implementing medical device surveillance culture is a way to manage the opportunities and risks of the early introduction of innovative medical devices.
Biomedical Technology ; Delivery of Health Care ; Diagnosis ; Ecosystem ; Health Care Sector ; Humans ; Insurance Carriers ; Korea ; Patient Safety ; Rabbits ; Technology Assessment, Biomedical ; Uncertainty

Two major definitions of metabolic syndrome have been proposed. One focuses on the accumulation of risk factors, a measure used by the American Heart Association (AHA) and the National Heart, Lung, and Blood Institute (NHLBI); the other focuses on abdominal obesity, a measure used by the International Diabetes Federation (IDF) and the Japanese government. The latter definition takes waist circumference (WC) into consideration as an obligatory component, whereas the former does not. In 2009, the IDF, NHLBI, AHA, and other organizations attempted to unify these criteria; as a result, WC is no longer an obligatory component of those systems, while it remains obligatory in the Japanese criteria. In 2008, a new Japanese cardiovascular screening and education system focused on metabolic syndrome was launched. People undergoing screening are classified into three groups according to the presence of abdominal obesity and the number of metabolic risk factors, and receive health educational support from insurers. This system has yielded several beneficial outcomes: the visibility of metabolic syndrome at the population level has drastically improved; preventive measures have been directed toward metabolic syndrome, which is expected to become more prevalent in future generations; and a post-screening education system has been established. However, several problems with the current system have been identified and are under debate. In this review, we discuss topics related to metabolic syndrome, including (1) the Japanese criteria for metabolic syndrome; (2) metabolic syndrome and the universal health screening and education system; and (3) recent debates about Japanese criteria for metabolic syndrome.
American Heart Association ; Asian Continental Ancestry Group ; Education* ; Health Education ; Humans ; Insurance Carriers ; Japan* ; Mass Screening* ; Metabolic Syndrome X ; National Heart, Lung, and Blood Institute (U.S.) ; Obesity, Abdominal ; Risk Factors ; Social Responsibility ; Waist Circumference

Two major definitions of metabolic syndrome have been proposed. One focuses on the accumulation of risk factors, a measure used by the American Heart Association (AHA) and the National Heart, Lung, and Blood Institute (NHLBI); the other focuses on abdominal obesity, a measure used by the International Diabetes Federation (IDF) and the Japanese government. The latter definition takes waist circumference (WC) into consideration as an obligatory component, whereas the former does not. In 2009, the IDF, NHLBI, AHA, and other organizations attempted to unify these criteria; as a result, WC is no longer an obligatory component of those systems, while it remains obligatory in the Japanese criteria. In 2008, a new Japanese cardiovascular screening and education system focused on metabolic syndrome was launched. People undergoing screening are classified into three groups according to the presence of abdominal obesity and the number of metabolic risk factors, and receive health educational support from insurers. This system has yielded several beneficial outcomes: the visibility of metabolic syndrome at the population level has drastically improved; preventive measures have been directed toward metabolic syndrome, which is expected to become more prevalent in future generations; and a post-screening education system has been established. However, several problems with the current system have been identified and are under debate. In this review, we discuss topics related to metabolic syndrome, including (1) the Japanese criteria for metabolic syndrome; (2) metabolic syndrome and the universal health screening and education system; and (3) recent debates about Japanese criteria for metabolic syndrome.
American Heart Association ; Asian Continental Ancestry Group ; Education ; Health Education ; Humans ; Insurance Carriers ; Japan ; Mass Screening ; Metabolic Syndrome X ; National Heart, Lung, and Blood Institute (U.S.) ; Obesity, Abdominal ; Risk Factors ; Social Responsibility ; Waist Circumference

BACKGROUND: The voluntary diagnosis-related groups (DRG)-based payment system was introduced in 2002 and the government mandated participation in the DRG for all hospitals from July 2013. The main purpose of this study is to examine the independent effect of mandatory participation in DRG on various outcomes of patients. METHODS: This study collected 1,809,948 inpatient DRG data from the Health Insurance Review and Assessment database which contains medical information for all patients for the period 2007 to 2014 and examined patient outcomes such as length of stay (LOS), total medical cost, spillover, and readmission rate according to hospital size. RESULTS: LOS of patients decreased after DRGs (large hospitals: adjusted odds ratio [aOR], 0.87; 95% confidence interval [CI], 0.78-0.97; small hospitals: aOR, 0.91; 95% CI, 0.91-0.92). The total medical cost of patients increased after DRGs (large hospitals: aOR, 1.22; 95% CI, 1.14-1.30; small hospitals: aOR, 1.22; 95% CI, 1.21-1.23). The results reveals that spillover of patients increased after DRGs (large hospitals: aOR, 1.27; 95% CI, 0.70-2.33; small hospitals: aOR, 1.18; 95% CI, 1.16-1.20). Finally, we found that readmission rates of patients decreased significantly after DRGs (large hospitals: aOR, 0.28; 95% CI, 0.26-0.29; small hospitals: aOR, 0.59; 95% CI, 0.56-0.63). CONCLUSION: The DRG payment system compared to fee-for-service payment in South Korea may be an alternative medical price policy which can reduce the LOS. However, government need to monitor inappropriate changes such as spillover increase. Since this study also is the results based on relatively simple surgery, insurer needs to compare or review bundled payment like new DRG for expansion of various inpatient-related diseases including internal medicine.
Diagnosis-Related Groups* ; Health Facility Size ; Humans ; Inpatients ; Insurance Carriers ; Insurance, Health ; Internal Medicine ; Korea ; Length of Stay ; Odds Ratio ; Patient Readmission

To achieve long-term diabetic complication reduction and decrease the health care costs, all diabetic patients must have access to the components of diabetes care modality, such as medications, supplies, and self-management education programs. However, our current government policies for diabetic patients are not sufficient to allow for adequate blood glucose control. Our national insurer does not reimburse for diabetes supplies such as blood glucose testing monitors, blood glucose test strips, lancet devices and lancets, insulin syringes and pen needles, and alcohol swabs. The government officer states that national laws, regulations, executive order, and financial problems prohibit the reimbursement of diabetes supplies. However, to achieve good outcomes and decrease the public burden of medical care costs, all stake holders, health care professionals, and diabetic patients should exert effort to require reimbursement of diabetic supplies.
Blood Glucose* ; Delivery of Health Care ; Diabetes Complications ; Education ; Equipment and Supplies* ; Health Care Costs ; Humans ; Insulin ; Insurance Carriers ; Jurisprudence ; Needles ; Self Care ; Social Control, Formal ; Syringes

OBJECTIVES: Work related Musculoskeletal disorders (WMSD) is one of the most important problem in occupational health system of Korea and Japan, where the OHS system developed in similar socio-cultural environment. This study compared WMSD in Korea and Japan to review similarities and differences in their historical background, and development of prevention policies. METHODS: Scientific articles, government reports, and related official and non-official statistics on WMSD since the 1960s in Japan and Korea were reviewed. RESULTS: The historical background and basic structure of the compensation system in Korea and Japan largely overlapped. The issuing of WMSD in both countries appeared as upper limb disorder (ULD), named occupational cervicobrachial diseases (OCD) in Japan, and neck-shoulder-arm syndrome (NSA) 30 years later in Korea, following the change from an industrial structure to automated office work. Both countries developed manuals for diagnosis, guidelines for workplace management, and prevention policies. At present, compensation cases per covered insurers for WMSD are higher in Korea than in Japan, due to the social welfare system and cultural environment. Prevention policies in Korea are enforced more strongly with punitive measures than in Japan. In contrast, the Japanese system requires autonomous effort toward risk control and management, focusing on specific risky processes. CONCLUSIONS: WMSD in Korea and Japan have a similar history of identification and compensation structure, yet different compensation proportions per covered insurer and prevention policies. Follow-up study with international cooperation is necessary to improve both systems.
Asian Continental Ancestry Group ; Compensation and Redress ; Diagnosis ; Follow-Up Studies ; Humans ; Insurance Carriers ; International Cooperation ; Japan* ; Korea* ; Occupational Health ; Social Welfare ; Upper Extremity

PURPOSE: This study was a retrospective survey to examine economic feasibility of home care services for patients with diabetic foot. METHODS: The participants were 33 patients in the home care services (HC) group and 27 in the non-home care services (non-HC) group, all of whom were discharged early after inpatient treatment. Data were collected from medical records. Direct medical costs were calculated using medical fee payment data. Cost-effectiveness ratio was calculated using direct medical costs paid by the patient and the insurer until complete cure of the diabetic foot. Effectiveness was the time required for a complete cure. Direct medical costs included fees for hospitalization, emergency care, home care, ambulatory fees, and hospitalization or ambulatory fees at other medical institutions. RESULTS: Mean for direct medical costs was 11,118,773 won per person in the HC group, and 16,005,883 won in the non-HC group. The difference between the groups was statistically significant (p=.042). Analysis of the results for cost-effectiveness ratio showed 91,891 won per day in the HC patients, and 109,629 won per day in the non-HC patients. CONCLUSION: Result shows that the cost-effectiveness ratio is lower HC patients than non-HC patients, that indicates home care services are economically feasible.
Costs and Cost Analysis ; Diabetic Foot ; Emergency Medical Services ; Fees and Charges ; Fees, Medical ; Home Care Services ; Hospitalization ; Humans ; Inpatients ; Insurance Carriers ; Medical Records ; Retrospective Studies

OBJECTIVES: To explore classification rules based on data mining methodologies which are to be used in defining strata in stratified sampling of healthcare providers with improved sampling efficiency. METHODS: We performed k-means clustering to group providers with similar characteristics, then, constructed decision trees on cluster labels to generate stratification rules. We assessed the variance explained by the stratification proposed in this study and by conventional stratification to evaluate the performance of the sampling design. We constructed a study database from health insurance claims data and providers' profile data made available to this study by the Health Insurance Review and Assessment Service of South Korea, and population data from Statistics Korea. From our database, we used the data for single specialty clinics or hospitals in two specialties, general surgery and ophthalmology, for the year 2011 in this study. RESULTS: Data mining resulted in five strata in general surgery with two stratification variables, the number of inpatients per specialist and population density of provider location, and five strata in ophthalmology with two stratification variables, the number of inpatients per specialist and number of beds. The percentages of variance in annual changes in the productivity of specialists explained by the stratification in general surgery and ophthalmology were 22% and 8%, respectively, whereas conventional stratification by the type of provider location and number of beds explained 2% and 0.2% of variance, respectively. CONCLUSIONS: This study demonstrated that data mining methods can be used in designing efficient stratified sampling with variables readily available to the insurer and government; it offers an alternative to the existing stratification method that is widely used in healthcare provider surveys in South Korea.
Data Mining ; Decision Trees ; Efficiency ; Health Personnel ; Humans ; Inpatients ; Insurance Carriers ; Insurance, Health ; Korea ; Ophthalmology ; Population Density ; Republic of Korea ; Sampling Studies ; Specialization

In Korea, the proportion of medical costs due to chronic diseases among total health care expenditures is increasing rapidly. This trend calls for immediate countermeasures. In the major developed countries in Europe, a gatekeeper system has been adopted at the national level as a universal policy to manage and prevent chronic disease. In South Korea, insurers and local governments offer management programs to individuals with chronic disease and metabolic syndrome under the Korean government's Health Plan 2020, but these programs are fragmented and there are some related limitations. The role of the national government is very important to overcome this problem because the chronic disease management systems of other players (insurers, local governments) must be integrated. In addition, the expert patients program, which is intended to improve the self-care skills of chronic disease patients, needs to be better promoted. Incentives should include "mileage programs" in which patients can accumulate points for successful self-care. It is also important to increase public awareness through large-scale promotional campaigns. Finally, it is necessary to raise funds to conduct national-level campaigns and provide incentives to patients, and to ensure that all processes establish an organic cooperation system. Such practices will maximize the positive effects of a nationwide chronic disease management system in South Korea.
Chronic Disease ; Collodion ; Delivery of Health Care ; Developed Countries ; Dietary Sucrose ; Europe ; Federal Government ; Financial Management ; Health Expenditures ; Humans ; Insurance Carriers ; Korea ; Motivation ; Republic of Korea ; Self Care